Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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We must clarfy current confusion
- Arjun Karki (19 November 2004)
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A threat of terrorist attack seems provocative than 2 million poisoned patients every year!
- Anil Pandit (19 November 2004)
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Reporting from Hyderabad, India on OP compound poisoning.
- Arafat Mirza (21 November 2004)
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Poor countries bear a brunt of organophosphate pesticide poisoning impact.
- Albert M. E. Coleman, (23 November 2004)
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Reverse Organophosphorus Poisoning Syndrome- only in the South East Asia?
- Ashadeep Chandrareddy (23 November 2004)
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Legislate dilute Organophosphate for public use in developing countries
- Philemon S. Sanmuganathan (25 November 2004)
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Censorship - a tradition in organophosphorus poisoning
- Richard Bruce (28 November 2004)
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Information on the treatment of OP poisoning on the Web
- Joanna H Tempowski (29 November 2004)
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Arjun Karki, Consultant Physician Patan Hospital, Kathmandu, Nepal
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I fully agree with the concern shown by Drs. Buckley, Roberts and Eddleston. The problem of organophosphorus poisoning (OPP) has indeed been neglected. Patan Hospital is a 300 bedded city hospital in Nepal that serves 300, 000 outpatients and 25, 000 inpatient per year. We admit on average 2-4 OPP patients every week. We are not convinced that there exists any well defined therapeutic guidelines in the treatment of OPP patients. This is high time that we address this issue and define the therapeutic protocol based on solid clinical evidence. Let us form an alliance for this purpose. We are willing to participate in such clinical research. Thanks Competing interests: None declared |
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Anil Pandit, Physician Kathmandu, Nepal
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Nepal is another South Asian country where attempted suicide and suicide due to organophosphate bears considerable morbidity and mortality. During year 2002 to 2003, 96 people died predominantly because of poisoning in Kathmandu district(1). In year 2001/ 2002, out of 3033 suicides, 546 (18%) was due to poisoning(2). Every government hospital in the Valley receives about approximately 2 to 3 cases of organophosphate poisoning per week. Last year a medical ward of Patan Hospital, Kathmandu received 60 patients of organophosphate poisoning(1). All most all patients were managed with atropine and pralidoxime in the medical. As a physician the problem we faced each time while treating patient with organophosphate poisoning was the amount of atropine to be given as a maintenance dose and the duration of treatment. No clear suggestion about duration of treatment is available in standard textbooks of internal medicine that is widely used in this sub-continent either, like Harrison's Text Book of Internal medicine, as for example. Having said this, I would like to ask those who have shown new interest in conducting research in organophosphate poisoning, wasn't the 2 million people being poisoned every year sufficient enough to carry out further research early on in this field. The world had to wait for 30 long years until the risk of having a terrorist attack in the Western world comes into the play. This brings us to an ethical point that poorer people are saving the richer people. This clearly means that poor people of this region are going to get subjected on different kind of clinical trials of different antidotes whose efficacy and safety in humans are not known, which could be potentially be fatal also. After conducting well designed randomized controlled trail in Asia-pacific region, and after establishing safety of the antidote, use it to save the Westerners seems odd. 1. Pandit A, "Circadian Rhythm in attempted Suicide and Completed Suicide due to Deliberate Self-Poisoning in Central Nepal," Biological Rhythm Research., Francis and Taylor. (accepted, September 2003) 2. Pandit A, "Suicide in Nepal: facts and figures." Trop Doct. 2004 Apr;34 (2):125. Competing interests: None declared |
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Arafat Mirza, Doctor ( graduate ) Hyderabad, India
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Hello. I am Dr Arafat Mirza. I work in Osmania General Hospital, in Hyderabad, India. I wanted to tell how much I share the views expressed in the article. I have felt the same way about OP poisoning since the time I started working in my hospital. I have felt that this area has been so much unexplored. There is hardly a paragraph of two about the management of OP poisoning in the western medical text books. There is no proper protocol followed for these cases--every one follows their own self made one. On an average, we get 100 cases of organophosphorous compound poisonings per month. All of them are suicidal. And all of them are farmers who have an easy access to the pesticides that are mostly organophosphorus compounds. They come at varied intervals after consuming the poison and in varied amounts. Most of the patients' attendants carry the can that contained the pesticide to the hospital. Many of them do not. But OP poisoning is such a common case, we assume that any poisoning is OP poisoning unless there is proof otherwise. These are the usual steps of management at our hospital. 1 Confirm OP poisoning from a. the container brought along by the attendants b. characteristic odor c. cholinergic signs--pin point pupils, salivation, lung secretions (coarse crepts). But these is not reliable in the first instance because we do not know for sure how much time has elapsed after the poisoning and that how much amount he has consumed. These signs may develop a little later on. We ideally should not be waiting until then. 2. Gastric lavage. If the patient is unconscious and has no cough reflex, he is intubated before the lavage. 3. 100% Atropine fast IV drip. This is done only if the patient is unconscious and pupils are pin point. This is done until pupils are completely dilated. In the cases I have managed, 200-300 ml of atropine was enough most of the times for unconscious patients. 4. Pralidoxime. 5. Respiratory support if poor effort. The patients are managed in Acute Medical Care until they become conscious. They are shifted to the ward. One problem that comes up late is the relapse. This is not uncommon. This happens around 5-6 days after the consumption. This is probably due to the shifting of the stores of OP compound from the peripheral fat into the blood stream. This poses a major problem in the wards because they cannot be managed adequately here. Deaths do occur. As it is said in the article, proper research hasn't been done on this, I do not know the exact death rate. Well!! All this may look so inadequate for the management of a medical condition that is so easily fatal. But this is how it is at our hospital. I think I can start a study at my hospital on OP poisoning. If anyone can suggest to me the lines on which to conduct a study, I can do it. We have a huge clinical material here. Please guide me. I am interested. Especially on the new treatment regimens that were suggested in the article. Dr Arafat. Please contact me at arafatmirza@hotmail.com Competing interests: None declared |
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Albert M. E. Coleman,, Associate specialist psychiatrist. Greenarces CMHT, WSHSS NHS Care trust, Homefield road. Worthing, BN11 2DH. W. Sussex.
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Editor. - Buckley et al hit the nail on the head when they tackled the issue of overcoming apathy in organophosphate poisoning research. Not only did they mention the potential risks of use of organophosphates in terrorists attacks, but also they highlighted the mostly unheralded problem of organophosphate pesticide poisoning in developing, countries.1 This latter issue of organophosphate poisoning in developing countries is a silent public health problem that occurs in a good number of developing countries where pesticides not only of the organophosphate type, but other acetycholinesterase inhibitory pesticides, are prevalently used for agricultural purposes 2,3 and deliberate self-harm or suicides.4 Hopefully in our era of evidence based practice, appropriate and validated guide lines for management and treatment of organophosphate poisoning, useful in managing mass casualties victims, may be developed in time. This if done will go a long way to help the silent victims of organophosphate poisoning and acetyl cholinesterase inhibitor based pesticide poisoning victims in developing countries, who experience this as a daily existential occurrence. 1.Buckley Nick A, Roberts Darren, Eddleston Michael. Overcoming apathy in research on organophosphate poisoning. BMJ 2004; 329:1231-33. 2.Coleman AME, Smith A, Watson L. Occupational carbamate pesticide poisoning in three farm workers. W.I. Med J. (1990) 39:109-113. 3.Koh D, Jeyaratnam J. Pesticides hazards in developing countries. Science of the total environment. 1996. Vo. 188, Supplement 1, pages S78-S85. 4.Singh S, Sharma N. Neurological syndromes following organophosphate poisoning. Neurol India 2000; 48:308-13. Competing interests: None declared |
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Ashadeep Chandrareddy, Specialist Registrar in Obstetrics & Gynaecology South East of Scotland Deanery
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I wholeheartedly appreciate the article and its timing. I certainly remember a pregnant woman with Organophosphorus poisoning (OPP) in India who recovered very well initially but unfortunately and sadly died. This is due to late redistribution of the chemical also known as Reverse OPP syndrome and somewhat presumed to be peculiar to South-East Asian countries. (I doubt if the attributed geographic peculiarity is not due to the fact that almost all research into OPP is in these countries.) We sadly realised that the woman was pregnant only after she miscarried. Although we could have done nothing better that was a learning experience for me in every way. This article brings back vivid memories of OPP. We used to see atleast one case of OPP every day. There were many cases even in pediatric age group, mostly due to accidental consumtion . Luckily for novices like me, then; one of our consultants took lot of interest in teaching us all about OPP and how to manage a case in the emergency department. We had a protocol for manging OPP which was very valuable considering the fact that none/very few of the textbooks mention in detail about OPP. Symptoms of OPP are due to the irreversible anticholinesterase action of the compound. Massive doses of atropine are used in treatment. The fact that these compounds are irreversible make antidote administration tricky. The chemical is absorbed by ingestion, inhalation or topical routes. Literature mentions more than 20-30 generic forms of organophosphorus compounds. It is really sad that it takes terrorism to make all people in the world equal. Nevertheless with the changing scenario we could hope and do with more research into OPP. Competing interests: I am into Obsterics and Gynaecology. OPP might not be really relevant to my speciality. However I take note of the fact that the current CEMD(Confidential enquiry into Maternal Deaths) mentions **suicide** as the most common cause of Maternal Death in the UK. |
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Philemon S. Sanmuganathan, Consultant Physicain Worcestershire Royal Hospital, WR1 1QX
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Legislate dilute Organophosphate for public use in developing countries Editor, Buckley et al. plea for further research to find yet more antidotes for organophosphate poisoning. Arguing their case with charitable intensions to reduce premature deaths due to suicidal organophosphate poisoning in developing countries with extensions to safeguard the western countries from possible chemical attacks. Having worked in Sri Lanka, I know, highly toxic concentrations of organophosphate compounds are freely available relatively cheap. It is cheap as it is subsidised, sold in a concentrated formula to facilitate agricultural use, diluted prior to use by the farmer. Mortality from paracetamol and salicylates reduced by 22% in England and Wales, a year after legislations to limit pack size of analgesics sold to the public came into effect in 1998. This trend continues ever since. Acetylcysteine an effective antidote to prevent toxic liver damage secondary to paracetamol overdose was licensed in 1979. Widespread use of acetylcysteine over nearly twenty years in the UK, made no major impact on paracetamol related deaths or need for liver transplants. Common sense would be to lobby governments in developing countries to legislate- restricted sale of concentrated organophosphate pesticide to farmers and to market a diluted formulation for public use. This simple measure will limit availability of lethal concentrations and thereby limit massive toxicity. Health services will save large amounts of money spent on medications and intensive care. Research agencies funding randomised controlled trials on antidotes for organophosphates should follow an ethical approach. They will hopefully, expect trials to be powered to detect at least a 20% absolute reduction in mortality, in line with benefit seen in intervention for parcetamol overdose. Philemon S. Sanmuganathan Consultant Physician, Worcestershire Royal Hospital. Phil.Sanmuganathan@worcsacute.wmids.nhs.uk Competing interests: none. 1. Buckley NA, Roberts D, Eddleston M. Overcoming apathy in research on organophosphate poisoning. BMJ 2004;329:1231-33. 2. Hawton K, Simkin S, Deeks J, Cooper J, Johnston A, Waters K, et al.UK legislation on analgesic packs: before and after study of long term effects of poisoning. BMJ 2004;329:1076-9. Competing interests: None declared |
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Richard Bruce, None None
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When the Nazis led their unsuspecting victims into the "showers" and poisoned them they kept the truth from the world. The United Kingdom had the task of clearing the stocks of German organophosphorus nerve gas and were still clearing them in the 1990s. Knowing the dangers the UK government used this group of chemicals in agriculture with devastating effect - on the workers. Lord Zuckerman declared these chemicals as "Deadly Poisons" in his report produced in 1951. He recommended that hospitals should be notified BEFORE such chemicals were used in the area around them. Those recommendations were never enacted and, as with the Nazis, the truth was hidden from the workers and the consumers. Now we have a hyped-up terror threat in the West. Wise and honest doctors overseas, who have witnessed the suffering first hand, ask why deaths in third world countries were not considered as important as theoretical threats to life in the West. Those in the West who have been poisoned and whose lives and livelihoods have been taken from them are asking why the known dangers have been hidden and why their lives have had no value. They might also ask why there is censorship of the truth. It is unlikely that they will get any answers but very likely that those who dare to tell the truth will find themselves at the mercy of a system which accepts disability resulting from exposures as a fair price to pay for chemical industry profits. Competing interests: One of thousands poisoned by orgasnophosphorus pesticides in the UK |
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Joanna H Tempowski, Scientist International Programme on Chemical Safety, WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland
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In the rapid responses to the article by Buckley et al, a number of correspondents have drawn attention to difficulty in finding information on the management of organophosphate poisoning. The International Programme on Chemical Safety (IPCS), a joint activity of the World Health Organization (WHO), the International Labour Organization (ILO) and the United Nations Environment Programme (UNEP), has compiled a databank of information on chemicals and chemical safety called the INTOX Databank. This databank provides a range of information on chemicals, pharmaceuticals and natural toxins. There are over 200 Poisons Information Monographs (PIMs) concerning the diagnosis and management of poisoning, including a PIM on organophosphate poisoning (PIM G001). The databank can be consulted free of charge to the end-user at www.intox.org. Other information on chemicals can be found on the INCHEM Databank (www.inchem.org) and on the IPCS website (http://www.who.int/ipcs/en/). Competing interests: None declared |
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