Background Poisoning is a major problem in India. However, there is little systematic information on the key poisons responsible for most deaths by geographical area and over time. We aimed to review the literature to identify the poison classes causing the greatest number of deaths in India over the last 20 years. Methods We performed a systematic literature review in Medline, Embase and Google Scholar (1999–2018), and Indian online medical journals, to find papers that reported deaths from all forms of poisoning in India, with last search 20 April 2020. We included epidemiological studies, observational studies, randomised trials, interventional studies, and case series published from 1999 to 2018 that showed the number of deaths and autopsy studies indicating the specific poisons or poison classes. Studies providing the case fatality for specific poisons or classes, which enabled calculation of the number of deaths, were also included. We excluded deaths due to animal bites and stings, ethanol or methanol poisoning, and gas inhalation as well as papers reporting a single death (case study of single patient). We grouped the papers into 5-year intervals and identified the two most common poison classes in each paper. We used descriptive statistics to summarise the findings over time based on the causative poison and the location of the study. Results We identified 186 papers reporting 16,659 poisoning deaths between 1999 and 2018. The number of publications per 5-year interval showed no clear trend over the period (48, 38, 67, and 36 for consecutive periods). Half of the deaths (n = 8338, 50.0%) were reported during the first 5 years of the study (1999–2003), the number of deaths declining thereafter (to n = 1714 in 2014–2018). Deaths due to pesticide poisoning (94.5%) were dominant across the study period compared to other classes of poison [hair dye paraphenylenediamine poisoning (2.6%), medicine overdose (1.4%) or plant poisoning (1.0%)]. Among the pesticides, aluminium phosphide was the most important lethal poison during the first 10 years before declining markedly; organophosphorus insecticides were important throughout the period, becoming dominant in the last decade as aluminium phosphide cases declined. Unfortunately, few papers identified the specific organophosphorus insecticide responsible for deaths. Conclusion Use of the published literature to better understand the epidemiology of lethal poisoning in India has clear limitations, including secular variation in publishing practices and interest in poisoning. Unfortunately, there are no long-term detailed, combination hospital and community studies from India to provide this information. In their absence, our review indicates that pesticides are the most important poison in India, with organophosphorus insecticides replacing aluminium phosphide as the key lethal poison after government regulatory changes in 2001 reduced the latter’s lethality. Plant and hair dye poisoning and medicines overdose caused few deaths. Aluminium phosphide deaths mostly occurred in northern Indian states, whereas deaths from organophosphorus insecticide poisoning occurred throughout India. Paraquat poisoning has become a clinical problem in the last 10 years. Lethal pesticide poisoning remains alarmingly common, emphasising the need for additional regulatory interventions to curtail the burden of pesticide poisoning deaths in India. More detailed reporting about the specific pesticide involved in lethal poisoning will be helpful to guide regulatory decisions.
Background Removing highly hazardous pesticides from agricultural practice in low- and middle-income countries is crucial to ensuring community and environmental health and occupational safety of farmers. However, the approach has been challenged as threatening food production, despite evidence from Asian countries that curbing agricultural use of highly hazardous pesticides does not affect crop yields. In 2011, the state of Kerala, India, banned 14 highly hazardous pesticides resulting in a marked reduction in deaths from pesticide poisoning. Objective We aimed to determine whether the Kerala pesticide bans impacted agricultural yields. Methods We collected data on agricultural production, area under cultivation, and rainfall, published by the Kerala state agricultural department from 2004 to 2018 for eight key crops that had been treated with the banned pesticides. Trends in crop yields (total production/area under cultivation) and rainfall across 14 districts in Kerala were aggregated and analysed using joinpoint regression. These trends were evaluated to ascertain possible associations with the pesticide bans. Results The joinpoint regression analyses showed no evidence for any change in yield trends for any of the eight crops in the year of the pesticide bans (2011), or the subsequent year (2012), suggesting a negligible impact of the bans on crop yields. Steady trends of predominately reductions in overall rainfall, without any change around the time of the pesticide bans, was observed in Kerala throughout the period. No evidence of district-level changes in rainfall that might have offset any potential adverse impacts of the pesticide bans on crop yields was noted. Fluctuations in yield until 2018 could be explained by variation in rainfall, changes in land use, and agricultural policies. Conclusion We found no evidence of an adverse effect on agricultural yields in Kerala that could be attributed to bans of highly hazardous pesticides. This work provides further evidence that such pesticides can be withdrawn from agricultural use without affecting yields. Further studies are required for the whole of India after the national bans of 12 pesticides in 2018 to identify state-level effects of the bans.
An estimated 28.75% of the world's suicides occur in India [1,2], emphasising the need for evidencebased interventions for suicide prevention that are particular to India and South Asia. We therefore read with great interest Pathare and colleagues' study protocol for a cluster-randomised controlled trial evaluating a programme of three interventions in Gujarat, India [3].The approach includes a secondary school intervention to reduce suicidal ideation among adolescents, a community-level pesticide storage facility to reduce access to pesticides at moments of crisis, and training for community health workers in recognition, management, and referral of people at high suicide risk. Follow-up is planned for up to 12 months. We note that the design of the study, with the rate of suicide and attempted suicide by all means as the primary outcome, will not allow the effect of any one intervention to be tested or quantified.Lethal pesticide self-poisoning is a particularly important means of suicide in India, because it is common (responsible for 30-40% of all suicides [4,5]) and quite preventable. The role of the second intervention-pesticide storage-as a way of preventing suicides is therefore important to understand.The World Health Organization (WHO) has supported several pilot studies to assess the feasibility of improved pesticide storage to prevent pesticide self-
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