Lessons From the Household Humidifier Disinfectant Tragedy (HHDT) With Focus on the Chemical Poisoning Surveillance System: Review and Recommendation.

BACKGROUND: Lessons learned from the Household Humidifier Disinfectant Tragedy (HHDT) in Korea, which poisoned thousands of citizens over a period of years, necessitated an examination of national poison prevention and surveillance systems. The objectives of this study are to identify essential changes needed in chemical poisoning prevention regulations and surveillance systems for effective poison control by comparing recent trends in international poison control center (PCC) operations, and to delineate the critical elements for establishing a state-of-the-art poison control surveillance system in Korea based on recent advances in PCCs with toxicovigilance. METHODS: A comprehensive review of Korea's regulatory and surveillance systems for chemical health hazards, with a focus on household products under the HHDT, was conducted. A review of toxicovigilance systems in major countries shows that creating an effective national PCC requires key elements: a centralized database of toxic substances and poisoning cases, mandatory or voluntary reporting of poisoning cases, real-time alerts, collaboration among health organizations, and targeted follow-up of poisoned individuals. RESULTS: Significant deficiencies in Korea's legislation, toxicological data management, and poisoning surveillance systems, explained the inadequate response of the Korean government to the HHDT for nearly 17 years until the end of 2011. Based on a review of PCC toxicovigilance systems in major countries, a national framework with five core components is recommended for establishing a modern comprehensive Korea PCC system with toxicovigilance capacity. The core components include establishment of a centralized database of toxic substances information and clinical poisoning cases, implementation of mandatory or permissive reporting of poisoning cases, real-time alert mechanisms, collaborative systems among health-related organizations, and clinical follow-up of poisoned sub-groups. CONCLUSION: A rationale and framework for a state-of-the-art national Korean PCC with toxicovigilance is justified and offered. This proposed system could assist neighboring countries in establishing their own sophisticated, globally integrated PCC networks.

Eye hazard classification according to UN GHS / EU CLP and the severity of eye symptoms caused by accidental exposures to detergents and cleaning products.

The use of lower cut-off values/concentration limits for the calculation of mixture classification in UN GHS/EU CLP versus the previous regulatory scheme (EU Dangerous Preparations Directive, DPD), has resulted in an increased number of classifications in the highest eye hazard category. Herein, a semi-quantitative categorisation of severity of eye effects, following accidental human exposures to detergents, was compared to the classification category of the products. Three schemes were evaluated: EU DPD; EU CLP (based on all available data and information, including weight of evidence); and EU CLP (based entirely on the calculation method). As reported by four EU Poison Centres, the vast majority of exposures had caused minor or no symptoms. Classification was a poor predictor of effects in man subjected to accidental exposure. Note however that this is also because effects are not only driven by the intrinsic hazard (as reflected in the classification), but also by the exposure conditions and mitigation (i.e. rinsing). EU CLP classification using all available data and information was more predictive of medically relevant symptoms than the EU CLP calculation method. The latter led to a poorer differentiation between irritating products versus products potentially causing serious eye damage.

Surveillance of paediatric exposures to liquid laundry detergent pods in Italy.

OBJECTIVE: To analyse paediatric exposures to pod and traditional laundry detergents in Italy and changes in exposure trends. METHODS: Analyses of a series of patients aged <5 years and exposed to laundry detergents between September 2010 and June 2015, identified by the National Poison Control in Milan. RESULTS: In comparison with patients exposed to traditional laundry detergents (n=1150), a higher proportion of those exposed to pods (n=1649) were managed in hospital (68% vs 42%), had clinical effects (75% vs 22%) and moderate/high severity outcomes (13% vs <1%). Exposure rates were stable over time for traditional detergents (average 0.65 cases/day), but an abrupt decline in major company pods was seen in December 2012, 4 months after the introduction of opaque outer packaging (from 1.03 to 0.36 cases/day and from 1.88 to 0.86 cases/million units sold). The odds of clinical effects was higher for exposure to pods than for traditional detergents (OR=10.8; 95% CI 9.0 to 12.9). Among patients exposed to pods, the odds of moderate/high severity outcomes was four times higher for children aged <1 years than for the other age groups (OR=3.9; 95% CI 2.2 to 7.0). Ten children exposed to laundry detergent pods had high severity outcomes while no children exposed to traditional laundry detergents developed high severity effects. CONCLUSIONS: The study confirms that exposure to laundry detergent pods is more dangerous than exposure to traditional detergents. In Italy, 4 months after the introduction of opaque outer packaging by a major company, product-specific exposure rates decreased sharply, suggesting that reducing visibility of laundry detergent pods may be an effective preventive measure. Further efforts are needed to improve safety.

Why are adults exposed to liquid laundry detergent capsules?

INTRODUCTION: Exposures to liquid laundry detergent capsules in adults are less well characterized than in children. METHODS: All enquiries to the Centro Antiveleni di Milano regarding adults (>18 years) who were exposed to these capsules between July 2010 and July 2023 were analyzed. Enquiries were followed up with one or more recalls depending on the severity of the patient. RESULTS: Over the study period, 127 adults were exposed. The age distribution was as follows: 34 patients were aged 18-39 years, 29 were 40-59 years, 24 were 60-79 years, 26 were 80-96 years, and the age was unknown in 14. Exposure occurred mainly as a result of ingestion alone (n = 54), skin contact alone (n = 23), and eye contact alone (n = 31). Oral exposure without swallowing occurred in nine cases, and inhalation of the odour from a disintegrated capsule in four. Multiple routes of exposure were involved in six patients. Thirty-four (63 per cent) of the 54 ingestions occurred in those with dementia or intellectual disability, and three patients in this group died. Dermal or eye exposures did not involve those with dementia. CONCLUSIONS: These data show that the majority of adults in Italy who ingest liquid laundry detergent capsules are suffering from dementia or other cognitive impairment.

Surveillance of toxic exposures: the pilot experience of the Poison Control Centers of Milan, Pavia and Bergamo in 2006.

Between 1 February and 31 March 2006, the Poison Control Centers (PPC) active in Lombardy collaborated with an integrated surveillance system carried out in Piedmont during the Olympic Games 2006. The collaborating PPC notified to the system 697 human cases of exposure occurred in Piedmont during the observation period. Among these cases, 70% were exposed accidentally, 40% were 6 years old or younger, and 45% reported at least a clinical effect. The agents more frequently reported were: cleaning substances (household) (110 cases), fumes/gases/vapors (63 cases, comprising 38 cases accidentally exposed to carbon monoxide), and sedative/hypnotics/antipsychotics (53 cases). Although very limited, the available observations focused the attention on specific hazards and were able to highlight the potential of a toxic exposure surveillance system based on the information reported by the Italian PPC.

A case of contact dermatitis to dimethylfumarate in shoes identified in Italy.

The present paper describes a case of shoe contact dermatitis from DMF identified by the Poison Control Centre of Milan (PCCM), Italy, in 2009. A 35 year old woman was affected by irritant reactions while wearing shoes contaminated with DMF. Exposure to these shoes was limited to a 8 hour period and was not repeated. In the following days the patient suffered feet blistering and swelling limited to the area in contact with shoe vamp. Topical application of cortisone did not prevent development of bullous eczema. After 20 days from exposure, the lesions were healed but the skin remained red, dry and very sensitive. Chemical analyses of shoes quantified an average concentration of DMF of 383 mg/kg. The patient refused to be patch tested. The observation here reported confirm that DMF should be considered a possible causal agent in shoe contact dermatitis. Documentation of cases exposed to this chemical provide a relevant support to characterize clinical manifestations and to identifying contaminated articles.