Current pesticide suicide surveillance methods used across the African continent: a scoping review protocol.

INTRODUCTION: Every year, more than 800 000 people die from suicides of which an estimated 20% are from pesticide ingestion. Multiple studies have estimated that around 77%-80% of these pesticide suicides occur in low/middle-income countries. The full burden of pesticide suicides in African countries remains poorly documented, one reason being the lack of systematic data collection. It is essential to know the number of pesticide suicide cases to guide prevention of further cases occurring. This can be done by informing policy and legislation, and the implementation of targeted bans, as well as raising community awareness around the use of these pesticides, training of healthcare personnel, and influencing the type and level of clinical facility investments into this area of healthcare. The scoping review aims to investigate how pesticide suicide deaths in Africa are recorded by exploring the various surveillance systems in place, as well as highlighting key limitations and data collection barriers. METHODS AND ANALYSIS: A scoping review will be carried out with the five-stage methodological frameworks set out by Arksey and O'Malley and the Joanna Briggs Institute. Studies in English that looked at pesticide suicide in African countries will be extracted and screened independently by two reviewers against the inclusion and exclusion criteria of this review. Studies' data will be extracted, and a descriptive synthesis developed of their main findings, as guided by the approach of Levac and colleagues. ETHICS AND DISSEMINATION: Ethics approval is not required for this review as no human participants will be involved. The study findings will be distributed in a peer-reviewed publication. REGISTRATION DETAILS: This protocol has been submitted for publication to BMJ Open.

Gatekeeper training for vendors to reduce pesticide self-poisoning in rural South Asia: a study protocol for a stepped-wedge cluster randomised controlled trial.

INTRODUCTION: Pesticide self-poisoning kills an estimated 110 000-168 000 people worldwide annually. Data from South Asia indicate that in 15%-20% of attempted suicides and 30%-50% of completed suicides involving pesticides these are purchased shortly beforehand for this purpose. Individuals who are intoxicated with alcohol and/or non-farmers represent 72% of such customers. We have developed a 'gatekeeper' training programme for vendors to enable them to identify individuals at high risk of self-poisoning (gatekeeper function) and prevent such individuals from accessing pesticides (means restriction). The primary aim of the study is to evaluate the effectiveness of the gatekeeper intervention in preventing pesticide self-poisoning in Sri Lanka. Other aims are to identify method substitution and to assess the cost and cost-effectiveness of the intervention. METHODS AND ANALYSIS: A stepped-wedge cluster randomised trial of a gatekeeper intervention is being conducted in rural Sri Lanka with a population of approximately 2.7 million. The gatekeeper intervention is being introduced into 70 administrative divisions in random order at each of 30 steps over a 40-month period. The primary outcome is the number of pesticide self-poisoning cases identified from surveillance of hospitals and police stations. Secondary outcomes include: number of self-poisoning cases using pesticides purchased within the previous 24 hours, total number of all forms of self-harm and suicides. Intervention effectiveness will be estimated by comparing outcome measures between the pretraining and post-training periods across the divisions in the study area. The original study protocol has been adapted as necessary in light of the impact of the COVID-19. ETHICS AND DISSEMINATION: The Ethical Review Committee of the Faculty of Medicine and Allied Sciences, Rajarata University, Sri Lanka (ERC/2018/30), and the ACCORD Medical Research Ethics Committee, Edinburgh University (18-HV-053) approved the study. Results will be disseminated in scientific peer-reviewed journals. TRIAL REGISTRATION NUMBER: SLCTR/2019/006, U1111-1220-8046.

Importance of pesticides for lethal poisoning in India during 1999 to 2018: a systematic review.

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.

Suicide by pesticide ingestion in Nepal and the impact of pesticide regulation.

BACKGROUND: Nepal recorded 5754 suicides in 2018-19 - a high number for a relatively small country. Over 24% of these suicides were by poisoning, most by ingestion of highly concentrated agricultural pesticides. Nepal has actively regulated pesticides to reduce their health impacts since 2001. We aimed to analyse Nepal's history of pesticide regulation, pesticides responsible for poisonings, and relate them to national suicide rates. METHODS: Information on pesticide regulation was collected from the Plant Quarantine and Pesticide Management Centre of the Ministry of Agriculture and Livestock Development. National data on suicides from 1980 to 2019 were obtained from the National Statistical Bureau and Nepal Police. Data on the pesticides responsible for self-poisoning and pesticide suicides over time were obtained from a systematic literature review. RESULTS: As of June 2020, 171 pesticides were registered for use in Nepal, of which one was extremely hazardous (WHO Class Ia), one other highly hazardous (WHO Class Ib), and 71 moderately hazardous (WHO Class II). Twenty-four pesticides have been banned since 2001, with eight (including five WHO Class I compounds) banned in 2019. Although the suicide rate has increased more than twelve-fold since 1980, particularly for hanging (15-fold increase from 1980 to 2018), fatal pesticide self-poisoning has increased by 13-fold. Methyl-parathion is reported to be the key pesticide responsible for pesticide self-poisoning in Nepal, despite being banned in 2006. CONCLUSION: The full effect of the recent pesticide policy reform in Nepal remains to be seen. Our analysis shows a continuing increase in suicide numbers, despite bans of the most important pesticide in 2006. This may indicate smuggling across the border and the use of the brand name (Metacid) for pesticides in general making it difficult to identify the responsible pesticide. More information is required from forensic toxicology labs that identify the individual compounds found. The effect of recent bans of common suicide pesticides needs to be monitored over the coming years. Evidence from other Asian countries suggests that HHPs bans will lead to a marked reduction in suicides, as well as fewer cases of occupational poisoning.

How many premature deaths from pesticide suicide have occurred since the agricultural Green Revolution?

Introduction: The agricultural Green Revolution in the 1950s and 60s is thought to have averted many deaths from famine. However, it also introduced highly hazardous pesticides such as parathion and endrin into poor rural communities that were totally unequipped to store or use them safely. Pesticide self-poisoning rapidly became one of the two most common global means of suicide. Thus far, no attempt has been made to enumerate the total number of deaths that have occurred subsequent to the Green Revolution.Objective: To calculate plausible estimates for the total global number of pesticide suicides that have occurred since 1960.Methods: We performed a literature review on Medline and Embase databases to July 2019 to find papers that reported national or global numbers of pesticide suicides. We restricted our search to papers published in English. We used the search terms: pesticide) OR insecticide) OR paraquat) OR organophosphate) OR organophosphorus) OR agrochemical) AND suicide) OR "") OR deliberate) AND poison in all fields. These searches identified 2,144 papers; a further 8 citations were added through the searching of reference lists and our own paper collections. 2,136 papers were excluded as they contained no data on pesticide suicide, or were case reports, case series, or related to specific socio-demographic groups, or were non-human studies. This left 16 papers giving country specific or global pesticide suicide data.Long-term national trend in pesticide suicides: We found studies from one low- and middle-income country (Sri Lanka) that recorded long-term trends in suicide throughout the Green Revolution. These data showed a steady increase in suicides from 1960 to the early 1970s, with a more rapid increase from 1979 to 1984. The number of suicides plateaued until 1995, when they started a steady almost linear decrease that has continued at least until 2015. We used the Sri Lankan epidemiology as a model of the incidence of pesticide suicides in other low- and middle-income countries. Data from Bangladesh suggested that the decrease might have started in 2002.Estimating global numbers since 1960: Starting from a conservative estimate of zero deaths in 1960, the best estimate of the total global burden of pesticide suicides from 1960 to 2018 is 14,272,105 or 14,936,000 (depending on whether a fall in incidence began in 1995 or 2002), with a plausible range of 9,859,667 to 17,303,333 deaths. These are likely underestimates because suicide is illegal in many countries, and most pesticide suicides occur in poor rural areas without effective death registration systems.Conclusions: Pesticide self-poisoning has been a major clinical and public health problem in rural Asia for decades, while being long ignored. Most pesticide suicides are relatively impulsive with little planning: in the absence of highly hazardous pesticides, many people would have survived their suicidal impulse, gone on to find support amongst family, community, and health services, and lived a full life. Pesticide suicides must therefore be considered a category 4 occupation condition following Schilling's classification - if they had not been brought into rural communities for agricultural use, pesticide suicides would not have occurred. Preventing these deaths should be a global public health priority.