Paraquat poisoning in the Caribbean

calendar year 1985 have reportedly been polio-free during the first 40 weeks of 1986; these countries are Argentina, Canada, the Dominican Republic, Ecuador, Paraguay, and the United States. One country (Bolivia) that re- ported no cases in 1985 has reported three cases during the first 40 weeks of 1986.

Since week 32, which ended on 9 Au- gust, a total of 18 cases have been reported-14 from El Salvador, three from Bolivia, and one from Honduras.

Laboratory results obtained with spec- imens taken from cases in Bolivia and Venezuela indicate that these cases were caused by type 3 poliovirus. Type 3 has also proved responsible for 7 1% of the cases in Brazil for which laboratory data are available (see page 403). These findings strongly suggest an increase in the circulation of type 3 po- liovirus in the Region.

Source: Pan American Health Organization, EPI Neudetter 8(5):1. 1986.

P

Paraquat, one of over 150 pesticides currently in use in the English-speaking Caribbean, has been gaining impor- tance as the main agent responsible for accidental or intentional poisoning since its introduction in the 1970s. To date, pesticide poisoning has been documented in at least seven Caribbean countries. However, pesticide- related illnesses are often unrecognized and are consequently underreported. Despite that shortcoming, it seems worthwhile to summarize reports recently received from Suriname and Dominica on the paraquat problem.

Suriname

Before 1979, hanging and drinking of full-strength “vinegar” (acetic acid) were the most commonly used suicide methods in Suriname. Beginning in 1980, however, the ingestion of herbi- cides (especially paraquat, also known as Gramoxone) and pesticides in- creased, and in 1981 it became the most frequently used method. During this period suicide by vinegar ingestion dropped sharply-from eight cases in 1979 to three in 1980 and two in 1981-partly because of a government decision to forbid the sale of undiluted acetic acid in stores.

TABLE 1. The numbers of recorded deaths attributed to accidental poisoning, suicide in general, intentional ingestion of agricultural poi- sons, and intentional ingestion of paraquat in Suriname from 1976 through 1983.

Suicide deaths resulting Deaths from: from ingestion of:

Accidental All agricultural

Year poisoning Suicide poisons Paraquat

1976 0 33 5 -

1977 2 22 0 -

1978 3 36 -

1979 0 49

1;

-

1980 1 58 17

1981 2 52 33 ::

1982 - 64 - 35

1983a la - - 59a

a Data from two hospitals onl$

not so much by more attempts as by a higher proportion of successful at- tempts resulting from paraquat’s high toxicity.

To obtain more information about in- toxications with paraquat and other pesticides, the Ministry of Health began a multifaceted surveillance effort. The ultimate purpose of this effort was to provide political decision-makers with information and to urge them to im- pose regulations on the distribution and use of agricultural poisons. As of 1984, bottles of paraquat could be seen standing on shelves in general stores, often next to groceries; and paraquat was often sold in soft-drink or beer bottles that carried no warning labels or instructions for proper use.

As part of this surveillance effort, a retrospective study was made of patients with paraquat poisoning who were admitted to Paramaribo’s Academic Hospital in 1983. It was found that there had been 70 such patients. As indicated in Table 2, most of these (76%) were admitted during the second half of the year. Thirty-six (51%) were less than 25 years old. Fifty-five (79%) were East Indians. The male to

TABLE 2. patients admitted to the Academic Hospital in Paramaribo, Suriname, in 1983 with paraquat poisoning and the outcomes of their cases, by period of admis- sion.

Time of admission No. dying No. recovering Total admissions

First half of 1983 19 5 24

Second half of 1983 37 Ii 46

Total 56 (80%) (20%) 70

a Includes five patients wRh cases of accidental paraquat poisoning, none of whom ingested large quantities

female ratio of cases was 2.7 to 1. Six of the cases of paraquat poisoning were known to be accidental, and only one of these was fatal. However, nearly all the other cases (55 of 64) were fatal.

Dominica

Twenty-seven deaths attributed to paraquat poisoning occurred in Dominica during the period from January 1980 through September 1984. Fifteen of these deaths (56%) were suicides, four were accidental, four occurred in uncertain circumstances, and in four cases the relevant records could not be located. The male : female ratio was 3 to 1. Cases were geographically distributed throughout the island with some clustering in the farming areas. In at least five cases (2 1% ) the drinking of paraquat was preceded by alcohol ingestion.

Since 1979 there has been an increase in the quantity of agricultural chemicals being used, partly because of an intense demand for increased crop production. Until the end of 1979 all chemicals were sold by the Division of Agriculture, which has full control over the retailing of most of them. After 1980 some retailers began to distrib- ute certain agricultural poisons. However, the Banana Growers’ Association and the Ministry of Agriculture remained the largest storers and suppliers of chemicals. There is a Pesticide Control Law with regulations governing regis- tration, labeling, recommendations for use, storage, application, residue handling, workers’ experience, and environmental impacts. The work of the Pesticide Control Board has been reviewed, and a Pesticide Inspector has been appointed whose duty is to ensure that the regulations are adhered to. However, the regulations do not cover the retailing of these substances.

Elsewhere, a review of admissions to the San Fernando General Hospital in Trinidad and Tobago from 1972 to

1982 showed that admissions for self-poisoning increased by 5 1% between

1972 and 1982. And while tablets remained the commonest ingested sub- stance, accounting for 32% of the total in 1982, paraquat poisoning had risen from 1.3% of the total in 1972 to 8.6% in 1982 (1).

More generally, a recent review of acute pesticide poisoning in the Caribbean (2) has shed some additional light on usage problems and risks for the population.

The true extent of pesticide intoxica- tion and the identities of the groups at increased risk should be defined for each country on the basis of epidemiologic studies. Such data will benefit decision-makers seeking to develop a proper broad-based strategy of pesti- cide management. In this regard, health personnel capable of appropriately recognizing and documenting acute and chronic cases of pesticide poisoning have a major responsibility. Indeed, some Caribbean countries have sought

improved pesticide management by adopting an interdisciplinary ‘agromed- ical’ approach, and suggestions have also been made that a Caribbean poison center or a Caribbean pesticide surveillance unit should be established.

References

1 Rabaman, R., and T. Poon-King. Paraquat as a cause of self-poisoning in South Trinidad (1972-1982). West Indian Mea’J 32(suppl):37-38, 1984.

2 Singh, P D. A., and P. West. Acute pesticide poisoning in the Caribbean. west Indian Mea’ J 34~75, 1985.

Sources: Caribbean Epidemiology Center, CAREC Surveillance Report 12( l(2): l-9, 1986; and Pan Ameri- can Health Organization, Epia’emro/ogicd Bdetin 7(1):11-13, 1986.

T

A SITU~ON ANALYSIS

Diseases

Caused by Tobacco Use

Tobacco smoking is a major avoidable cause of ill health and premature mortality in countries where it is wide- spread. It is responsible for about 90% of all lung cancer cases, 75 % of all chronic bronchitis and emphysema cases, and 25 % of all ischemic heart dis- ease cases among men under 65 years old (1). An estimated one-third of all cancer cases are related to tobacco use.

Calculations indicate that at least one million premature deaths occur yearly worldwide because of tobacco use (2). In the United States, some 25 % of all deaths can be attributed to the conse- quences of smoking, compared with 5 % linked to alcohol and 2% to use of other addictive substances (3). Smoking-related diseases account for over

30% of all deaths in Cuba (4), and for about 15-20% in the United King- dom (J-7). According to a report of the Royal College of Physicians, the extent of the problem is such that of 1,000 young male adults in England and Wales who smoke cigarettes, an average of one will be murdered, six will be killed on the roads, and 250 will die prematurely of tobacco-related diseases (7).