The global distribution of fatal pesticide self-poisoning: Systematic review
David Gunnell
1
2
Michael Eddleston
0
1
Michael R Phillips
4
5
6
Flemming Konradsen
1
3
0
Scottish Poisons Information Bureau, University of Edinburgh
,
Edinburgh
,
UK
1
South Asian Clinical Toxicology Research Collaboration (SACTRC)
2
Department of Social Medicine, University of Bristol
,
Bristol
,
UK
3
Department of International Health, University of Copenhagen
,
Copenhagen
,
Denmark
4
Department of Epidemiology, Columbia University
,
New York
,
USA
5
Department of Psychiatry, Columbia University
,
New York
,
USA
6
Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital
,
Beijing
,
China
Background: Evidence is accumulating that pesticide self-poisoning is one of the most commonly used methods of suicide worldwide, but the magnitude of the problem and the global distribution of these deaths is unknown. Methods: We have systematically reviewed the worldwide literature to estimate the number of pesticide suicides in each of the World Health Organisation's six regions and the global burden of fatal self-poisoning with pesticides. We used the following data sources: Medline, EMBASE and psycINFO (1990-2007), papers cited in publications retrieved, the worldwide web (using Google) and our personal collections of papers and books. Our aim was to identify papers enabling us to estimate the proportion of a country's suicides due to pesticide self-poisoning. Results: We conservatively estimate that there are 258,234 (plausible range 233,997 to 325,907) deaths from pesticide self-poisoning worldwide each year, accounting for 30% (range 27% to 37%) of suicides globally. Official data from India probably underestimate the incidence of suicides; applying evidence-based corrections to India's official data, our estimate for world suicides using pesticides increases to 371,594 (range 347,357 to 439,267). The proportion of all suicides using pesticides varies from 4% in the European Region to over 50% in the Western Pacific Region but this proportion is not concordant with the volume of pesticides sold in each region; it is the pattern of pesticide use and the toxicity of the products, not the quantity used, that influences the likelihood they will be used in acts of fatal self-harm. Conclusion: Pesticide self-poisoning accounts for about one-third of the world's suicides. Epidemiological and toxicological data suggest that many of these deaths might be prevented if (a) the use of pesticides most toxic to humans was restricted, (b) pesticides could be safely stored in rural communities, and (c) the accessibility and quality of care for poisoning could be improved.
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Background
The World Health Organisation (WHO) estimated that
there were 873,000 suicides worldwide in 2002[1] which
makes suicide a major cause of premature mortality
globally. A central component of suicide prevention
strategies is restricting access to lethal means [2]; this is because
impulsive acts of self-harm in persons with a low intent to
die may, nevertheless, be fatal if high-lethality methods
are easily accessible [3,4]. It is therefore important to
identify the most commonly used methods of suicide
worldwide both to formulate appropriate strategies for
restricting access to highly-lethal methods and to improve
the ability of health care systems to effectively treat
individuals who use these methods
Based on studies carried out in Sri Lanka, in 1984
Jeyaratnam estimated there were 220,000 pesticide related
deaths every year worldwide, most of which were suicides
[5]. Recent extrapolations of data from a few countries in
Asia suggest that there may be 300,000 suicides by
deliberate ingestion of pesticides annually in this region
alone[6,7]. The WHO reports that pesticides are now the
most common method of suicide worldwide[8].
The most likely explanation for the high numbers of
pesticide suicides in developing countries is the high case
fatality associated with pesticide ingestion compared to
the relatively low case fatality of many of the substances
commonly taken in acts of self-poisoning in the West. For
example case fatality among persons admitted to hospital
for treatment of self-poisoning in England and Wales is
<0.5% [9] but in rural areas of Sri Lanka it is 7%[10].
Selfpoisoning with some commonly used pesticides is
particularly lethal case-fatality following paraquat and
aluminium phosphide ingestion is in excess of 70% [11,12].
To date efforts to estimate the international burden of
pesticide suicides have been based on relatively crude
extrapolations from studies carried out in one or two
countries[5-7]. The aim of this paper is to systematically
review the world literature on the use of pesticides for
suicide and, using the data retrieved, to estimate the number
of pesticide suicides worldwide and in each of the WHO's
six regions. For the purpose of this review we define
pesticides as chemical products used for the control of
unwanted animals, plants and fungi primarily
rodenticides, insecticides, weedi (...truncated)