20171023 Suicide by Pesticide Poisoning: a Priority for Suicide Prevention by Prof. David Gunnell

Suicide by pesticide poisoning: a priority for suicide prevention

Professor David Gunnell FMedSci University of Bristol, UK

Population Health Sciences

Think of a 15 year old girl you know…..


(source: Eddleston and Phillips BMJ 2004)

A 15 year old girl drank 20% paraquat after an argument and fight with her 11 year old brother… She told doctors she had not known it was paraquat and in her distress had simply grabbed the nearest bottle in the house and drunk it. She died from cardio-respiratory arrest 2 days after admission.

Now imagine this was her……


100,000 people


Outline• Background – epidemiology, industry involvement

and prevention approaches• The evidenceRegulation – bansRegulation - sales regulationLocked boxes

• Impact on crop yields


Source: FAO statistics http://www.fao.org/faostat/en/#data/RT[accessed 12 June 2017]

Market projected to be worth US ($) 71 billion by 2018

Trends in global pesticide imports 1990-2014 (US $(1000))


Source: FAO statisticshttp://www.fao.org/faostat/en/#data/RT

[accessed 6 October 2017]

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Trends in pesticide imports 1990-2014, Taiwan

Pesticides


1 in 5-7 of all suicides worldwide 110,000-168,000 deaths per year

Over 1 million deaths in the last decade.

In 2016 in Taiwan pesticides accounted for 467 (12.4%) suicides

Mostly in low and middle income countries


Global burden of pesticide poisoning mortality: systematic review

Easy access to pesticides for self-poisoning


來源：全國自殺防治中心

2012 全球平均world average: 11.4 per 100,000

83-105年全國自殺死亡人數 / 死亡率Number and rate of suicide in Taiwan, 1994-2016

105年自殺人數：3765人自殺，增加90人105年標準化自殺率：12.3/10萬人，增加1.7%There were 3765 suicides in 2016 (a rise of 90 over 2015) and suicide rate was 12.3 per 100,000 (a 1.7% rise compared to 2015)

Number of suicideCrude rate

Age-stand. rate

1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

Thanks to Shu-Sen Chang for slide

507 480 484537 493 475 494 483 478 462 448 466 468 479 467

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每年自殺人數依方法別 2002-2016

Number of suicide by method(1) 上吊 hanging

(2) 燒炭 charcoal

(3) 農藥

pesticide(4) 墜落 fall

(5) 溺水 drowning

農藥中毒是第三位自殺方式

Pesticide poisoning is the third common suicide method

來源：衛生福利部

105年：農藥自殺467人，占全部自殺12.4%巴拉刈是主要致死農藥，造成194人死亡每19名自殺當中就有一人死於巴拉刈中毒There were 467 pesticide suicides in 2016, accounting for 12.4% of total suicides.Paraquat was the main pesticide involved, accounting for 194 suicides or one in 19 of all suicides.


There are huge differences in toxicity / case fatality for different pesticides

• Paraquat >50%• Aluminium Phosphide >50%

• Organophosphate/ organochlorine and other pesticides

• Monocrotofos 35%• Endosulfan 28%• Chlorpyrifos 8%• Glyphosate 2%• Carbofuran 1%

• Paracetamol (acetaminophen) <0.5%

Sources: Ganeshamoorthy 1985; Siwach 1988; Eddleston 2005; Rao 2005; Gunnell 1997 , Dawson 2010


Commonest substance No. hospital No. deathsin self-poisoning admissions per year per year

England Paracetamol 40,000 100

Sri Lanka Pesticides 20,000 2,000

Gunnell et al 1996; Roberts et al 2003

Most frequently ingested poisons: England and Sri Lanka


Approaches to prevention

Regulation: • Outright ban• Sales restrictions (reduced concentration / limit availability to particular occupations / licenced purchasers)

Safe storage (lockable boxes / village stores);



Restricting access to commonly used, high-lethality suicide methods leads to falls in overall suicides

UK domestic gas: % of carbon monoxide in domestic gas: UK 1955-74

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Kreitman N Brit. J. Prev. Soc. Med. (1976), 30, 86-93

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Evidence from the UK and USA


England & Wales: sex-specific suicide rates by mode of death

Kreitman N Brit. J. Prev. Soc. Med. (1976)30,86-93

Male Female

Total: all methods

Total: all methodsNon-carbon monoxide

Non-carbon monoxide

Carbon monoxide Carbon monoxide

year

Suicide rate

year


Access to methods: account of suicide attempt by Jerry Lewis

He was preparing to kill himself and feeling for the trigger of his gun when “Thank God I heard my children laughing and running through the hall. That snapped me out of it. The suicide impulse lasted only a moment – but that’s all it takes.”

(source: Farmer RDT 1988)


Age-adjusted suicide rates by mechanism, United States vs. New Jersey, 1999 – 2001 (Hempstead, 2006)

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WHO, 2014Key messages (page 9)…

“An effective strategy for preventing suicides and suicide attempts is to restrict access to the most common means including pesticides, firearms and certain medications.”


Should the most toxic pesticides be banned?


Challenge to banning pesticides – influence of pesticide manufacturers

Pesticide industry influence

• Regular meets with Government Agricultural extension services (provide farmer education) to encourage upscaling their preferred approaches

• Funding researchers and influential bodies• Free distribution of locked boxes (sometimes without padlocks)• Production of promotional videos encouraging the use of locked boxes• Co-funding workshops at suicide prevention conferences focusing on boxes• Focus on challenges of regulation – black market / substitution


Dilemmas in preventing suicides by pesticide poisoning

•Is it possible to enforce sales bans / regulations?•Are safe storage/locked box approaches effective and sustainable?•Will ‘method substitution’ occur to more lethal methods of suicide?•Will changes in pesticide use impact on crop yield?


The evidence: bans and sales regulations


Systematic review: Lancet Global Health 2017


Findings….

• Identified 27 studies carried out in sixteen countries.

• Impact of bans evaluated in 6 countries (South Korea,Taiwan, Greece, Jordan, Sri Lanka, and Bangladesh)

• Impact of sales restrictions evaluated in 5 countries (Denmark, India, Ireland, UK and USA)


Interventions evaluated

• Import or sales ban• Sales restricted to licensed retailers

• Sales restricted to farmers / occupational use

• Non-specific restrictions to sales

• Ban on sale of pesticides in small containers

• Dilution of pesticide concentration


Findings….

• In 5 of the 6 countries where bans studied there were reductions in pesticide suicides and, in three countries, falls in overall suicide mortality.

• Sales restrictions were followed by falls in pesticide suicides in 3 of the 5 countries; impacts on overall suicides unclear.


Impact of paraquat regulation in S Korea: 2011-12

2013 vs 2011•Pesticide suicide mortality halved•Pesticide mortality falls accounted for 56% of the decline in S Korea’s overall suicide decline

Population Health SciencesCha et al Int J Epid 2016

Suicide trends in Sri Lanka: impact of pesticide regulation

Knipe et al Lancet Global Health 2017

Estimated number of deaths Prevented 1995-2015 – 90,000


Suicide and suicide attempt rates in Sri Lanka 1880-2005

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1880 1886 1892 1898 1904 1910 1916 1922 1928 1934 1940 1946 1952 1958 1964 1970 1976 1982 1988 1994 2000


斯里蘭卡禁用劇毒農藥後自殺率下降Trends in suicide in Sri Lanka

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農藥自殺率預測值全部自殺率預測值農藥自殺率實際值全部自殺率實際值

2008-2011禁用三種劇毒農藥Ban on three toxic pesticides

2015年農藥自殺率減少51%(937人)51% drop in pesticide suicides in 2015 (937 deaths avoided)

2011-2015：農藥自殺率下降 50% drop in pesticide suicides 全部自殺率下降 21% drop in overall suicides其它方法自殺率微增 2% rise in other suicides


Trends in “unnatural”deaths in Bangladesh 1996-2014

WHO Class I products banned in 2000.

Other arrows mark timing of other regulations


Paraquat imports and suicide in Western Samoa 1956-1988 (Bowles 1995)

Year


"Bureau of Animal and Plant Health Inspection and Quarantine formally announced the schedule to ban two pesticide products containing paraquat.“ (5th Oct 2017)

Bureau of Animal and Plant Health Inspection and Quarantine, Council of Agriculture, Taiwan. (2017-10-05). from http://www.baphiq.gov.tw/view_news.php?id=13445.


http://www.baphiq.gov.tw/view_news.php?id=13445

UN Sustainable Development Goals (SDG)

Suicide rate is a SDG indicator (3.4.2) Population Health Sciences

3. The evidence: locked boxes


1. Rural China• 2 intervention (received boxes) and 8

control townships. Use promoted every 6 months

2. Rural Sri Lanka• Lock boxes issued to all farming

households (570) in in 2 villages; two control villages

3. Tamil Nadu, India• Locked central storage facility in two

villages; two control villages


RCT evidence: Pearson et al Lancet 2017

53,000 households, (223,000 people)

•Over 3 years follow-up the incidence of pesticide self-poisoning (RR 0.93, 95%CI 0.80, 1.08) and overall suicide (RR 1.22, 95%CI 0.88 to 1.68) did not differ between intervention and control villages


Challenges with lock boxes:•Highlight whereabouts of

Pesticides•Many kept unlocked (75-80%

in China in year 2) (WHO 2016)•Increased access to pesticides

in the home•Non-sustainable: boxes &

locks need replacing


4. Do bans affect crop yields?


Manuweera et al 2008

Yields of cereals, pulses and roots/tubers in South Asian countries between 1980 - 2005


Cereals

1980 1985 1990 1995 2000 20050

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BangladeshIndiaPakistanSri Lanka

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/hec

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Yields of cereals, pulses and roots/tubers in South Asian countries between 1980 - 2005


禁用劇毒農藥沒有影響農作產量Sri Lanka’s 2008-2011 bans on 3 pesticides: no

evidence for an impact on crop yield

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2008-2011禁用三種劇毒農藥Ban on three toxic pesticides

Conclusions• 110,000 + suicides from pesticide poisoning per year• In Taiwan Pesticides account for 12.4% of suicides; paraquat is the

main pesticide involved • Bans appear to be most effective approach – if target key pesticides

(frequent use / high mortality)• No evidence of significant substitution • No evidence of impact on crop yield• The recently announced ban on the two registered paraquat

formulations has potential to substantially reduce suicide in Taiwan


Think of a 15 year old girl you know…..


Acknowledgements

Bristol: Dee Knipe, Chris Metcalfe, Prianka PadmanathanEdinburgh: Michael Eddleston, Melissa PearsonDenmark: Flemming KonradsenSri Lanka: Ravindra Fernando Taiwan: Shu-Sen ChangCanada: Emma MewChina: Michael Phillips, Shiwei LiuSouth Korea: Won-Jin Lee, Eun Shil ChaAustralia: Andrew Page


THANK YOU谢谢

David Gunnell University of Bristol, UK

[email protected] Health Sciences

http://upload.wikimedia.org/wikipedia/commons/c/c0/Clifton.bridge.longview.750pix.jpg

WHO region % suicides due to pesticides Estimated no. pesticide suicides

Africa (LMIC) 3.5% 2,100

Americas (LMIC) 8.8% 3,100

E Mediterranean (LMIC) 7.1% 2,100

European (LMIC) 0.9% 300

SE Asia (LMIC) 11.3% 35,500

W Pacific (LMIC) 48.3% 63,300

All High Income Countries 1.7% 3,300

WORLD TOTAL 13.7% 109,700


20171023 Suicide by Pesticide Poisoning: a Priority for Suicide Prevention by Prof. David Gunnell

Government & Nonprofit

Transcript of 20171023 Suicide by Pesticide Poisoning: a Priority for Suicide Prevention by Prof. David Gunnell