Pesticide intoxications in Cukurova,Turkey: three years analysis

Introduction

The Cukurova region is the most important agricultural area and is responsible for 32% pesticide use in Turkey. As a consequence of this wide pesticide use, acute pesticide poisoning cases are quite common in this region. These poisonings are generally suicidal self-poisonings; however, they can be accidental or homicidal as well. Exposure to pesticides might occur via oral intake within the home environment while occupational expose occurs via dermal contact and inhalation. Due to the ease of pesticide accessibility, hundreds of suicidal ingestion is encountered in rural areas. ¹ Accidental pesticide poisonings might also occur due to inappropriate storage and consequent contamination with food and kitchen equipment.

The most important pesticide groups, with regard to acute poisoning globally, are organochlorines (OC), organophoshates (OP), and carbamates. Today, most OC insecticides are banned or severely restricted in developing countries. ² OC poisoning is not common today, with the exception of endosulfan, which is an acknowledged cause of severe and fatal poisoning in developing countries such as India, ³ Sri Lanka ⁴ and South Korea. ⁵

This retrospective analysis was aimed to determine demographic features and general characteristics of cases of death due to pesticide poisoning, in the Cukurova region.

Methods

The autopsy records of the Adana Group Authority of the Council of Forensic Medicine (Adana Group), between 2006 and 2008, were evaluated retrospectively. Pesticides were studied in biological samples by gas chromatography-mass spectrometry (GC-MS; Agilent 6890 GC and 5973 MS, USA), ⁶ gas chromatography-electron capture detector (GC-ECD; Perkin Elmer Autosystem XL, USA), ⁷ and gas chromatography-nitrogen phosphorus detector (GC-NPD; Perkin Elmer Autosystem XL, USA). ⁸ Deaths that were attributed to pesticide poisoning were included in the scope of the study in order to identify the type of pesticide, as well as the etiology with related demographic properties. The frequency and distribution of intoxications were also analyzed in terms of sex and age.

Results

As a routine procedure, pesticides are examined in biological samples that underwent a toxicological examination in the toxicology laboratory of the Adana Group. The total number of requests for toxicological analyses of pesticides to the Forensic Toxicology Laboratory of the Adana Group between 2006 and 2008 was 4199. In 2006, 30 cases (2.11% of the 1418 analyses) revealed intoxications. Of these, 16 (53.33%) were from male individuals and 14 (46.67%) from female. In 2007, 20 cases (1.55% of the 1293 cases) showed intoxications and 9 (45.0%) of these were from male individuals while 11 (55.0%) from female. In 2008, 22 (1.48% of the 1488 analyses) cases confirmed intoxications, of which 17 (77.27%) were from male individuals, and 5 (22.73%) from female (Table 1).

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Table 1.

Number of pesticide analysis requests between 2006 and 2008 and the corresponding number of confirmed pesticide cases

Year	Analysis requests	Positive cases
		Total, n (%)	Male, n (%)	Female, n (%)
2006	1418	30 (2.11)	16 (53.33)	14 (46.67)
2007	1293	20 (1.55)	9 (45.00)	11 (55.00)
2008	1488	22 (1.48)	17 (77.27)	5 (22.73)
Total	4199	72 (1.71)	42 (58.33)	30 (41.67)

Out of all pesticide-positive cases (n = 72) 13.89% had undergone therapeutic process in a hospital. From the total number of requested pesticide analyses between 2006 and 2008, the majority of deaths due to pesticide poisonings (n = 37, 51.38%) were suicidal, while 17 (23.61%) of them were accidental. However, there was no information about the cause of the incident in 18 (25.01%) of the requests (Figure 1).

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Figure 1.

Origin of pesticide intoxication cases between 2006 and 2008.

Of all pesticide-positive cases, 58.33% were male while 41.67% were female (Table 1). Age and sex distribution of the positive cases is presented in Figure 2. The mean age of cases was 38.8 ± 20.6 (mean ± SD) years. The highest frequency of poisoning was found in the age group of 21–30 years. The number of female cases was higher than males in the 11–20 age group, while number of males was significantly higher among cases over 51 years of age.

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Figure 2.

Age and sex distribution of the total positive pesticide cases between 2006 and 2008.

The total number of pesticides detected by the toxicological analysis is presented in Table 2. Among the inspected pesticides, endosulfan was found to be the most common with a percentage of 47.2%, followed by an organophosphorus insecticide dichlorvos with 16.7% of cases. Other detected pesticides were chlorpyrifos, aldicarb, diazinon and methyl parathion.

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Table 2.

Detected pesticides in fatal pesticide poisoning cases between 2006 and 2008

Detected pesticide	Year
	2006	2007	2008	Total
Endosulfan	12	13	9	34
Dichlorvos	4	6	2	12
Chlorpyrifos	3	–	1	4
Diazinon	–	–	2	2
Methyl parathion	1	–	2	3
Aldicarb	3	–	1	4
Aluminium phosphide	2	–	1	3
Methidathion	1	–	–	1
Monocrotophos	2	–	–	2
Phenoxy	1	–	–	1
Thiocarbamic acid ester	1	–	–	1
Methomyl	–	1	–	1
Carbofuran	–	–	2	2
Lambda-cyhalothrin	–	–	1	1
DNOC a	–	–	1	1
Total	30	20	22	72

^a DNOC: 4,6-dinitro-ortho-cresol.

Data from the Forensic Toxicology Laboratory of Adana Group shows that endosulfan intoxication remains as a significant cause of death in the Cukurova region.

Discussion

Acute pesticides poisoning remains a considerable cause of morbidity and mortality in developing countries. It has been estimated that around 3 million severe cases of acute pesticide poisoning occur, with 220,000 deaths annually. ⁹ In developing countries, where there is insufficient regulation, lack of surveillance systems, less enforcement, lack of training, inadequate access to information systems, poorly maintained or nonexistent personal protective equipment, and larger agriculturally based populations, the incidences are expected to be higher. ¹⁰

A study performed by Ministry of Justice, Directorate of the Council of Forensic Medicine, between 1997 and 2001, revealed that of 3990 cases of intoxication 849 were due to pesticides. In that study, 55% of cases were female while 45% were male, with a suicidal frequency of 75% for all genders. In a study previously conducted by Salacin et al., ¹¹ 343 (68%) deaths due to pesticide intoxications revealed that 60% of cases were suicidal self-intoxication and 52% of cases were young adult females. However, the present study showed a male predominance with 58.33% of cases, which might be a consequence of higher ratio of male agricultural workers in our region.

In accordance with the related literature, the most affected age group was 21–30 years (Figure 2) with a male predominance in this age group, which might indicate vulnerability of young adults.

In this study, the ratio of suicidal intoxication (51.30%) was higher than the accidental intoxication cases, which was supported by previous studies.^11,12 Parron et al. ¹³ stated that the incidence and circumstances of self-poisoning by pesticides are largely unknown due to lack of research and were the first one to investigate all suicides occurring in an intensive agricultural area with significant use of pesticides, accounting for 56.1% of the total. Pesticides have emerged as agents for choice to commit suicide, especially in the younger age group because it is cheap, easily available and highly lethal. The high ratio of suicidal deaths due to pesticides might be a consequence of easy availability and accessibility of uncontrolled pesticides in households in city centers as well as in villages in the countryside. On the other hand, in our region, inhabitants often have grape trees in their backyard, that need endosulfan to control pests. Many households have stocks of endosulfan readily available for impulsive acts. Storage facilities and knowledge concerning pesticide toxicity are frequently poor.

With respect to the 3 years (2006–2008) analyzed in this paper, we can see that endosulfan still remains as the most important class of pesticides detected in forensic intoxications, representing 47.2% of the total positive cases, followed by organophosphorus pesticides, with 30.55% of all. Teixeira et al. ¹⁴ reported 111 positive cases out of 639 alleged pesticide intoxication between 2000 and 2002, in Portugal. Organophosphorus was the most common group among pesticide positive cases, in Teixeira et al. Additionally, Soltaninejad et al. ¹⁵ reported 51 positive cases out of 3885 autopsies with the predominance of aluminum phosphide positivity.

The present study found that endosulfan is the most commonly exposed pesticide as it was detected in 34 of the 72 positive cases. Because of the high intoxication rate with endosulfan, the use of it has been restricted since 1985, in Turkey. ¹⁶ Accidental and suicidal poisonings with endosulfan have been reported.^17–20 Organochlorine pesticides are highly toxic compounds that are responsible for a number of severe intoxications in Turkey, with several deaths.^21–23 Thus, during last 3 years, endosulfan, a banned pesticide in the USA and Europe, caused several intoxication cases in our region.

Among less toxic pesticides, organophosphorus, comprising 30.55% of the positive cases, dichlorvos was the most commonly detected pesticide, followed by chlorpyrifos and methyl parathion (Table 2).

In conclusion, this report showed that endosulfan is commonly used in the Cukurova region. Moreover, frequency of acute and chronic exposure to endosulfan is considerably high in Cukurova. Recently, strict regulations have been enacted for restricting and controlling the use of endosulfan, a charge from usage previously allowed. Furthermore, authorities should set more efficient educational facilities for agricultural workers in order to reduce the number of accidental pesticide poisonings. Profound changes in international and national agricultural policies, steering towards sustainable agriculture based on non-chemical pest management are, in our opinion, the main way to reduce poisonings.