Pattern and outcome of acute organophosphate poisoning at health facilities of Harari Region,Eastern Ethiopia

Abstract

Introduction:

Pesticides are frequently used by plant cultivars to control pests that could affect yield. Although many local farmers in Eastern Ethiopia use organophosphate insecticides extensively for the production of khat, the pattern and treatment outcome of acute poisoning of these organophosphates has been poorly quantified and reported in this region.

Materials and Method:

A cross-sectional study design was employed at two public hospitals found in Harari region, Ethiopia. The data were collected through face-to-face interviews and card review, then analyzed with SPSS version 20. Pearson’s Chi-square test was used to compare independent variables with the treatment outcome. Statistical significance is defined at 95% confidence interval of odds ratio not including 1 or p < 0.05.

Results:

A total of 135 cases of organophosphate were admitted in the emergency departments of the hospitals during the study period. 42.2% of participants were adolescents (age: 11–20 years) while the mean age of all participants was 18.8 ± 12.9 years with a range of 1–61 years. 73.7% of the study participants were rural residents. The result showed that 47.4% of the cases were exposed to the poison accidentally. Family disharmony was the common reason among cases poisoned intentionally. The mean time elapsed between poisoning and reaching the health facility was 3.1 h. Atropine was administered for 47% of the cases. About 11% of cases expired following the poison. The home remedy given, lag time, and residency were found to be factors significantly related to poor treatment outcomes.

Conclusion:

Easy availability, low cost, and excessive popularity of organophosphate use as pesticides in Eastern Ethiopia have increased the incidence of ingestion, resulting in increasing intentional and unintentional poisoning. In the present study, accidental exposure accounts for 47.4%.

Keywords

Acute poisoning Harar khat organophosphate pesticide treatment outcome

Introduction

Plant cultivars commonly use pesticides to control the pests that are potentially affecting the yield. Organophosphate (OP) pesticide are a class of substances frequently encountered in agro-industrial settings despite their deleterious effecon human health.^1,2 Organophosphate poisoning (OPP) is a poisoning due to OPs, which are compounds containing carbon and phosphorous acid derivatives. OPs are potent inhibitors of acetylcholinesterase (ACE) that can cause severe cholinergic toxicity after dermal contact, inhalation, and ingestion.³ Chlorpyrifos, parathion, diazinon, dichlorvos, tetrachlorvinphos, fenitrothion, and azinphos-methy are among the frequently used OPs.⁴ It is one of the leading causes of emergency hospitalization.⁵

The diagnosis of OPP is made through history of the poisoning, clinical manifestations, smell of the pesticide and laboratory evaluation of plasma cholinesterase.^6–8 It has been reported that early antagonism of OP toxicity is associated with better outcomes. Patients with markedly depressed mental status require 100% oxygen and immediate endotracheal intubation. Additionally, atropine and oxime therapy are administrated for patients with cholinergic toxicity. Upon achieving airway protection, placement of a nasogastric tube and a gastric lavage is indicated if a large volume of OP is suspected, and the patient presents within 1–2 h. following ingestion.^9,10 Nevertheless, OPs have been classified as highly toxic pesticides by World Health Organization, whereas, developing countries like Ethiopia are still widely using them due to the low cost and easy availability of OPs.¹¹ According to reports,¹² around 3 million individuals globally are exposed to OPs annually, resulting in a death rate of 300,000 each year. Research has indicated that in developing nations with underdeveloped healthcare systems and higher populations dependent on agriculture, a higher incidence rate is anticipated.¹³

According to reports from different parts of Ethiopia, OPP is a leading cause of poisoning. In Addis Ababa, a retrospective study found that OP was the second most common cause of poisoning (with a magnitude of 21.6%), and it was also the cause of most deaths.¹⁴ In contrast, a 4-year retrospective study on acute OPP patterns at the University of Gondar Teaching Hospital in Northwest Ethiopia found that acute OPP accounted for approximately 38.4% of all poisoning-related emergency room admissions.¹⁵ Furthermore, a recent retrospective study carried out in Northeast Ethiopia’s Dessie Referral Hospital revealed that approximately 54% of all poisoning cases are OPP cases.¹⁶ A 2-year retrospective study on acute poisoning done in two hospitals in Ambo City, Western Ethiopia, has reported that 53.7% of poisoning cases were linked to OP.¹⁷ On the other hand, a hospital-based prospective cross-sectional study conducted in four administrative zones, in West Ethiopia identified that 26.8% of poisoning cases were caused by OP pesticides.¹⁸

The eastern part of Ethiopia is the one where khat is highly cultivated. Most of the farmers in this region who grow khat use various pesticides, like malathion, to enhance productivity.¹⁹ Consequently, there would be a high possibility for the interaction of pesticides with farmers. The widespread availability of OP-containing household and occupational products provides significant opportunities for suicidal attempts. OP and other pesticide residue concentrations in khat leaves were found to be greater than the maximum residue level, according to a study conducted in Northwest Ethiopia to assess the level of pesticide exposure and potential health hazards associated with pesticide residues on khat.²⁰ The fresh, uncooked khat leaves in our study area are chewed without any kind of treatment that could lower the leaves’ high content of pesticide residue. This pesticide residue may have both long- and short-term detrimental impacts on health.

Despite the fact that local farmers in Eastern Ethiopia often use OP pesticides for the production of khat, the pattern of acute OPP has not received much attention from the researchers. A recent study at the Hiwot Fana Comprehensive Specialized University Hospital (HFCSUH) in the Harari region of Eastern Ethiopia found that among patients referred to the emergency room for acute poisoning, OP was the most common poisoning agent.⁵ Knowledge about OPP in a certain area of the country would be beneficial for early case detection and treatment, which would lower the rates of death and morbidity. Thus, this study had been carried out to assess the pattern and determinants of treatment outcomes of acute OPP at public hospitals in the Harari region of Eastern Ethiopia. Besides, it would fill the knowledge gap in the field, and enhance the effectiveness of the healthcare system.

Methods

A cross-sectional study design was employed at HFCSUH and Jugol Regional Hospital (JRH), which are found in the Harari region, Eastern Ethiopia, from December 2021 to June 2022. All acute OPP patients admitted to the emergency departments of the selected hospitals during the study period were included in the study. OPP patients who were below 18 years and admitted without their family or guardian, and also who were dead at arrival were excluded from the study.

The data collection questionnaire was developed after reviewing relevant literature^15,18 with necessary adjustments (Table S1). In-person interviews with patients and/or caregivers as well as a review of the patients’ medical records were used to gather data. To assure the quality of the data, a pretest was conducted at Haramaya Hospital on 30 participants, which is the default sample for the pretest.²¹ Moreover, Cronbach’s alpha test (0.8) was done to check the reliability of the questionnaire. In addition, the supervisors and investigators monitored the data collection process, and checked for the completeness and logical consistencies of the collected data and provided appropriate feedbacks. Finally, the data were analyzed using SPSS version 22. Pearson’s Chi-square test of independence was used to determine the association between independent variables and outcome variables. The odds ratio with 95% confidence interval was used for a measure of the strength of the association. Statistical significance was defined at 95% confidence interval of odds ratio not including 1 or p < 0.05.

Ethical clearance was obtained from the Institutional Health Research Ethics Review Committee of College of Health and Medical Sciences at Haramaya University. Informed, voluntary, written, and signed consent was obtained from the head of each hospital and patient. For underage patients, oral assent was obtained, and consent was obtained from their parents.

Operational definitions

Acute OPP: In this study, diagnosis of OPP was done through signs and symptoms and history; in doubtful and denial cases, the typical sign of garlic or petroleum odor in breath, vomitus, or feces was used.

Treatment outcome: If the patient is survived at the time of discharge, it was considered as good treatment outcome, whereas poor treatment outcome was considered if the patient has died before discharge.

Results

Sociodemographic characteristics

A total of 135 patients acutely poisoned with OP were admitted to the emergency department of the selected health facilities during the study period. 42.2% (57) of the study participants were adolescents who were found in the age group of 11–20 years, the mean age of the participants was 18.8 ± 12.9 years, which ranged from 1–61 years. The male participants were 74 (54.8%), with a female-to-male ratio of 1:1.2. The majority (73.5%) of the study participants were rural residents, with urban-to-rural ratio of 1:2.75. About 42.2% of participants were students, followed by farmers at 23.7%. It was observed that 41.4% of the participants had no monthly income (Table 1).

Table 1.

Sociodemographic characteristics and manner of poisoning of OP-poisoned patients at public hospitals of Harari region, Eastern Ethiopia.

Variables	Category	Frequency	Percentage
Age in years	>10	33	24.4
	11–20	57	42.2
	21–30	31	23
	31–40	7	5.2
	<41	7	5.2
Sex	Female	61	45.2
Sex	Male	74	54.8
Residence	Rural	99	73.3
Residence	Urban	36	26.7
Route of administration	Ingestion	96	71.1
	Inhalation	29	21.4
	Unknown	10	7.4
Reason for taking the poison (intentional users)	Family disharmony	53	74.6
	Unplanned pregnancy	7	9.8
	Financial problem	6	8.4
	Others	5	7
Home remedies given	Yes	79	58.5
Home remedies given	No	56	41.5
Remedies given	Milk only	34	43
	Milk and water	27	34
	Milk and soil	4	5
	Traditional medicine	14	17.7

Manner of the poison

OPPs may enter the body through inhalation, ingestion, and dermal routes. Ingestion was the most prevalent route (71.1%) among the poisoned study participants; however, 7.4% of instances involved unknown routes. In terms of the intention of the poison, almost half (47.4%) of the cases included accidental poison exposure. 34.3% of the 64 cases of accidental poisoning were exposed to the poison when the victims were applying pesticides on their farm. The most common cause for intentional users (79.4%) was family disharmony; unintended pregnancy and financial difficulties came in second and third, respectively. Among those who intentionally used the poison, home was the commonest source (85.9%; Figure 1).

Figure 1.

Intention and sources of OPP at public hospitals of Harari region, Eastern Ethiopia.

In the study area, giving home remedies to poisoned patients is a prevalent practice. Before visiting medical institutions, over half (58.5%) of the individuals were given home remedies. Among them, milk was the most often used home remedy (82%). A total of 43% consumed milk alone, while 34% and 5% took milk with water and soil, respectively. With respect to the poison’s frequency, 5.9% of the cases involved exposure to the poison twice (Table 1).

Clinical and therapeutic features

The time elapsed from the poison and hospital arrival ranged from 1 to 7 h. More than half of the cases (57%) arrived at the health facilities 4 h after getting poisoned, with a mean time of 3.1 h. Regarding the level of consciousness, the majority (68.8%) of respondents scored 13–15 (mild) on the Glasgow coma scale and 14.8% of them scored 5–8 (severe).

Based on the patients’ case both pharmacological and non-pharmacological treatments were given. Atropine was given to 47% of the patients to reverse the activity of ACE. Regarding non-pharmacological treatment, in 38.5% of patients who came to health facilities timely, gastric lavage was administrated for decontamination of the poison. Oxygen was also administrated to 23% of the patients with respiratory failure. In the rest of the cases, 33.3% were treated with both oxygen and gastric lavage. Despite being an effective drug for, reversing the effects of OPP, pralidoxime was not available in the study area during the study period, so none of the patients were treated with it (Table 2).

Table 2.

Clinical features of OP-poisoned patients at public hospitals of Harari region, Eastern Ethiopia.

Variable	Catagory	Frequency	Percentage
Time elapsed	⩽4 h	58	42.9
Time elapsed	>4 h	77	57
Glasgow coma scale*	Sever	20	14.8
	Moderate	22	16.2
	Mild	93	68.8
Treatment given	Atropine	64	47
	Maintenance fluid	74	54.8
	Cimetidine	77	57
	Antiacid	31	22.9
	Plasil	39	28.8
Non-pharmacological treatment given	Gastric lavage	52	38.5
	Oxygen	31	23
	Both	45	33.3
Duration of hospital stay	>24 h	94	69
	48 h	20	14.8
	72 h	21	15.5

Patients’ level of consciousness was assessed using Glasgow coma scale.²²

The majority 69% of the cases stayed in the hospitals for more than 24 h with a mean duration of 25 h. The study also assessed if the participants had any comorbid disease, and fortunately, none of them had any known comorbid disease.

Treatment outcome

Treatment outcome was assessed in terms of the status of the patient at the time of discharge (survived and expired). Accordingly, 88.9% of the participants survived while 11.1% expired at the time of discharge (Figure 2).

Figure 2.

Treatment outcome of OP-poisoned patients at public hospitals of Harari region, Eastern Ethiopia.

Factors associated with treatment outcome

To determine the factors associated with treatment outcomes, a Chi-square test had been carried out. Residency, home remedy given, and time elapsed between exposure to the poison and initiation of treatment were factors that had statistically significant association with the treatment outcome (p < 0.05).

In this study, participants were both rural and urban residents. Mortality was significantly higher in patients who came from rural areas (p = 0.048, OR = 3.014; 95% CI: 1.002–9.065). Time elapsed before initiation of treatment was a negatively related factor. The probability of death was lower in patients who initiate treatment before 4 h (p = 0.046, OR 0.333; 95% CI: 0.107–0.986). Mortality was higher in patients who took home remedies before the initiation of treatment (p = 0.35, OR 3.217; 95% CI: 1.034–10.008) (Table 3).

Table 3.

Factors associated with treatment outcome of OP poisoning at public hospitals of Harari region, Eastern Ethiopia.

Variables	Treatment outcome		OR	p-Value
Variables	Death (15)	Resolution (110)	OR	p-Value
Age
⩽20	11	80	1.375 (0.412–4.591)	0.421
⩾20	4	40
Sex
Female	9	52	0.510 (0.171–1.523)	0.172
Male	6	68
Residence
Rural	6	93	3.014 (1.002–9.065)	0.048
Urban	9	27
Frequency of poison
1	14	113	1.153 (0.132–10.075)	0.621
2	1	7
Intention of the poison
Accidental	10	54	0.409 (0.132–1.269)	0.095
Intentional	5	66
Time elapsed
⩽4 h	10	48	0.333 (0.107–0.986)	0.046
>4 h	5	72
Home remedy given
Yes	5	74	3.217 (1.034–10.008)	0.035
No	10	46

Discussion

Developing nations like Ethiopia continue to use OPs for environmental insect management and agricultural pest control because of their widespread availability. Poisoning, both intentional and accidental, became more common when OP substances became widely available and used.⁸ Based on the current study, almost 25% of participants were found in the age group of less than 10 years old. Since children in this age range are unintentionally exposed to the poison, improper handling of the poison at home and elsewhere is evident.¹⁹ The finding of this study is in contrary to the study conducted in Gondar, which found only one occurrence involving children under the age of 14 years.¹⁵ Furthermore, 40% of this study participants were found in the age group of 11–20 years. The majority of teenagers in this age group are students, and in their free time, they typically help their parents in the agricultural field. Thus, they are vulnerable to inhalation of OPs used for pest control. Additionally, teenagers are most ambitious and more vulnerable to various emotional conflicts that may lead them to suicidal attempts at this phase of life.⁸ A study conducted at Haramaya Woreda, which is one of the study areas of this study, reported poor knowledge and practice regarding the proper use, handling, and storage of pesticides among khat-growing farmers.¹⁹ Similarly, another study conducted in Chiro, Eastern Ethiopia, identified low level of awareness regarding pesticide use in the community.²³

In the present study, accidental exposure is responsible for 47.4% of the study participants, which is significantly higher than the studies reported in South India and North Ethiopia.^15,24 The age group of this study participants was one contributing factor to the discrepancy. 24.4% of the study participants were children less than 10 years of age, who all came with accidental exposure. Being a rural resident is the other contributing factor since they have less awareness about poison, which corroborates with studies reported in South Africa and Egypt.^8,25 Family disharmony was the leading cause of suicidal attempts among intentional users of this study, which is in agreement with the study conducted in Gondor, North Ethiopia.¹⁵

It has been reported elsewhere^25–27 that the fatality of OPP ranges from 3%–31%. The mortality rate in the present study was 11% which is comparable with the study reported in South India (14.9%).²⁴ Risk factors associated with mortality in the current study participants are home remedy given (p = 0.035), lag time (p = 0.046), and residency (p = 0.048).

The lag time between the consumption of the poison and initiation of treatment is very crucial in the prognosis of poison, as the speed at which treatment is administered determines the patient’s outcome. Based on the current investigation, individuals who arrived at the hospital 4 h after consuming the poison had a greater mortality rate. It has been reported that OP-poisoned patients start to manifest life-threatening conditions soon after they consume the poison.²⁸ Additionally, a study conducted in India indicated an increased duration of mechanical ventilation in patients with increased lag time.²⁶ Therefore, an increase in lag time results in the worsening of the symptoms and further complications. The finding of this study is in agreement with other reports.^8,26,27

It became evident that receiving home remedies before initiation of treatment was a significantly related factor to mortality. Mortality was higher in patients who received home remedies before they came to the hospitals. Giving home remedies before bringing the poisoned patient to the hospital is common practice in the selected study area as well as in other parts of the world. There was no direct information regarding giving home remedies after acute poisoning of OP. Nevertheless, it is evident that giving a large amount of fluid to dilute the poison or to make the person vomit results in an increase in the rate of emptying into the small bowel where the pesticide is absorbed.²⁹ Furthermore, according to Eyer,³⁰ milk should be avoided after acute exposure to OP as it facilitates absorption of the poison.

The residence of the patients was the other significantly associated factor with mortality. Rural residents have a greater mortality rate than urban ones. This could be due to rural residents often encountering barriers to health care that limit their ability to obtain the care they need. Because most rural individuals have poor levels of education, they are less likely to seek health care when they need it. For patients who live in rural areas, access to medical services presents additional challenges. These are contributing factors to the delay in the initiation of medical treatment for rural residents, which leads to poor treatment outcomes even after they reach the hospitals.³¹

Strength and limitation of the study

The strength of this study includes using of the primary data and employing a prospective type of cross-sectional study for determining the treatment outcomes. Whereas, the delimitation of this study includes a lack of laboratory tests, not predetermined sample size due to the rare cases of the incident which resulted in a small sample size, and not distinguishing the specific type of OP consumed by the patients.

Recommendation

Acute OP poisoning is an emergency case that can be prevented. There is a need for community awareness about OPP, especially in rural areas. Better regulatory control of pesticide handling and use would also reduce the burden of pesticide poisoning. Better care at health facilities would reduce the frequency of acute or chronic complications and the mortality rate. Moreover, establishing separate toxicological centers at hospitals and upgrading health facilities to manage OP poisoning cases would help to provide better care. The authors recommend further investigation of the long-term effect of OPs in low and chronic exposure.

Conclusion

OPP remains a health concern in developing countries like Ethiopia because it affects a productive group of society. As Ethiopia is majorly dependent on agriculture, there is a widespread usage and application of pesticides on farms as well as for pest control at home. Easy availability, low cost, and excessive popularity of OP use as a pesticide have increased the incidence of ingestion, resulting in increasing suicidal and unintentional poisoning. In the present study, accidental exposure accounted for 47.4%, while 2/3 of them were under 20 years old. The mortality rate was found to be 11.1%. Besides, a lag time of greater than 4 h, receiving home remedies, and being a rural resident were found to be factors that are directly associate with mortality.

Supplemental Material

sj-docx-1-smo-10.1177_20503121231216603 – Supplemental material for Pattern and outcome of acute organophosphate poisoning at health facilities of Harari Region, Eastern Ethiopia

Supplemental material, sj-docx-1-smo-10.1177_20503121231216603 for Pattern and outcome of acute organophosphate poisoning at health facilities of Harari Region, Eastern Ethiopia by Barkot Tadesse, Haregeweyn Kibret, Helina Heluf, Sinetibeb Mesfin and Yordanos Alemu in SAGE Open Medicine

Footnotes

Acknowledgements

The authors are very thankful to Haramaya University, particularly to the Office of the Vice President for Research Affairs, and the College of Health and Medical Sciences, for funding this study. We want to express our deep gratitude to the administrators and staff of HFCSH and JRH, data collectors, and study participants.

Authors’ contribution

Barkot Tadesse: Conceptualization, methodology, discussion, and preparation of the original draft article, reviewing, and editing; Haregeweyn Kibret: Methodology, discussion, supervision, editing, and reviewing; Helina Heluf: Methodology, supervision, editing, and reviewing; Sinetibeb Mesfin: Discussion, editing, and reviewing; Yordanos Alemu: Conceptualization, discussion, super vision, and editing.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is supported by Haramaya University (Grant code: HUWG_2021_02_01_48). The fund did not include publication charges.

Ethics approval

Ethical approval for this study was obtained from Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee (IHRERC/220/2021).

Informed consent

Written informed consent was obtained from all subjects before the study. For underage patients, oral assent was obtained and consent was obtained from their parents.

ORCID iDs

Barkot Tadesse

Helina Heluf

Sinetibeb Mesfin

Supplemental material

Supplemental material for this article is available online.

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