Prof.(Dr.)Dalbir Singh HEAD

DEPARTMENT OF FORENSIC MEDICINE POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH

CHANDIGARH (INDIA)

EXTENT AND DETERMINANTS OF COSTS OF ACUTE POISONING IN TRICITY OF

CHANDIGARH-AN EXPLORATORY STUDY

MORTALITY DUE TO ACUTE POISONING

HAS AN ENORMOUS MEDICAL, LEGAL,

SOCIAL AND ECONOMICAL

SIGNIFICANCE OWING TO THE

INVOLVMENT OF YOUGER AND

PRODUCTIVE AGE GROUPS

INCREASING INCIDENCE OF

MORTALITY AND MORBIDITY

DUE TO ACUTE POISONING IS A

WORLD WIDE PHENOMENON.

TREMENDOUS ADVANCES IN THE FIELD OF AGRICULTUREINDUSTRIAL TECHNOLOGIES MEDICAL PHARMACOLOGY

IN LAST FEW DECADES

HAVE BEEN PARALLELED WITH REMARKABLE CHANGES IN THE TRENDS OF ACUTE POISONING IN DEVELOPING COUNTRIES INCLUDING INDIA.

WHERE NEW POISONOUS SUBSTANCES HAVE COME TO THE FOREFRONT.

IN DEVELOPED COUNTRIES :

HOUSEHOLD CHEMICAL AGENTS

PRESCRIBED DRUGS

IN DEVELOPING COUNTRIES:

AGROCHEMICALS

MOST COMMON OFFENDERS

WHILE POISONING IN ADULTS HAS BEEN

THE CYNOSURE OF SOME ACADEMICIANS

BUT SUCH SCENARIO IN

CHILDHOOD AND ADOLESCENTS

GENERALLY SUFFER BECAUSE OF SUB-

OPTIMAL PARENTAL SUPERVISION AND

ACCESSIBILITY OF PRODUCT WITH

HAZARDOUS POTENTIAL.

ENORMOUS LITERATURE IS AVAILABLE ON VARIOUS ASPECTS POISONING WORLD OVER BUT ON ITS ECONOMICAL ASPECT IS SCANTY

OBJECTIVES

To ascertain the epidemiological profile of acute poisoning cases in Tri city of Chandigarh (India).

To ascertain the annual direct cost because of acute poisoning in Tri city of Chandigarh (India).

To ascertain the annual productive cost of acute poisoning in Tri city of Chandigarh (India).

To ascertain the determinants of such cost in Tri city of Chandigarh (India).

METHODOLOGY

Punjab

HimachalPardash

Haryana

TRI CITY OF CHANDIGARH (SHADED AREA)

Tricity of Chandigarh

TRICITY OF CHANDIGARH

Study area : Tricity of ChandigarhSource of data: Police /Hospital records of tri city

of ChandigarhNature of data : Information regarding the victims of

acute poisoning from tri city of Chandigarh

Reference period:1st Jan 2011 - 31st Dec 2013

Tools : Structured questionnaire Medical records and bills available

were reviewed

Analysis : IBM Statistics package (SPSS 18)

Distribution of cost

Cost of acute poisoning cases calculated under three categories Direct cost:

Cost incurred on medical treatment like expenditure on

hospitalization, medicines and other emergency services. Indirect cost:

Cost of emergency transport to the hospital and transport during follow up care made by victims or their relatives during treatment.

Productivity cost:

Costs refer to lost production capacity of individuals as a

consequence of acute poisoning divided into 2 headings:

Morbidity cost:

Value of lost output resulting from the reduced productivity including the value of lost workdays and lost housekeeping

days because of acute poisoning.

Mortality cost:

Value of lost output resulting from premature death.

Study Design  

  Applied the Eligibility Criteria

Resident of tricity of Chandigarh (1799) Not resident of tricity of Chandigarh (111) (Eligible) (Not eligible, Excluded)

 Made a list & attempt was made to trace the victim

  

Traceable (1238) Untraceable (561)

Consent given (1126) Consent not given (112)

cont.

Particulars of 1910 poisoning victims collected from Police stations/ Hospitals

Consent given (1126)

  Status of Victim

Alive (1042) Dead (84) 

Interview of Victim (398), Family (447) & Relative (197) Interview Family (84)

  Distribution of Cost

Direct Cost Indirect Cost Productivity Cost

( $. 82,377.65 ) ( $. 13,391.03 ) ( $. 5,599872.77 )

Total Cost ($. 5,695641.45 ) 

RESULTS

2011 2012 2013

218

406

502

YEAR WISE DISTRIBUTION OF ACUTE POISONING VICTIMS (N=1126)

Elementry Level High School Secondary School

Graduation

29

65 76

145

Relationship between Educational Qualifica-tion and incidence of acute poisoning among

the students (n=315)

Age and sex wise distribution of acute poisoning victims

Age in years Sex

TotalMale Female

<14

<5 32(61.5%) 20(38.5%) 52(4.6%)

5-10 8(42.1%) 11(57.9%) 19(1.7%)

10-14 5(62.5%) 3(37.5%) 8(0.7%)

Total 45(57%) 34(43%) 79(7%)

14-19 47(39.5%) 72(60.5%) 119(10.6%)

19-26 204(50.0%) 204(50.0%) 408(36.2%)

26-40 186(52.2%) 170(47.8%) 356(31.6%)

40-60 95(68.8%) 43(31.2%) 138(12.3%)

>60 17(65.4%) 9(34.6%) 26(2.3%)

Total 594(52.8%) 532(47.2%)1126(100.0%

)

Urban/rural and marital status wise distribution of acute

poisoning cases

Socio-demographic variable

Group

Sex

Total

Pearson

Chi- Square

p-valueMale Female

AreaUrban

404(52.1%)

371(47.9%)

775(68.8%).388 .533ns

Rural190(54.1

%)161(45.9

%)351(31.2%)

Marital status

Married277(47.7

%)304(52.3

%)581(51.6%)

12.412 .0001**

Unmarried

317(58.2%)

228(41.8%)

545(48.4%)

Total594(52.8

%)532(47.2

%)1126(100.0

%)

Age Wise distribution of mode of acute poisoning

AgeMode of Poisoning

Pearson Chi-

Square

p-valueAccidental Suicidal Homicidal Total

<1479(100.0%

)0(0.0%) 0(0.0%) 79(7.0%)

194.985

.0001**

14-19 36(30.3%) 80(67.2%) 3(2.5%) 119(10.6%)

19-26114(27.9%

)281(68.9%) 13(3.2%) 408(36.2%)

26-40126(35.4%

)226(63.5%) 4(1.1%) 356(31.6%)

40-60 82(59.4%) 53(38.4%) 3(2.2%) 138(12.3%)

>60 17(65.4%) 6(23.1%) 3(11.5%) 26(2.3%)

Total 454(40.3%)

646(57.4%) 26(2.3%)1126(100.0

%) 

Sex Wise distribution of mode of acute poisoning

Sex

Mode of PoisoningPearson

Chi- Square

p-value

Accidental Suicidal Homicidal Total

Male 265(44.6%)310(52.2

%)19(3.2%) 594(52.8%)

15.942.0001*

*Female 189(35.5%)

336(63.2%)

7(1.3%) 532(47.2%)

Total454(40.3%)

646(57.4%)

26(2.3%)1126(100.0

%) 

Marital status wise distribution of mode of acute poisoning

Marital status

Mode of PoisoningPearso

n Chi-

Square

p-valueAccidental Suicidal Homicidal Total

Married 222(38.2%)348(59.9%

)11(1.9%)

581(51.6%)

3.558 .169ns

Unmarried 232(42.6%)298(54.7%

)15(2.8%) 545(48.4%)

Total454(40.3%)

646(57.4%)

26(2.3%)1126(100.0

%) 

Area wise distribution of mode of acute poisoning

Area

Mode of PoisoningPearso

n Chi-

Square

p-value

Accidental Suicidal Homicidal Total

Urban 310(40.0%) 446(57.5%) 19(2.5%) 775(68.8%)

.295 .863ns

Rural 144(41.0%) 200(57.0%) 7(2.0%) 351(31.2%)

Total454(40.3%) 646(57.4%) 26(2.3%)

1126(100.0%)

Occupation wise distribution of mode of acute poisoning

OccupationMode of Poisoning

PearsonChi-

Squarep-value

Accidental Suicidal Homicidal Total

Students 119(37.8%)186(59.0%

)10(3.2%) 315(28.0%)

133.345 .000**

House wives 73(31.7%)154(67.0%

)3(1.3%) 230(20.4%)

Pvt. Job 47(42.3%) 62(55.9%) 2(1.8%) 111(9.9%)

Govt. Job 51(48.6%) 53(50.5%) 1(1.0%) 105(9.3%)

Businessmen 48(51.1%) 42(44.7%) 4(4.3%) 94(8.3%)

Skilled workers 16(19.5%) 65(79.3%) 1(1.2%) 82(7.3%)

Children 49(100.0%) 0(0.0%) 0(0.0%) 49(4.4%)

Unskilled workers 18(37.5%) 28(58.3%) 2(4.2%) 48(4.3%)

Unemployed 8(18.2%) 33(75.0%) 3(6.8%) 44(3.9%)

House maids 10(35.7%) 18(64.3%) 0(0.0%) 28(2.5%)

Farmers 15(75.0%) 5(25.0%) 0(0.0%) 20(1.8%)

Total 454(40.3%)646(57.4%

)26(2.3%)

1126(100.0%)

 

Relationship between family type and incidence of acute poisoning

(n=1126)

33

217

876

Single memberJointNuclear

Toxic substances causing acute poisoning in males

(n=594)

OPC

/Car

bam

ate

Ther

apeu

tic p

oiso

n

Alcoh

ol

Food

bas

ed p

oiso

n

Domes

tic p

oiso

nALP

Hyd

ro-car

bon

com

...

Corros

ive

Chem

ical

217

157

9254

27 24 17 4 2

Toxic substances causing acute poisoning in females (n=532)

OPC

/Car

bam

ate

Ther

apeu

tic p

oiso

n

Food

bas

ed p

oiso

n

Domes

tic p

oiso

n

Alum

iniu

m p

hosp

hide

Hyd

ro-c

arbo

n co

mpo

...

Chem

ical

Corros

ive

Alcoh

ol

251

171

5424 11 11 5 4 1

Circumstances leading to acute poisoning in males (n=594)

146

114102

93

38 3525

14 11 8 6

Circumstances leading to acute poisoning in females (n=532)

Sickn

ess

Mar

ital

dispute

Fam

ily d

ispute

Accid

enta

l poi

son

Failu

re in

exa

m.

Failu

re in

love

affai

rs

Finan

cial

dispute

/pro

blem

Siblin

g riv

alry

Dow

ry

Unemplo

yem

ent

Lonel

ines

s

Victim

of r

obber

y

131118 113

60

4026 26

10 4 2 2 2

Home Market Working place

733

349

44

Place of procuring the poisonous substances (n=1126)

Place of exposure to poisonous substances (n=1126)

927

91

6048

HomePartyMarketWorking place

Time of exposure to poisonous substances (n=1126)

0-6hrs 6-12hrs 12-18hrs 18-24hrs

26

140

319

641

Monthly distribution of acute poisoning cases (n=1126)

82 80 85 89

113 107 107 106 10396

81 77

Medical help at the site of exposure

Medical help No. of victims Percentage

Yes

Co victim 13 25.5%

Public 30 58.8%

Paramedical/nurse 2 3.9%

Doctor 2 3.9%

Parents 4 7.8%

Total 51 4.5%

No 1075 95.5%

G . Total 1126 100.0%

Escorted to hospitalEscorted to hospital No. of victims Percentage

Self 58 5.2%

Parents 416 36.9%

Relative 422 37.5%

Neighbors 130 11.5%

Police 67 6.0%

Para medical/ nurse 6 0.5%

Spouse 27 2.4%

Total 1126 100.0%

Means of conveyance to hospital (n=1126)

Hired vehicle Police van Ambulance Own vehicle

497

69 18

542

Current status

Doctor AvailablePearson

Chi- Squarep-value

Yes No Total

Alive 1027 15 1042

.463 .496ns

Dead 82 2 84

Total 1109 17 1126

Status of victim and availability of doctor

at first site of treatment

Current status Total Percentage

Non-fatal 1042 92.5%

Fatal 84 7.5%

Total 1126 100.0%

Current status of victims

Current Status of Non-fatal cases of acute poisoning

Current Status Total Percentage

Fully recovered 964 92.5

Having residual health problems

78 7.5

Total 1042 100

Special features and level of significance of explanatory variable by maximum likelihood method for logistic

regression equation

Variables B(SE) Wald p-value

Occupation Students .095(.027) 12.457 .0001**

Time 18-24hrs .051(.017) 8.684 .003**

Type of poison OPC/Carbamate -.785(.061) 165.096 .0001**

Poison procuring place Home -2.103(.191) 121.430 .0001**

Poison consumption place

Home .245(.116) 4.472 .034*

Constant - 3.710(.394) 88.835 .0001**

d.f= 1 for all

Overall financial burden

Distribution of costTotal amount

(USD/`)Average cost per

victim (USD/`)

Direct Cost$ - 82,377.65

`-51,89,792.00$- 74.97

`- 4,722.29

Indirect Cost$- 13,391.03`-8,43,635.00

$- 11.90`-749.23

Morbidity Cost$-94,883.98

`-59,77,690.88$- 100.14`-5,308.78

Mortality Cost

Cremation Ceremony Expenses

$-63,784.79`-40,18,441.60

$-759.34`-47,838.59

lost output resulting from premature death

$- 5,441204`-

34,27,95,832.00

$-64776.23`-40,80,902.76

Total$ - 5,695641.45` - 35,88,25,391.5

Conclusion 764 (68%) victims of acute poisoning were in the age

group of 19 to 40 years with male preponderance (53%) and rural dominance(69%).

Victims below 14 and above 40 years mostly had accidental and in between 14 to 40 years had suicidal poisoning.

52% married females consumed toxic substance with suicidal intent where as 58% unmarried males had accidental poisoning.

There was positive relationship between educational qualification & incidence of acute poisoning among the students.

Sickness followed by financial/family/marital disputes, failure in examination, sibling rivalry were the most common circumstances leading to poisoning.

OPC/Carbamate followed by therapeutic poisons, domestic poisons, food based poisons, aluminum phosphide and alcohol were most common offenders. Cont.

78% of incidence of acute poisoning were in nuclear family.

Students (28%) followed by house wives (20%), employee (19%), businessman (8%), skilled workers (7%) were the most common victims.

In majority of instances place of procurement and exposure was at home.

Most of incidence acute poisoning were between 18 to 24 hours followed by 12 to 18 hours.

In 96% instances, no medical help was available at the site of exposure.

Doctor was available at first site of treatment in most instances (98.5%).

Most of instances (84.4%) relatives/family members were informed from site of exposure to acute poisoning.

Conclusion

ACKNOWLEDGMENT

Authors are thankful to Indian Council of Medical Research New Delhi (India) for providing financial assistance to this study

Thank You

Type of poison Therapeutic poison : Alprex, Amloid, Amoxycillin,Atrazine,

Azothrin, Betadine, Brufen, Cetrizine, Combiflam, Cough syrup,

Diclovin+, Disprin, Envas, Gatequin, Medalor, Mexafied, Neupokine, Neurobion, Paracetamol, Tripride, Tranquil

OPC/Carbamate Aluminum phosphide, Cannabis Fuels: Kerosene oil, Petrol, Diesel, Turpentine

oil

Domestic : LPG inhalation

Chemical : Mercury, Ammonia, Boric Acid

Corrosive : Acid & Alkalis