MEETING REPORT ON

IPCSIEMRO WORKSHOPS ON: I. CHEMICALS INFORMATION MANAGEMENT

U. COLLECTION OF HARMONIZED CASE DATA (INTOX) AND MANAGEMENT OF TOXIC EXPOSURES

Amman, Jordan 3-6 November 1997

INTERNATIONAL PROGRAMME ON CHEMICAL SAFETY (IPCS) WHO REGIONAL OFFICE FOR THE EASTERN MEDITERRANEAN (EMRO)

REGIONAL CENTRE FOR ENVIRONMENTAL HEALTH ACTMTIES (CEHA) AMMAN, JORDAN

November 1997

CONTENTS Page

1 . INTRODUCTION ............................. .. ....................................................... 1

2 . TECHNICAL PRESENTATIONS ..................................................................... 3

2.1 IPCS INTOX and IPCS INCHEM .................................................................... 3 2.2 IPCS products register database ...................... .. ........................................... 5 2.3 IPCS chemical incidents database project ............................................................ 5

........................................................................... 2.4 Environmental health databases 6 2.5 UNEP Chemicals: Clearing house for information on chemicals

.................................................................... management. safety and assessment 6 2.6 ILO/CIS database ............................................................................................... 8 2.7 Jordanian experience: Chemical information centre .......................................... 9 2.8 Presentation of IPCS INTOX package ................ ................. ............................... 11

......................................................... 2.9 Management of specific types of poisoning 11 . . ...................................................................... 2.10 Main types of poisoning In Jordan 1 1

......................................................................... 2.1 1 Management of acute poisoning 12 ..................................... 2.12 Elirtiir~atiuri pi uc;edu~ es arid erlharicelr~e~it uf eli~iii~iativ~i 12

................................................................... 2.13 Role of the toxicological laboratory 13 2.14 Toxic exposure to household products

...................................................................... (particularly kerosene and bleach) 14 .............................................................. 2.15 Solvent exposure (including "sniffing") 14

........................................................................................... . 2 16 Pesticide poisoning 15 ............................................................... 2.17 Poisoning by metals (particularly lead) 15

2.18 Poisoning by pharmaceuticals: Psychotrophic drug overdose .............................. 16 ................................................................................ 2.19 Management of snake bites 16

............................................. 2.20 Management of scorpion stings: Prospective study 17 .................................................... 2.2 1 Management of exposure to aquatic biotoxins 18

. ............................................................. 3 PLENARY SESSION-DISCUSSIONS 18

............................................................................................... . 4 CONCLUSIONS 19

................................................................................... . 5 RECOMMENDATIONS 21

............................................................................................................... . 1 Agenda... 24 ............................................................................................................ . 2 Programme 26

. ................................................................................................. 3 List of Participants 29

1. INTRODUCTION

Two training workshops on chemicals information management were held in Amman, Jordan, 3-6 November 1997, for experts in the fields of chemical safety from 10 EMR countries (Egypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Morocco, Pakistan, Palestine, Syrian Arab Republic and Tunisia).

Dr A. Abbas, Under-Secretary. Ministry of Health and Health Care, Jordan, opened the meeting. After an overview of various chemicals information resources provided by the International Programme on Chemical Safety (IPCS) and its three collaborating organizations (the World Health Organisation (WHO), the International Labour Organization ( L O ) and the United Nations Environment Programme (UNEP)), experts divided into two groups for specific training.

Group I, hosted by CEHA and co-chaired by Dr J.A. Haines and Dr Semra Uluatam, trained on the IPCS INCHEM CD-ROM, the computerized databases of UNEP Chemicals International Register of Potentially Toxic Chemicals (IRPTC) and ILO/International Occupational Safety and Health Information Centre, and the use of the P C S chemical incident reporting formats. A demonstration was made of the WHO environmental health databases and the IPCS Product Register prototype.

Group 11, hosted by the Chemical Information Centre, Jordanian Ministry of Health and Health Care and co-chaired by Dr J. Pronczuk and Mr M. Khalil, trained on the P C S N T O X package and exchanged experience on the latest trends concerning diagnosis and management of poisoning, including: decontamination and enhanced elimination, household products, solvents, pesticides, lead, psychoactive drugs, analgesics, aquatic biotoxins, snake bites and scorpion stings. The role of the toxicological laboratory was also presented.

The Agenda of the workshops is in Annex I , the programme in Annex 2 and the list of participants in Annex 3 .

In the Opening Ceremony, Dr E. Clevenstine, International Labour Organisation/International Occupational Safety and Health Information Centre (ILOICIS), and M s B. Bender, United Nations Environment Programme (UNEP)/Chemicals (IRPTC), addressed the workshops on behalf of their organisations.

On behalf of the Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mcditcrranean. Dr M.Z. Ali Khan, Coordinator of the Regional Centre for Environmental Health Activities, addressed the workshops.

Dr Gezairy thanked the Jordanian Government for their hospitality, in particular Dr Ashraf Al-Kurdi, Minister of Health and Health Care.

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He then outlined the steady increase in the use of chemicals, not only in the Eastern Mediterranean countries but throughout the world. Globally approximately 100000 kinds of chemicals are produced and 1000 to 2000 new chemicals are introduced to the market yearly. It has been estin~ated ~11al at pl~esent over 11 million chemicals are known. Because of this extensive use of chemicals, nearly 400 million tonnes of hazardous waste are produced globally each year.

As a result of increased industrialization and agricultural activities in the Region, a significant portion of the population are being exposed to chemicals in the workplace, the home and in the environment generally, and this exposure and its related health problems are increasing.

The Regional Office has many activities in progress to prevent ur I-educ;e tlie Iiealth hazards caused by misuse or overuse of chemicals, as stated in the Regional Strategy for Health and Environment. Some of these are:

development of national chemical safety programmes including, labelling of imports, transport, licensing, storage, information, legislation and regulation; prevention of misuse of chemicals and pesticides; preparation of inventories of potentially hazardous industries and chemicals within the country and of chemicals imported; and development of a regional plan for promoting the use of nontoxic alternatives.

IPCS and EMRO have similar strategies and objectives, which could be achieved through cooperative activities in training personnel and supporting national programmes for the prevention and treatment of poisonings involving chemicals.

He said that workshops constituted a good example of such collaboration. They would strengthen the capabilities of Member States in the management of information on chemicals. in the harmonized collection of clinical cases and incident data, and in the diagnosis, prevention and treatment of toxic exposures for both the health and environment sectors.

During the workshop on Management of Information on Chemicals existing databases would be introduced and training of trainers carried out to facilitate sound management of chemicals including emergency response.

The P C S INTOX package is a tool for poisons information management and harmonized collection of case data, it would bring with it approaches to patient management for a number of types of poisoning commonly found in the Region. This package would be introduced and discussed in the second workshop.

Dr Abbas emphasized the importance of the role of continuing education, the availability of information and the exchange of information between diierent countries of the Region. The Government of Jordan, had a great interest in exchanging information with other countries. and Dr Abbas stressed the importance of poisons information centres and their role in controlling and reducing poisoning cases.

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I Dr J.A. Haines, IPCS INTOX Project Leader and Chief, Poisoning Prevention and Treatment Unit at the World Health Organisation, stated the importance of the workshops' objectives. He welcomed participants on behalf of Dr M. Mercier, Director of the IPCS, and

I the Executive Heads of the three P C S Collaborating Urganizations ( U N k P , ILU and WHO). Referring to the 1992 declaration of the United Nations Conference on Environment and Development (UNCED) and the strategy for environmentally sound management of cheniicals adopted in Agenda 2 1 Chapter 19, all countries had recognized the need for safe use of chemicals in the economic development process. The Intergovernmental Forum on Chemical Safety, set up to implement the UNCED recommendations on sound management of

I chemicals, had set priorities for this purpose. EMR countries at the workshop held in Cairo (October 1996) on the development of national strategies for sound management of chemicals had identified the strengthening of chemicals information facilities and the establishment of poisons control services as essential elements for implementing chemical safety in all countries of the region.

Besides IPCS activities to provide evaluated information and information management tools, the three P C S cooperating organizations have chemicals information activities. particularly through UNEP Chemicals (IRPTC), ILOICIS and the WHO Programme for the Promotion of Environmental Health. Further, these organizations, along with Food and Ajigriculture Organization of the United Nations, United Nations Industrial Development Organization and Organization for Economic Cooperation and Development, through the Inter-Organization Programme for Sound Management of Chemicals (IOMC), collaborate in the Global Information Network on Chemicals (GINC) which is promoting access of countries to eval~~ated information via the Internet.

The P C S issues the lNCHEM CD-ROM twice a year, which contains all IPCS publications. and this is now available on the Internet. The IPCS INTOX package provides health professionals dealing with prevention and treatment of toxic exposures both a database on CD-ROM and information management software. Through the INTOX project, networking among centres throughout the world is heing prnrnnted, including through e-mail discussion groups. Other information management tools, for chemical product registers and chemical incident preparedness and response, are in preparation.

Dr Haines expressed appreciation to the Jordanian authorities for co-hosting the meeting and orsanising the INTOX workshop.

2. TECHNICAL PRESENTATIONS

2.1 IF'CS INTOX and IPCS JNCHEM Dr 1M.J. RIISL', ZF'('S INT0,Y !'otrsrrlttrtrf, .Medictrl Toxicology Ilttlt

Dr Ruse felt that the wide variety of participants present at the meeting (clinicians, occupational and environmental health workers, engineers, agents from ministries, toxicologists, analytical toxicologists, poisons information specialists) indicated that a wide spectrum of informatiun, relating tu the promotion of the sound management of chemicals is required by those working in this field. It was also important that acoess to the relevant information was both easy and rapid.

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He presented the IPCS INCHEM CD-ROM, which is a collection of over 2400 documents published by the IPCS, demonstrating the wide variety of information in this database and the facilities which are provided for searching and rapid access. These internationaliy reviewed documents covered many of the areas of interest to the meeting participants:

Environmental Health Criteria Monographs which provide data for the establishment of safety standards and regulations. Health and Safety Guides which contain information, in non-technical language, for those making decisions on the risks from exposure to chemicals. International Chemical Safety Cards which summarize essential information on chemical substances. Pesticide Data Sheets which contain basic information for the safe use of pesticides. Poisons Information Monographs-global database with evaluated information on the biochemistry, toxicology and medical management of different substances and natural toxins (chemicals, pharmaceuticals, poisonous plants, animals. fingi and bacteria). Joint FAOniVHO Expert Committee on Food Additives Monographs-toxicological evaluations of food additives, contaminants and residues of veterinary drugs. Joint FAO/WHO Meeting on Pesticides Monographs- toxicological evaluations of pesticides. IPCSEuropean Community Evaluation of Antidotes-definitions and authoritative guidelines on the use of antidotes to treat poisoning. International Occupational Safety and Health Information Centre Chemical Information which provides chemical information for those responsible for health and safety in the workplace.

It was important that those requiring chemical information were able to access it as easily and as quickly as possible and Dr Ruse explained and demonstrated the MCHEM user- friendly full-text search capabilities. The INCHEM database was also available through the INCHEM Website on the Internet.

The IPCS INTOX database, available on CD-ROM, was also presented. This contains documents that are directed towards those health care professionals, such as emergency clinicians and poisons information specialists, working in the treatment of human poisoning. As well as peer reviewed, evaluated documents covering the toxicology, clinical features and medical management of human poisoning by specific substances and organisms, the CD-ROM also contains guidelines on the setting up and strengthening of poison information centres, a global dircctory of such ccntrcs and thcir available library rcsourccs, plus a products database containing over 62000 product records.

Developed in conjunction with the INTOX database was the N O X data management system which provides the capability for the collection of harmonised data on human poisoning. In order to facilitate the collection of data which can be shared and accessed across regional, national and international boundaries the MTOX data management system uses authority lists and controlled vocabulary. The system is currently available in English, French, Spanish and Portuguese but the possibility of translating the system into Arabic was discussed during the questions session. The INTOX data management system also provides the

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capability for the local generation of records on products, chemicals, pharmaceuticals and poisonous plants, fungi and animals using standardised formats. The system could also produce annual reports on the data collected.

Both the INTOX database and data management system had been developed during

I the last ten years through the JNTOX project, which is a global network of health care

I professionals who work in the field of human poisoning. The project encompasses nearly 100 professionals in over 60 countries.

I I i Participants were introduced hands-on to the P C S INCHEM CD-ROM.

The spectrum of documents available were looked at in detail, and the various user-friendly

I capabilities on the CD-ROM were demonstrated. These include table of contents options for individual documents; hotlinks within the CD-ROM connecting related documents; links to all available figures, graphs and chemical structure diagrams within a document; annotation capabilities; a "back through history" option; powerful fill-text and key-word search fbnctions; printing; and copy and pasteing to other software systems.

2.2 P C S products register database Dr LA. Harrres, /F'('.S INTIIX F'rcyecf Le~rder. WHO Mr D. Brophy, ( irrrclimr ('e~rlre.for. Occr~pcrtiotrtrl Hetrlth trrid S~!fity

Information on commercial products is required by a variety of institutions in countries, including those responsible for the registration of chemicals, regulating their use and for responding tn chemical incidents. including the emergency services and health professionals. The IPCS INTOX system provides the possibility to create a record on a chemical product. This record covers irrter alia the identification of the product, details of the manufacturer or importer, the physico-chemical properties, composition and packaging. It also includes the possibility of entering information on toxicity, kinetics and patient management. The data fields of the INTOX products record conform with the 16 information areas recommended for Material Safety Data Sheets (MSDSq) in K O Convention 170. By entering local product data into the PITOX system, a chemical prodirct database can be created. A stand-alone information management tool for creating a chemical products registry was also being developed using the INTOX product record format. controlled vocabulary and classes. The tool would be for use on a single compiiter or network of computers at a centre. Network systems among centres and Internet versions of the information management tool would also be developed.

The MTOX CD-ROM contains nearly 63000 product records. corresponding to MSDSs on Canadian commercial products. This database would be expanded in the future.

David Brophy demonstrated the prototype IPCS INTOX Product Writer

2.3 IPCS chemical incidents database project Dr J. A. Haines

In order to prepare for and respond to chemical incidents, thaemergency services require information on potential locations where such incidents may occur. Formats have been developed to prepare a registry of sites containing toxic chemicals and a registry of transporters of chemicals.

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A tool was being developed to establish a national database on chemical incidents. for which a format for recording data had been prepared. This tool also contains formats for registries of persons exposed in a chemical incident and of persons evacuated in a chemical incident. A number of centres t h r o u ~ h o u t the world were testing the International Exchange of Harmonized Data on Chemical Incidents using a subset of the information collected in the full chemical incident format.

2.4 Environmental health databases Ms A.M. Iffister, (?f,ce of (;lohtrl trnd 1trtegrtrtc.d Health. WHO

The Environmental Health Documentation Centre provides access to the information products of the WHO Programme for the Promotion of Environmental Health in the fields of air quality, water quality, water supply and sanitation, environmental health in urban settlements, ionizing and non-ionizing radiation, hazardous waste management, environmental epidemiology, noise, climate change.

Bibliographic data management

To hlfill this function, the Environmental Health Documentation Centre maintains two databases:

EHEBIS (Environmental Health Bibliographic Information System) HELM (Health and Environment Library Modules)

EHEBIS is maintained in CDSIISIS in the WHO bibliographic data management standard format established for CDSIISIS: WHOBIS. It includes 4 180 records, out of which 46% are WHO generated information; there is a strong emphasis on water supply and sanitation issues with 45% of the information on these subjects.

HELM is maintained in CARDBOX in the WHO bibliographic data management standard format established for CARDBOX: STANDBIB. It includes over 500 records and represents the core collection of WHO environmental health information. There is a strong emphasis on chemical safety with 3 13 records addressing this subject.

Both CDSIISIS and CARDBOX allow the creation of as many printing formats as necessary so as to facilitate the production of bibliographies, catalogues, lists, etc. Copies of EHEBIS are available at the WHO libraries in CEPIS, Lima, and CEHA, Amman.

HELM is distributed free of charge to GELNET libraries and other interested institutions either in a read-only CARDBOX electronic file, as a CDSASIS database nr even as a text file. It is also available on the WHO website (http://www. who. ch./programmes/peh/gelnet/).

2.5 UNEP chemicals: Clearing house for information on chemicals management, safety and assessment Ms B. Bender, INEF' ('hemicnls ( IWT(7 Facilitator: Ms Fntimtr Al-Ttrwalbeh, E~rvirol~mejrtnl Health Directorate, Ministry of Health and Health ('(ire, .Jordtur

?

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During the last 20 years, UNEP has operated through Chemicals (IRPTC), a programme to improve information collection, information exchange, networking and capacity building on toxic chemicals. Working within a framework of information management, Chemicals ( W T C ) ultimately aim to:

r help the world community make better use of existing global resources and to give developing countries and countries in transition, the information base to manage chemicals effectively; and to enhance the decision making processes by providing reliable scientific and technical data and information for risk assessment.

The work of the organization has been greatly enhanced by modern information technologies which have helped to manage the core information base and assured greater access for users worldwide. Today UNEP, in the interest of facilitating the sharing of scientific chemicals information, has integrated information dissemination into the Internet environment via websites on all the main programmes mandated to strengthen information exchange. An overview of the main websites which operate from the UNCP Chemicals servors were briefly described.

Chemicals Website: http://irptc.unep.ch/irptc

The home pages provide the UNEP chemicals mandates, major activities and f u n ~ l i u l ~ s that ensure the sound management of toxic chemicals and waste. Users would also gain access to the IRPTC databank on chemicals, the Screening Information Data Sets (SIDS), user manuals for the IRPTC-PC databank system and new publications as they became available.

Prior informed consent Website: http://irptc.unep.ch/pic/default.htrnl

An expert group to develop a legally-binding instrument on Prior Lnformed Consent (PIC) procedure. A list of chemicals and pesticides subject to PIC could also be found.

Persistent organic pollutants Website: http://irptc.unep.ch/pops/

The home pages inform users on issues and the progress made by countries and international organisations to initiate action to reduce or eliminate emissions and discharges of persistent organic pollutants (POPs). Users could also learn more about the recommendations which may lead to the development of a legally-binding instrument on POPs.

Pollutant release transfer register Website: http://irptc.unep.ch/prtr/

The home pages describe the collaboration and activities of international, national and non governmental organisations on the pollutant release and transfer register and the use of

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the Pollutant Release Transfer Register Pollutant Release Transfer Register systems to track emissions and waste transfers to achieve sound management of chemicals.

Inventory to information sources on c l ~ e ~ ~ l i c i ~ l s Website: http://irptc.unep.ch/irptc/irptc/invent/igo.html

This website provides detailed descriptions of publications on chemicals from intergovernmental organizations in the field of chemicals management, assessment and safety. The Commission of the European Union, FAO. IAEA, IARC, ILO, OECD, UNfECE, UNEP, UNESCO, UNIDO, WHO and WMO have contributed information. The online inventory not only tells you who does what, but also provides links to the web page of the organisation responsible for the published information.

Internet guide-finding information on chemicals Website: http://irptc.unep.ch/irptc/irptc/guide/coverpg.html

This Guide is a source for links and a tutorial to Internet resources on chemical safety and hazards, covering a broad range of world scientific environmental knowledge in the field.

IRPTC Legal File Website: http://irptc.unep.ch/

IRPTC Legal File is the largest database of the IRPTC databank system. It contains regulatory information on toxic chemicals contributed by 14 countries and six international ur ganisatiolls. Thel-e are over 50000 records available for use.

The Internet access to all the information described above is accorded without a password protocol, enabling users to access the website and homepages at any time for the information they require. UNEP wishes to encourage countries to make use of these sources as support tools in decision making and for the management of chemicals information and data of national interest.

UNEP recognizing the great difficulties countries have in getting the information and information sources on toxic chemicals, organises more and more the dissemination of major information products (databases, publications, sources) on the Internet for access on a 24 hour basis.

Participants were guided by lecture/demonstration on how to contact the websites for the inventory of Sources of Information on Chemicals (IOMC) and the IRPTC Legal File, locate the homepages, select content, organize a query and obtain the output report.

2.6 ILOICIS database Dr E. C:levet~stine, Ititerr~atio~ml Occr~patior~al Safety and Health It formation Centre, ILO

The output of the International Occupational Safety and Health Information Centre (CIS) of the International Labour Organization include databases, topical bibliographies. provision of expertise to constituents and others and support of tech'nical cooperation work. The CIS also disseminates print and electronic publications by third parties, for example CD- ROMs from the Canadian Centre for Occupational Health and Safety. Each of kind of output

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is represented on CIS'S chemical safety CD-ROM. Whereas many of the materials presented at I this workshop are distributed free of charge, CIS is required by its constitution to recover as I I much of its operating costs as possible, and so must sell its publications I

I The principal database produced by the CIS is CISDOC. a file of bibliographic

I references to publications in all areas of occupational safety and health (OSH) - not only

I chemistry but ergonomics, machinery guarding, protection against falls, noise control, psychosocial factors and every other relevant areas. Associated with CISDOC is the CIS

i thesaurus, the collection of fixed terms used to index CISDOC. An important factual database is a collection of occupational exposure limits for chemical substances and products, covering 16 countries and over 2000 materials. Also qualifying as a database is the CD-ROM version of the 4th edition of the ILO Encyclopaedia of Occupational Health and Safety.

Growing at a rate of 2 100-2300 abstracts per year, CISDOC cannot be exhaustive; it tries to provide a world-wide sample of what is happening in Occupational Health and Safety. Help comes from a network of focal points at country level and national collaborating centres. Its breadth is shown by the fact that publications in 50 languages are cited, although over half of the references are to documents in English. The abstracts themselves are fully bilingual EnglishRrench, as is the indexing; Spanish is planned for the fi~ture.

CISDOC is basically a standard bibliographic database. Its distinctive feature is two levels of indexing, one representing the terms that appear in the subject index to the printed version of the database, and the other being additional terms to provide extra entry points to persons searching the database on-line or on CD-ROM. These so-called secondary descriptors include Chemical Abstracts Service Registry Numbers, which obviate problems of chemical nomenclature and provide a link to other sources of chemical information.

The thesaurus helps the user find registry numbers and to determine what term CIS uses to index a given concept. It is organised hierarchically, but the assignment of a chemical with several fbnctional groups to one particular branch of the hierarchy is not fully systematic. For example, an organophosphorus compound could find itself on the organlc compounds hierarchy or the pesticides one, and a double assignment is not permitted. This is not important for searching in CISDOC, only when using the tt~esaurus to develop a search.

Whereas CISDOC is available in print, on-line and on CD-ROM, and will soon be accessible on the Internet, the thesaurus is presently available routinely only on diskette. Computer printouts are made on demand, and the thesaurus will soon be on the website with CISDOC.

2.7 Jordanian experience: Chemical information centre Mr M. Khalil. Director., ('heniictrl Iifi)rntatioi~ ( 'eirtre. Et~viroimieirtal Health D~rectortrte, Miriist~y c$He~rlth titid Health ( i v e . ./or.u'cui

The Chemical Information Centre is part of the Environmental Health Directorate at the Ministry of Health and Health Care. It was established in 1994 in order to promote chemical safety programmes in Jordan. The Chemical Information Centre consists of a group of databases on chemicals and a well-equipped laboratory to conduct analyses of different types of samples of chemical substances. In early 1997, the centre was chosen by an expert committee at the National Information Centre to be the National Focal Point for Information

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on Chemicals. In the same year. the centre was accepted as the National Designated Authority (Chemicals) for the PIC 1 procedure.

The Chemical Information Centre has many kinds of information available, among which are:

health and environmental effects of chemicals abstracts of studies on the health and environmental effects of chemicals list of chemicals restricted or banned in Jordan list of pesticides registered in Jordan list of importers of chemicals into Jordan list of chemicals imported into Jordan MSDSs of hazardous chemicals in Arabic monthly newsletter.

The Centre is responsible for monitoring chemicals imported into Jordan; preparing Material Safety Data Sheets (MSDS) in Arabic; providing information on chemicals; participating in the preparation of standards and specifications on chemicals; recording chemical poisoning cases in the country; participating in technical committees on chemicals; carrying out studies and research on the health and environmental effects of chemicals; analyzing environmental and biological samples to detect toxic levels of chemicals and training.

The planned activities of the Chemical Information Centre are:

registration of chemicals imported into Jordan registration of chemical products in Jordan registration of chemical accidents in Jordan registration of chemical poisoning cases cstablishmcnt of a poisons information ccntrc.

The databases available at the Centre are: IPCS WCI-LEM; IPCS INTOX; IRPTC-PC Databank on Chemicals; WinSPIRS (CHEM-Bank); WinSPIRS (POLTOX); and Micromedex (Environmental Health and Safety Series).

The services of the Chemical Information Centre can be obtain through a personal visit; a telephone call; fax; mail; InternetIIntranet (in the near kture) or e-mail (in the near future).

The Centre is supported by the following international organisations; WHO Regional Centre for Environmental Health Activities (CEHA); WHO Regional Office for the Eastern Mediterranean (EMRO); the International Programme on Chemical Safety (PCS); and UNEP Chemicals (IRPTC).

The Ministry of Health and Health Care hopes that the Chemiqal Information Centre will be recognized as a collaborating centre with international organisations in order to enable Jordan to better promote chemical safety programmes in the Region.

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2.8 Presentation of IPCS INTOX package Mr D. Brophy

David Brophy presented the IPCS DJTOX system and CD-ROM to the wurkshup. The system and CD-ROM were demonstrated in detail to give the participants a f i l l understanding. Participants were given exercises to complete.

Participants also worked with the IPCS INTOX CD-ROM. The different types of documents available on the CD-ROM were explained and shown. This included the prototype databases for the Products Database and the Candidate Substances.

2.9 Management of specific types of poisoning Dr J. Pronczirk, Poisoriirig Prevention a?lJ ('oiltrol, Ir~ten~atioi~al Programme on I.'hemicnl ,Sqjiety, WO

The session on Management of Specific Types of Poisoning was held at the Food Safety Department of the Ministry of Health and Health Safety. Participants from Egypt, Iraq. Jordan, Lebanon, Morocco, Pakistan, Syrian Arab Republic and Tunisia took part and the main objectives were to present the latest trends in diagnosis and management of poisoning and to review and discuss the main toxic exposure and envenomation problems observed in countries of the Region.

Active discussions followed, especially concerning the advantages and disadvantages of decontamination procedures. The efficacy of dilutants, demulcents and oils for treating the ingestion of alkalis, kerosene and phenol. The restrictions in the use of gastric lavage and the limited value of methods, such as induced emesis or catharsis were reviewed. Discussions took place on the role of the analytical toxicology laboratory in clinical toxicology and the audience was briefed on the activities of the Analytical Toxicology Working Group of the IPCS NTOX project. Interest was expressed by participants on the setting up and/or strengthening of poisons centres, especially in Amman, where initiatives were undertaken several years ago. and in Beirut. where an initial nucleus is already developing a number of activities. The presentations on housetiold products focused mainly on the effects of hydrocarbons and corrosives, and on the importance of prevention through community education.

2.10 Main types of poisoning in Jordan Dr Samir Qammaz, Director, Ilrrlg Qr~~zlity ('oirtrol L ~ r h o r ~ d ~ t y , Ministry of Health and Health ('are, Jordcrli

The idea of establishing a poisons information centre in Jordan started in 1980. In 1988 a unit for poisons information was started at the Directorate of Pharmacy and Drug Quality Control. The main duties of the unit were to collect information and to prepare poisons information cards. In 1993, the unit was renamed the General Information Unit for Drugs.

To make up for the lack of information on chemical and pharmaceutical poisoning cases, the Chemical Information Centre at the Environmental Health'birectorate distributed a questionnaire in 1995 to public hospitals and centres to report on poisoning cases treated by them.

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Poisoning cases in Jordan are similar to those in other countries with regard to age, sex, toxic substance causing the poisoning, etc. It is noted that, during the winter season, there is an increase in carbon monoxide poisoning cases, due to the use of traditional heating devices. These poisoning cases usually affect a group of pcoplc and cause the most deaths.

The Ministry of Health and Health Care in Jordan understands the important role of a poisons information centre and one will be established very soon, given the help and support of the World Health Organization.

2.1 1 Management of acute poisoning Dr Ahdelkder Bnttah, Fl~crilty ofMedicirlc., lirriversity of Jorcr'nrr, Jordar~

The presentarion summarized the general presentation of patients with acute poisunir~g, the common types of poison observed in the community, such as household products (medication, cleaning products and chemicals). Other poisons include toxic gases, pesticides and plant toxins. Routes and circumstances of poisoning were also covered.

The general approach to management of patients presenting with acute poisoning was addressed and the utilization of the supportive management approach, which includes the following points:

patient stabilization; measures to stabilize the vital hnctions of the patient, such as keeping a patent airway, breathing and circulation complete patient assessment, including complete medical history, physical examination, and laboratory investigations, in order to identify a certain syndrome of a toxic substance, rule out other similar medical presentations, and diagnose and evaluate the patient decontamination enhancement of elimination the consideration of the use of antidotes: ethanol. chelating agents. etc. continuous supportive care: hypotherrnia, hyperthermia, convulsions, coma, etc.

2.12 Elimination procedures and enhancement of elimination 111. .J. I'ru?~czrik

The early management of toxic exposures by decontamination prevents damage and absorption, but once absorption takes place, only measures to enhance the elimination of drugs and toxins may be considered.

Therapeutic interventions which can be used to decrease the absorption of a toxic substance (or prevent damage) include: irrigation of the skin and eyes; dilution or neutralization within the gastrointestinal tract; emesis induction; gastric aspiration and lavage; single dose activated charcoal; catharsis; and whole bowel imgation. On extremely rare occasions, endoscopic or surgical procedures may become necessary to physically remove toxic agents.

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Only following stabilization of the patient's cardiorespiratory system and the administration of life-sustaining pharmaceuticals and oxygen (where indicated) are decontamination procedures to be considered and indicated in poisoned patients. The decision regarding the type of intervention must take into account how and when the exposure occurred, the physical, chemical and toxicological properties of the toxic substances and the clinical condition and stability of the patient. The principles and recommended techniques for each of the decontamination procedures were described in detail.

The main procedures to enhance the elimination of poisons are: modified dieresis; haemodialysis; haemopetfusion; peritoneal dialysis; and repeat-dose activated charcoal. The value of procedures to enhance the elimination of poisons is currently controversial, as in the large majority of poisoning cases the rapid elimination of absorbed chemicals is not feasible (due to toxicokinetics) and may also be impractical and unsafe. However, if the drug is removable by extracorporeal procedures, their use might be considered under circumstances including: severely deteriorating condition of the patient; renal impairment; and underlying medical problems. The repeated administration of activated charcoal remains a relatively easy, inexpensive, non-invasive procedure recommended to enhance the elimination of some toxic agents.

The development of immunotherapeutic methods (specifically Fab fragments), involving the generation of an antibody-toxic molecule complex in the antibody distribution space, is promising. This mechanism produces an eftlux of the toxic molecule from its binding site (receptor) leading to tissue depletion and to a plasmatic redistribution that facilitates the elimination of the d n ~ g s Benefits nf the use of Fab fragments have been shown with cardiac glycosides and colchicine, but remain to be proven with tricyclic antidepressants and other chemicals.

2.13 Role of the toxicological laboratory Ilr Kumnl A. HnJiJi, I)epnrtmer/f P a t h o l ~ , Microhiolo~ rn~d Forensic Medicine, Chziversiiy of Jorda?r, J o r h r

In life there are thousands of chemicals available for ingestion. Non research laboratories are able to detect about 100 toxins and quantitative fewer in body fluids. In toxicology screening there is no single, accurate, inexpensive method to detect all toxins and, therefore, the use of several methods to screen for toxins is a must in all toxicology laboratories. Each method differs in cost, accuracy, complexity, speed and specificity, and depends on the experience of the toxicologist.

The r u l ~ uf thr: physician is very important in dirccting the toxicology screen by providing the basic clinical information: toxins suspected; time of sampling in relation to time of ingestion and clinical condition of the patient. On the other hand, the toxicologist has a role in determining the techniques used for qualitative and quantitative analysis of toxins, interpretation of findings and the limitation of the toxicology screen within the laboratory setting.

In conclusion, the toxicology laboratory remains a selective adjunct to the clinical evaluation of the patient. Good communication between the clinician and toxicologist, proper specimens, knowledge of the laboratory procedure, and the proper use of each test are required to maximize the effectiveness of a clinical toxicology laboratory.

WHO-EM/CEHAf83-E Page 14

2.14 Toxic exposure to household products (particularly kerosene and bleach) Dr A.J. Nantel, Director, (blrtre de Toxrcolog~e dr~ Quebec, (ycrper,jolntly prepared wrrh Dr hi. R~zk,,Sy~-r~~tr F'OIJO~I O!furrn~iiiut~ ( ' e l r ~ e, hiitrr~ily uf Hecrlilr)

In North America during the last 30 years, although the number of calls to poisons information centres have increased considerably due to the fact that both the public and the health professionals are more aware of the availability of these centres; the morbidity and the mortality related to those products has decreased dramatically.

This is the result of various preventive measures that have been implemented. For example, the concentration of sodium hydroxide in household bleach has been reduced to a level that may still produce irritation of the digestive tract, but will not produce corrosive lesions. Childproof containers are now the rule for all toxic products. Even though they are not 100% effective, they significantly reduce the number of accidental exposures. As far as pesticides are concerned, these are severely regulated.

The situation is quite different in the Middle East. where household products still represent a significant risk for children. Kerosene is the substance most frequently involved and produces a significant level of morbidity and mortality. The clinical management of these cases has not changed significantly in recent years and is still symptomatic in most instances.

2.15 Solvent exposure (including "sniffing") Dr A. J. Natrtel (paper jointly prepczred wilh Dr M. Kizk)

Solvent poisoning occurs occasionally at home. Tk~products involved are paint, paint remover, leather water proofing and a few other household products. However, it is in the workplace that we find the more severe exposures. The toxicity of solvents varies greatly according not only to the dose, but also to its chemical structure. Aliphatic hydrocarbons containing 1 to 4 carbons are gases and act as simple asphyxiants. Those having between 5 and 10 carbons are volatile solvents with narcotic properties. Long-chain hydrocarbons have little toxicity since they are not volatile and are poorly absorbed by the gastrointestinal tract and skin. Cyclic hydrocarbons share the same toxicity as their aliphatic equivalent. Aromatic hydrocarbons are more complex in their toxicological properties. The same is true of halogenated hydrocarbons. c he level or narcotic effect varies greatly fi-om one to another. There are also differences in the target organs.

Chronic exposure may produce central nervous system lesions which may be either reversible or irreversible. The organic cerebral syndrome has been described both in chronically exposed workers and in solvent sniffers. This may produce neurobehavioural abnormalities, memory loss, ataxia, conhsion and, in severe cases, dementia.

In the household, solvent exposure occurs mainly by ingestion. It is usually accidental in both children and adults. The transfer of a solvent into a different container (e.g. soft drink bottle) is a frequent cause of accident.

Chemical pnuemonitis by choking or pulmonary aspiration while vomiting is still the main complication.

WHO-EWCEHA183-E Page 15

2.16 Pesticide poisoning Dr S. Shabeer H~rssain, Head, t)eparfmel~t of Medici?re. National Poison (tntre, Pakista~i

Dr Hussein described the general measures to be taken in cases of pesticide poisoning.

Organophosphate poisoning

After opening of airway and breathing, general measures of decontamination and supportive care Gastric lavage in left lateral position and after cuffed endotracheal intubation, first aspirate and then wash with water/saline Inject atropine IV, 4 mg stat. and 2 mg every 15 minutes IV. No continuous i f i s ion or syringe pump Use of sodium bicarbonate solution for stomach wash. IV infi~sion to maintain HCO; level 24 mm Eq/hour by continuous inhsion Use of oximes: paraldoxine IV 1-2 gm IV stat and gm 1-0.5 IV six-hourly. Obidoxime and newer oximcs are not used because o f cost in Pakistan and Sri Lanka Retain nasogastric tube connected to drainage bag as this prevents aspiration of ingested organophosphate into the lung Gentle restraints to prevent irritation Inject diazepam IV, 10 mg/IV whenever necessary. Repeat as required. For respiratory failure, ventilate Cardiac monitoring

2.17 Metal poisoning (particularly lead) Or A.J. Nmtel

Heavy metal poisoning is one of the main challenges in clinical toxicology. Few doctors are aware of the potential risks to health and the diagnostic methods available. Furthermore, the symptomatology of these poisonings is, most of the time. non-characteristic (i.e. fatigue, headache, loss of appetite. irritability. abdominal pain). The main problems related to heavy metals may be classified according to their frequency of occurrence:

iron in children iron in adults lead in children metallic mercury in adults lead in adults chromium in workers zinc in workers (metal fume fever) arsenic in workers and public (well water) methylmercury in specific populations aluminium in dialysis patients.

Each situation was reviewed in relation with epidemiology, clinical signs and symptoms, laboratory diagnosis and medical management.

WHO-EM/CEHA/83-E Page 16

2.18 Poisoning by pharmaceuticals: psychotrophic drug overdose Dr L.A.M. Ahdelmegid, Direcfor, Alexa~tdrin Poison Centre. Alexa~~dria (Jriiversi@

Dr Abdelmegid stressed the clinical presentation, d~agnos~s and management of the most common psychotropic drug overdose (e.g. phenothiazines), anxiolytic drugs (mainly meprobamates and benzodiazepines). antidepressant drugs (especially tricyclic antidepressants), central nervous system stimulants (amphetamine groups, cannabis group, hallucinogens and khat).

The pattern of acute poisoning cases encountered by the Alexandria Poisons Centre (APC) is as follows:

The total number of patients admitted to the APC with acute poisoning was 6500 for 1996. Over a third of the patients (36%) were aged between 15 and 25. Children under five accounted for 19.4% of the total. As a whole, males outnumbered females, except in the age g o u p 15 to 25, where females predominated. Self-poisoning accounted for 40.3% of all patients.

The frequency of types of poisoning was as follows:

food poisoning (24.7%) household preparations (2 1.2%) drug poisoning (I 8.1%) pesticides ( 14 ?Oh)

alcoholic intoxication (8.7%) gaseous poisons (mainly CO) (4.1%)

Addiction (acute overdose) was responsible for 3.8%, especially by opiates, benzodiazepines, hypnotics, antiparkinsonians and cannabis.

2.19 Management of snake bites Dr. A hcielkder Hat fah

Dr Battah surnmarised the occurrence and distribution snake bites in Jordan. A summary of the clinical manifestation of snake bites and the factors affecting the severity of envenomation were included, such as age (dose/kg) and the health of the victim, clothing, amount of venom, potency and constituent. size of snake and type and time of treatment.

Thc local manifcstatiori ursr~ake biles includes. Fdng marks, burning sensation, oedema, ecchymosis, petechiae, purpura, hemorrhagic spots, vesiculation, swelling of the extremities. The systemic manifestation includes perioral paresthesia, facial fasciculation weakness, diaphoresis. light headedness, nausea, coagulopathies (coagulation and platelets disorders and microangiopathic hemolytic anemias), organ dyshnction (pulmonary edema due to damage of the alveolar membrance which might be the cause of fatalities within 6-48 hours, [enal dysfunction, hypovolaemia, and hypotension)

The management of victims of snake bites mainly includes supportive measures (TV fluids, blood, allergy, pulmonary oedema, analgesia), the use of specific antivenin (it neutralizes

WHO-EMlCEHA183-E Page 17

the venom but does not reverse local injury and should be used as early as possible) and wound care. First aid measures include the transfer the patient to a clinic, removal of all constricting items, bed rest and reassurance light immobilization of the affected part. Below the heart the application of light constricting band above the swelling that admits a finger beneath the band.

2.20 Management of scorpion stings: Prospective study I r R. Bertkirat~e, (letltre Anti-1'0iso11.s dlr Maroc et de Pharmncovigilance, Ministdre de la Sat~td

Morocco belongs to a tropical zone where the most dangerous species of scorpions can be found. In Morocco, the most dangerous black species is A~iu'roclo?nrs matrretaniczrs, which belongs to the Buthidae family.

Scorpion stings are a serious public health problem due to their repercussions on morbidity and mortality. Assessments by the Moroccan Poisons Control Centre have shown that they are the first cause of poisoning (30%) and their lethality rate is 1.28%.

A prospective study carried out by the centre from 1995 to 1996 in four endemic regions of the country outlined the epidemiological profile as follows:

average incidence is 0.42 per mile frequency of scorpion stings among intoxications is 46% rural population represents 72% of victims average age is 25.5 years black species is implicated in 80% of cases.

According to the Abroad classification (1 995):

57.15% of the victims are in the first class 36.2%inthesecondclass 6.6% in the third class.

The average rate of lethality is 3.45% (89% of these victims being children).

The assessment of risk factors showed that:

Children are more vulnerable Clinical symptoms include priapism. fever > 38%. vomiting and sweating, and all these predict that the condition will wurberi.

The treatment given by physicians is varied and sometimes irrational. Serotherapy, as it has been used by physicians (intramuscular administration) does not prevent the victims worsening, but it gives a sense of "false security" to the physician, who then neglects the patients and delays hospitalization.

Through the centre's study. the management proposals that emerge a re as follows.

Monitor patients for 4 hours by surveying the pulse rate, blood pressure, respiratory rate and temperature, until complete recovery. Hospitalize patients with vital distress signs in an intensive care unit.

WHO-EM/CEHA/83 -E Page 18

Promote symptomatic treatment by using inotropic drugs and assisted ventilation in cardiac distress. Eliminate serotherapy as it is presently used. Promote a broad pl eventiur~ p~ ugl aliune ill tlie enderriic I egioris.

2.21 Management of exposure to aquatic biotoxins Dr A bdelkcrder Bcrttnh

Exposure to aquatic biotoxins can occur as food borne poisoning or due to direct contact with poisonous aquatic animals. Examples of aquatic venom include:

coelenterates serotonin, ATPase, hyaluronidase, filorinolysin, peripheral calcium antagonist, neurotoxin (tetramine), myocardial depressing proteins Sea Urchins: serotonin. steroid glycosides, acetyl choline like substances Sea Cucumbers: holothurin, cardiac glycosides Motlusca: neurotoxins Scorpion fish, stone fish: high molecular weight substances, heat labile protein.

Local manifestat~ons of exposure to poisonous aquatic animals include several presentations depending on the animal venom and include local pain, oedemas. linear erythematous vesicular lesion on the skin which might last up to 1 month, hyposthasia, cyanosis and ischaemia, indolent ulcer and contact dermatitis.

The systemic manifestation includes weakness, paralysis, hoarseness of voice, dysphasia, diplopia, slurred speech, fever, chill, abdominal pain, muscle spasm, vasodilatation, hypotension, muscular weakness, respiratory paralysis, tachycardia, dyspnoea, vomiting, pallor and headache.

The management of victims of such exposure mainly includes supportive measures and special precautions to limit further discharge of the venom, inactivate the nematocysts or other structures containing the venom, wound cleaning to remove the structures and other supportive management, e.g. hot water bath of 40-45 "C, and consideration of the use of antihistamines, antibiotics, analgesics. local steroids, tetanus and antivenins as applicable.

3. PLENARY SESSION AND DISCUSSIONS

Dr Haines reviewed the five questionnaires received and he summarized their content:

most of those who replied have basic facilities for access to information such as libraries, computers, Windows 95 most have poor access to commercial data bases or other computerized information systems all lack resources lack of ability to collect local data. requirements: need for training of professionals in toxicology; need for on-the-job training

Dr Haines summarized the recommendations of the other group and then opened the

WHO-EM/CEHA/83-E Page 19

discussion to identify other needs.

Mrs Hennawy (Fgypt), stressed the importance of local data collection

The participant from Palestine proposed the creation of a Regional Toxicology Centre, well equipped and well funded instead of a national centre in each country. Dr Semra considered this proposal theoretically interesting but that in practice it would be very di£Eicult to establish and manage, particularly as far as national data collection is concerned. Dr Haines stressed that the networking of national centres seemed more appropriate. In addition, large countries should establish several centres as was the case in Islamic Republic of Iran and Pakistan. The collection of data in an harmonized way is important for an efficient networking between centres.

Dr Semra suggested a review of the various possibilities offered by P C S

Dr Haines briefly reviewed the access to information presented and demonstrated by ILO, UNEP, WHO as well as those which can be provided by IPCS, such as INCHEM, the N T O X project.

Upon the request from the participant from Palestine. Dr Haines mentioned the three components of a National Poison Centre which are a) treatment facilities, b) laboratory facilities and c) poison information centre.

Dr Semra recommended 1t1e i r ~ ~ l u s i u ~ ~ iri the plan uf action uf the national centres a programme of public awareness e.g. television, radio, printed material.

The participant from Pakistan recommended the inclusion of clinical toxicology in the education of professionals and su,ogested that the WHO advise and make recommendations to countries on this issue.

1. CONCLUSIONS

Participants of Workshop I and Workshop 11 reviewed the capabilities and capacities for chemicals information management in relation to their own responsibilities. Most participants reported that chemicals information facilities in their own country were inadequate for implementing the sound management of chemicals. Adequate space and resources were lacking. While some library resources are available, access to scientific literature is often limited and few countries have access to a full range of databases on chemicals. Computers are available in most countries, but capacities need strengthening and access to e-mail and the Internec improved. A few countries have developed information management tools for specific applications, but there are no systems in operation allowing international comparability of data. There is a strong need for education and training of human resources in the field of chemicals information.

Poisonings are due mainly to pesticides (organophosphorus compounds, carbarnates, pyrethroids, warfarines, phosphides), hydrocarbons (mainly kerosene) and pharmaceuticals (benzodiazepines, trycyclic an tidepressan ts, an ticonvulsants and paracetamol). Opiate overdoses are observed with increasing frequency. Poisoning by carbon monoxide is quite

WHO-EMJCEHA.83 -E Page 20

frequent in winter months, due to primitive heating systems, and affects mainly the poor population. Several mass poisoning episodes by methanol and ethylene glycol, with dramatic consequences have been registered. In the occupational setting, poisonings are quite common, but unfortunately not registered by the poisons centre (eg. sulfur dioxide encephalopathy in the sulfur industry). Poisoning by plants is seen mainly in the Mahgreb countries. The main circumstances of exposures are accidents in children and suicides (or parasuicides) in adults, as observed in the rest of the world.

Discussions on poison centre needs were based upon the results of surveys undertaken on Poisons Control Facilities and Initiatives, completed by participants. The surveys demonstrated that Poison Centres (PC) have already been set up in Egypt (Alexandria), Iraq (Mosul) , Morocco (Rabat), Syrian Arab Republic (Damascus) and Tunisia (Tunis). Some of these centres have been established and running for many years, have clinical and analytical facilities and have developed training and prevention activities. Other centres, such as the one in Damascus, have been set up very recently and are still facing the difficulties concerning the organisation of activities, training of the staff and recognition by the medical community. A Chemical Information Centre has been set up in Amman, at the Ministry of Health and Health Care, but it does not have medical nor analytical functions, and has not yet developed training or preventive activities. Initiatives for the setting-up of a poisons centre have been identified in Lebanon as a result of this workshop.

The workshops noted that all governments have recognised through the Rio ~eclarat ionl , and recently reaffirmed at the Special Session of thc UN Gcncral ~ s s e r n b l ~ ' ,

that, while the use of chemicals is essential in the development process, they must be managed in a sound manner, so as to protect human health and the integrity of the environment. All countries have been called upon to develop policies for sound management of chemicals and to establish and implement chemical safety programmes at national, regional and local levels, taking into consideration the intersectoral dimension of the use of chemicals and the need for all segments ofthe comrnunlty in a country to be involved. Thls calls tor policy direction at the highest level in government, so as to ensure efficient co-ordination among all departments concerned and effective implementation of chemical safety measures. Ministries of health need to be active partners in national chemical safety programmes and should establish and strengthen their own programmes for sound management of chemicals.

Access to chemicals information in forms easily used is reco,snized as a prerequisite for implementing specific aspects of chemical safety in countries. The workshops recognized that the databases and information management systems provided by international orga~sations, such as WHO, ILO and UNEP and the collaborative programme PCS. are valuable chemicals information resources for countries, which further promote the collection of comparable data among countries.

A poison control programme is further recognized as an essential element of chemical safety in a country. Chemical information centres and related clinical and analytical facilities

I United Nations Conference on Environment and Developtnmt, held in Rio de Janciro. Bnzil. June 1992.

7 - New York June 1997

WHO-EWCEHA183 -E Page 2 1

provide the infrastructure for implementing poison control programmes, including the medical response to chemical emergencies. In implementing the Rio Declaration all countries are called upon to establish and strengthen poison control facilities3. The meeting recognized and appreciated that the IPCS Guidelines on Poisons Control provide a basis for countries to establish their own poisons control programmes. Further, the P C S INTOX package has been developed to provide an information management system for poisons information centres.

5. RECOMMENDATIONS

1. Each country should strengthen its capabilities and capacity for chemicals information with improved access to evaluated data. the implementation of chemicals information management systems for recording local data and the provision of information to all who need it to implement sound management of chemicals.

2. Each country should develop a comprehensive programme for poisons control and chemical emergency response, building on existing facilities and planning a realistic time- framed implementation plan, to ensure adequate coverage for the whole country. Plans should be drawn up to establish and strengthen poisons information and related clinical and analytical facilities consistent with the internationally agreed criteria given in the IPCS Guidelines on Poisons Control, including availability of antidotes.

3 . Each country should ensure adequate access for those responsible for implementing sound management of chemicals to the databases of international organizations which provide evaluated pccr reviewed information o n chemicals, such as through the databases of IPCS INTOX and INCHEM, UNEPIIRPTC, ILOICIS and WHO

4. Each country should strengthen library resources at key chemical information centres, ensuring adequate geographic coverage within a country. Each centre should be equipped with up-to-date computing facilities, dedicated telephone and fax lines and ready, permanent access to e-mail and the Interr~el. Appr up1 iatc internationally available chemicals information management systems, e.g. IPCS INTOX system for poisons centres and IPCS product registry system for ministries, should also be made available and staff trained to use such systems.

5 . A11 countries should ensure that in their area, educational opportunities on toxicology, particularly in the areas of human toxicology. On-the-job training for chemicals information specialists, clinical and analytical toxicologists should be provided. Where appropriate, fellowships for training at centres of excellence in other countries may be provided.

6 . Each country should establish a register of all chemical substances and products commercially traded in the country, ensuring that data conforming to the recommendations for Material Safety Data Sheets (MSDS) of IL0 Convention 170 are provided, making this data available to bona fide chemicals information providers, such as

3 Recommendation for priority action by the lntergovcm~nental Forum on Chemical Safety (IFCS) at its first session,

Siackholm. Sweden, April 1994.

WHO-EMICEHAI83 -E Page 22

poisons information and chemical emergency centres. It is recommended that consideration be given to the use of the IPCS products database management system for this purpose.

Harmonized data collection based on internationally agreed formats, such as the IPCS INTOX formats for poisoning cases and chemical incidents, should be promoted. Poisons centres and chemical emergency centres should prepare annual reports of their activities. It is proposed that all countries exchange these annual reports and provide copies to the IPCS.

Centres collecting poisoning cases should participate in multi-centre studies of specific types of poisoning of local interest, e.g. pesticide poisoning. Chemical emergency centres should participate in reporting chemical incidents to the WHO Collaborating Centre established for this purpose.

Each country should promote programmes for prevention of exposure to toxic chemicals and for public awareness, with the training of personnel for this purpose. Furthermore, appropriate available information on chemicals should be adapted and disseminated in each country for this purpose.

Newly established poisons centres in countries should be encouraged to twin with well- established centres within the Region or in other regions, through which exchange of materials, antidotes, equipment and training can be promoted.

The establishment of professional bodies for promoting toxicology within a country and at a Regional level should be promoted.

Poisons centres should be encouraged to participate in international meetings of the IPCS INTOX project and contribute to the IPCS TNTOX Library Union Listing: Chemical emergency centres should be encouraged to participate in the international IPCS activities on chemical incidents. Centres should take part in the INTOX e-mail networking arrangements.

While recognizing the (advanced) development of a legally-binding instrument on the UNEPBAO Prior Informed Consent (PIC), countries are encouraged to establish their own lists of banned and restricted chemicals and make them available for exchange among countries of the Region

In order to support the implementation of these recommendations, WHO/EMRO. WHO/HQ, UNEP, K O and the IPCS are requested, as appropriate, to:

promote the provision of and hnding for subscriptions to international databases and information management systems, e.8. P C S mTOX package and INCHEM CD-ROM, and ILOICIS, UNEP/TRPTC, WHO Environmental Health. At leqst one set should be provided in each country for the 1998- 1999 biennium; promote the participation of poisons centres and chemicals information centres in the IPCS global projects in these fields, providing the necessary hnding;

WHO-EMICEHN83-E Page 23

c) promote the provision of P C S information management systems in languages used in the Region, such as Arabic, Farsi and French;

d) organize, on a regular basis, sub-regional meetings of experts to promote the strengthening of chemicals information capabilities in countries; and

e) organize training workshops for professionals in the field of chemicals information, including poisons control; also providing, as appropriate, training fellowships.

15. WHOIEMRO is requested to give consideration to identifying. during the 1998-1999 biennium, WHO Collaborating Centres to provide information resources to countries of

I the Region for chemicals information. including poisons control.

I

16. The workshops recommended that hrther collaboration be promoted among the , international organizations providing chemicals information resources in their work of

i technical cooperation with countries of the Region.

Annex I

AGENDA

1. Registration 2. Opening session 3. Overview of Chemicals lnformation Systems

INTOX and INCHEM Products database, chemical incidents database project WHOEHG environmental health databases Clearing house for information on chemicals management and safety ILOICIS database Jordanian experience

Workshop I Chemicals Information Management

TPCS INCHEM CD-ROM Presentation and practical work (Dr M. Ruse) P C S products register Presentation and practical work (Mr D. Brophy) IPCS chemical incidents database project Collection and reporting, presentation and practical work Environmental health databases Presentation and practical work (Ms A. M. Pfister) UNEP Databases Presentation and practical work (Ms B. Bender) ILO/CIS databases Presentation and practical work (Dr E. Clevenstine) Practical Training Review of Workshop Evaluation of the workshop/Recommendations

Workshop II. Collection of Harmonised Case Data (IYTOX) and Management of Toxic Exposures

12. IPCS MTOX system Presentation: Data searching (Mr D. Brophy) - Data entry arid preparatiuri fur pra~tical trair~irig (MI D. B~uplly) Practical training in use of MTOX system (Dr M. Ruse)

13. Management of specific types of poisoning Management of acute poisoning Decontamination techniques and enhancement of elimination Role of the toxicology laboratory Toxic exposure to household products, particularly kerosene and bleach Solvent exposure (including "sniffing")

7

Poisoning by pesticides (particularly organophosphorus) * Poisoning by metals, particularly lead

WHO-EM/CEHA/83 -E Page 25

Poisoning by pharmaceuticals: Psychoactive drugs and analgesics Exposure to natural toxins: Management of snake bites Management of scorpion stings Management of exposure to aquatic biotoxins

1. Review of workshop 2. Evaluation of the workshop 3 . Plenary session held jointly for both workshops 4. Adoption of recommendations 5. Closing ceremony

WHO-EM/CEHA/83-E Page 26

Annex 2

PROGRAMME Monday, 3 Novembcr 1997

08:30 - 09:OO Openins sessiol~ Presentations by Representatives of Government of Jordan; IPCS, EMRO, UNEP and ILO Session I : Overview of chemicals information systems

09:30 - 1O:OO P C S INTOX (1)r M. Klrse) IPCS INCHEM (Dr. M. RIISC)

1O:OO - 10:30: P C S Products Database (Ilr ./.A. Hni~res) IPCS Chemical Incidents Database Project (ilr J.A. Htrities)

10:30- 11:OO : WHO/EHG environmental health databases (Ms A.M. Iljister) 1l:OO - 11130 UNEP clearing house for information on chemicals management

and safety (%is H . Hc'IIL'I) 11 :30 - 12:OO ILOICIS Database (111. E. ( 'leve~r.stirre) 12:OO - 12:30 Jordanian Experience: Chemicals Information Centre (1Mr M. Khnlil)

Workshop 1. Chemicals Information Management (at CEHA)

Monday, 3 November 1997

14:UU - 17:UU Sess~on 1l:lPC:S lNCHEM CD-ROM Presentation and practical work (ilr M. Hnse)

Tuesday, 4 November 1997

09:OO - 10:30 Session 111: UNEP Databases Presentation and practical work (1Ms H. He)~der)

11:OO - 12:30 Session IV: ILO/CIS Database Presentation and practical work (111. E. ( ' I ~ I Y I I S ~ ~ ) I ~ )

13:30 - 15:OO Session V: IPCS Chemical Incidents Database Project Collection and reporting, presentation and practical work (ilr .].A. Hairtes)

15:30 - 17:OO Session VI: Environmental Health Databases Presentation and practical work (Us A.M. Pfster)

Wednesday, 5 November 1997

09:OO - 12:30 Session VII: IPCS Products Register Presentation and practical work & f r D. Brophy)

13:30 - 17:OO Session VIII: Practical Training Working groups

WHO-EMlCEHAf83 -E Page 27

Thursday, 6 November 1997

09:OO - 12:OO Session IX: Review of Workshop Evaluation of the Workshop Recommendations

12:OO - 12:30 Closing Ceremony

Workshop 11. Collection of Harmonized Case Data (INTOX) and Management of Toxic Exposures

(at the Chemicals Information Centre, Ministry of Health)

Monday, 3 November 1997

l3:30 - 15:OO Session 11: P C S INTOX System Presentation: Data Searching ('Mr 1). Hrophy)

15:30 - 17:OO Session 11 continued Data entry and preparation for practical training ('MI' 1). Hruphy)

Tuesday, 4 November 1997

09:OO - 12:30 Session 111: IPCS INTOX System Practical training in use of TNTOX system (1)r M. Krisc?)

13:30 - 17:OO Session 111 continued (A4r D. Hrophy)

Wednesday. 5 November 1997

Session IV: Management of specific types of poisoning Objectives: To present the latest trends concerning the diagnosis and managment of poisoning. to review and discuss the main poisoning/envenoming problems observed in countries of the region.

Management of acute poisoning (Ilr A. Htittcih) Decontamination techniques and enhancement of elimination (Ilr .I. F'rotrczrik) Role of the toxicology laboratory (Ilr Ktintal A1 Htrdidi) Toxic exposure to household products, particularly kerosene and bleach (Dr A .J. N~itttel4lr M. Rizk) Solvent exposure (including "sniffing") (Ilr A.J. N~nrtel/Ilr M. Rizk) Poisoning b y pesticides (particularly Organophosphonls) /I)r _J F'ror~cz~~hDr S. Shahrer H~l.s.snitl) Poisoning by metals, particularly lead (I)r A..I. NmtteI) Poisoning by pharmaceuticals: Psychoactive drugs and Analgesics (Ilr L. Ahdrl Magiici)

Thursday, 6 November 1997 f

09:OO - 11 :00 Exposure to natural toxins: 09:OO - 09:45 Management of snake bites (Ilr A. Hnttnh) 09:45 - 10: 15 Management of scorpion stings (Ilr K. Hetrhrrnrr)

WHO-EM/CEHA/83-E Page 28

10115 - 11:OO Management of exposure to aquatic biotoxins fllr A. Battah) i 11:30 - 12:OO Session V: Review of Workshop

I Evaluation of the Workshop

I 12.00 - 12.30 Closing Ceremony

WHO-EMICEHN83-E Page 29

Annex 3

LIST OF PARTICIPANTS

Workshop I

EGYPT

Dr Hala El Hennawy Chemical Safety Oficer, Chemical Safety Unit Ministry of Health and Population Cairo

ISLAMIC REPUBLIC OF lRAN

Miss Taybeh Elahi Department of Environmental and Occupational Health Ministry of Health and Medical Education Boulvnr Ave. Building No. 2 of Ministry of Health P.O. Box 16346 Teheran

JORDAN

Mr Akram Al-Salahat Chemist, Directorate of Environmental Health Ministry of Health P.O. Box 86 h m a n

Mr Maher Shehadeh Chemist, Directorate of Environmental Health Ministry of Health P. 0. Box 86 Amman

Mr Nart Ismail Information Centre hfinistry of Health P. 0. Box 86 Amman

Major Abed Al-Karim Rashrash Civil Defence Amman

Ms Ghada Khriesat Chemist, Ministry of Agriculture Amman

Mr Mounir Asaad National Information Centre Amman

MOROCCO

Mr Driss Machraa Chemical Engineer, Environmental Health Department Millist~y uT Public Health Rabat 1 1400

PAKISTAN

Professor Zafarullah Sheikh Director, Institute of Chemical Engineering and Technology University of Punjab Quaid-e-Azam Campus Lahore 54590

Mr Zaheer Nasir Internat~onal Llalson Section Palustan Scientific & Technological Information Centre (PASTIC) Quaid-Azam University Campus P. 0. Box 12 17 Islamabad

PALESTINE

Mr Hazem H. Qawasmeh Environmental Engineer, Palestinian Environmental Authority P.O. Box 296 Hebron

Mr Mohamed Othman Manager, Waste Disposal Unit Department of Environmental Health Ministry of Health P.O. Box 3676 Albireh Ramallah

WHO-EMlCEHN83-E Page 3 0

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WHO-EIWCEHA183 -E Page 3 1

SYRIAN ARAB REPUBLIC

Mrs Mayada Sheikh Al-Haddadine Plant Protection Directorate Division of Pesticides Ministry of Agriculture Damascus

Dr Bassam Abou-Alzahab Head, Occupational Health Division Ministry of Health Damascus

TUNISIA

Dr Samira Miled Ministere des Affaires Sociales Institut de Sante et de Securite au Travail 5 avenue Mustapha Khaznadar Mellassine C.P. 1007 Tunis

Workshop I1

EGYPT

Dr Laila Abdel Maguid Director, Alexandria Poison Centre Department nf Fnrensic Medicine, Faculty of Medicine Alexandria University P.O. Box 525 Manshia 2 1 1 1 1 Alexandria

Professor Raad A. Ahmad Clinical Pharmacologist, Dean of College of Pharmacy University of Mosul Mosul

JORDAN

Dr AbedelKader Battah The University of Jordan Faculty of Medicine Amman

WHO-EWCEH.4183-E Page 32

Dr Kamal A. Hadidi University of Jordan Hospital Department Pathology, Microbiology

and Forensic Medicine University of Jordan Amman

Major Dr Mohamed Al-Zubi Royal Medical Service Amman

Dr Ali Al Qudah Health Directorate of 11-bid Irbid

Dr Samir Al-Faouri Al-Basheer Hospital Amman

LEBANON

Dr Aziz Geahchan Toxicologist, Toxicology Laboratory Mar Youssef Hospital U~liversity uf Lebanon Beirut

MOROCCO

Dr Raja Benkirane Centre Anti-Poisons du Maroc et de Pharrnacovigilance Institut National &Hygiene Ministere de la Sante 27 avenue Ibn Batouta B.P. 769 Rabat 1 1400

PAKISTAN

Dr S. Shabeer Hussain Head, Department of Medicine National Poison Control Centre Jinnah Postgraduate Medical Centre Karachi 755 10

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WHO-EM/CEHA/83-E Page 33

PALESTINE

Mr Sarnir Abu-El-Haj Birzeit University Center for Environmental & Occupational Health Sciences P.O. Box 14 RamallahIWest Bank

SYRIAN ARAB REPUBLIC

Dr Marina Rizk Syrian Poison Information Centre Ministry of Health Qaymariah Bab Torna No. 157 Damascus

Dr Firas Abdolwahed Syrian Poison Information Centre Ministry of Health Qaymariah Bab Toma No. 157 Damascus

Dr Mona Khoury Syrian Poison Information Centre Ministry of Healt h Qaymariah Bab Toma No. 157 Damascus

TUNISIA

Dr Mongi Zhioua Centre Anti-Poisons Centrea dlAssistance Medicale Urgente 1008 Montfleury Tunis

Other Organizations

Ms Brenda Bender. UNEP Chemicals (IRPTC), 15 chemin des Anemones. C.P. 356, 12 19 Chhelaine, Switzerland Tel: 4 1-22-9699 187, Fax: 4 1-22-7973460 E-mail: bbender@unep.ch

Mr David Brophy, Canadian Centre for Occupational Health and Safety, 250 Main Street East Hamilton, Ontario L8N lH6, Canada Tel: 1-905-572449 1, Fax: 1-905-5722206, E-mail: d.brophy@ccohs.ca

Mr Emrnert Clevenstine, International Occupational Safety and Health Information Centre (CISEO), International Labour Organisation, 4 rue des Morillons

WHO-EWCEHM83-E Page 34

12 1 1 Geneva 22, Switzerland Tel: 4 1-22-79983 17, Fax: 4 1-22-7986253, E-mail: clevenstine@ilo.org

Dr Albert J. Nantel, Director, Centre de Toxicologic du Quebec, 2705 boulevard Laurier Sainte-Foy, Quebec GI V 4G2, Canada Tel: 1-4 18-6542254, Fax: 1-4 18-6542 148, E-mail: ajnantel@riq.qc.ca

Ms Anne-Marie Pfister, Office of Global and Integrated Environmental Health (EHG), World Health Organization, 20 avenue Appia, 12 1 1 Geneva 27, Switzerland Tel: 4 1-22-79 13548, Fax: 4 1-22-79 14 123, E-mail: pfisteram@who.ch

Dr Mike J. Ruse, IPCS PJTOX Consultant, Medical Toxicology Unit, Avonley Road London SE14 SER, United Kingdom Tel: 44- 17 1-77 15364, Fax: 44- 17 1-77 15363. E-mail: ruseOdircon.co.uk

0 bservers

Ms Samar Al-Rawashdeh, Chemist, Directorate of Environmental Health, Ministry of Health and Health Care, Amman, Jordan

Dr Baseem Bani Hani, Doctor. Directorate of Health Safety. Ministry of Health and Health Care, Amman, Jordan

Dr Fayez Al-Jarery, Doctor, Directorate of Health Safety, Ministry of Health and Health Care, Amman. Jordan

Major Dr Wahid Al-Shakouri, Royal Medical Services, Amman, Jordan

Dr Saed Al-Azab, Al-Basheer Hospital. Amrnan, Jordan

L)r Abdallah Al-Sharman, Al-Basheer Hospital, Amman, Jordan

Dr Manvan Hiyyassat, Al-Basheer Hospital, Amman, Jordan

Lieutenant Ahmad Habahbeh, Public Security Directorate. Amman, Jordan Eng. Hussein M.S. Al-Hamidi, Protection Department, Civil Defence, Amrnan, Jordan

WHO Secretariat

Dr M.Z. Ali Khan, Coordinator, WHO Regional Centre for Environmental Health Activities, P.O. Box 926 967, Amman 1 1 1 10. Jordan Tel: 962-6-55246551553 1657, Fax: 962-6-55 1659 1, E-mail: who-ceha@go.com.jo

Dr Semra Uluatam, Training and Research Adviser, WHO Regional Centre for Environmental Health Activities, P.O. Box 926 967, Amman 1 1 1 10, Jordan Tel: 962-6-55246551553 1657, Fax: 962-6-55 1659 1, E-mail: who-ceha@go.com.jo

WHO-EM/CEHA/83 -E Page 3 5

Mr Mazen Khalil, Director, Chemical Information Centre, Environmental Health Directorate Ministry of Health and Health Care, P.O. Box 86, Amman Tel: 962-6-666 147. Fax: 962-6-666 147

Mrs Fatirna Al-Tawalbeh, Environmental Health Directorate, Ministry of Health and Health Care, P.O. Box 86, Amman, Tel: 962-6-666 147. Fax: 962-6-666 147,

Dr Sarnir Qammaz, Director, Drug Quality Control Laboratory, Ministry of Health and Health Care, Amman

Mrs Janet Dumenil, Poisoning Prevention and Control, International Programme on Chemical Safety, World Health Organizatiur~, 20 avenue Appia, 12 1 1 Geneva 27, Switzcrland Tel: 41 -22-79 13 590, Fax: 4 1-22-79 14848. E-mail: dumenil@who.ch or dumenilj@who.ch

Dr John A. Haines, IPCS INTOX Project Leader, Chief, Poisoning Prevention and Control, International Programme on Chemical Safety. World Health Organization, 20 avenue Appia. 12 1 1 Geneva 27, Switzerland 1 el: 4 1-22-79 13573, Fax: 4 1-22-79 14848, E-mail. haines@whu.c;h ur l~ai~i~sja@who.cli

Dr J. Pronczuk, Poisoning Prevention and Control. International Programme on Chemical Safety, World Health Organization, 20 avenue Appia, 12 1 1 Geneva 27, Switzerland Tel: 41-22-79 13602, Fax: 4 1-22-79 14848, E-mail: pronczukj@who.ch