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      Effectiveness of household lockable pesticide storage to reduce pesticide self-poisoning in rural Asia: a community-based, cluster-randomised controlled trial

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          Summary

          Background

          Agricultural pesticide self-poisoning is a major public health problem in rural Asia. The use of safer household pesticide storage has been promoted to prevent deaths, but there is no evidence of effectiveness. We aimed to test the effectiveness of lockable household containers for prevention of pesticide self-poisoning.

          Methods

          We did a community-based, cluster-randomised controlled trial in a rural area of North Central Province, Sri Lanka. Clusters of households were randomly assigned (1:1), with a sequence computer-generated by a minimisation process, to intervention or usual practice (control) groups. Intervention households that had farmed or had used or stored pesticide in the preceding agricultural season were given a lockable storage container. Further promotion of use of the containers was restricted to community posters and 6-monthly reminders during routine community meetings. The primary outcome was incidence of pesticide self-poisoning in people aged 14 years or older during 3 years of follow-up. Identification of outcome events was done by staff who were unaware of group allocation. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT1146496.

          Findings

          Between Dec 31, 2010, and Feb 2, 2013, we randomly assigned 90 rural villages to the intervention group and 90 to the control group. 27 091 households (114 168 individuals) in the intervention group and 26 291 households (109 693 individuals) in the control group consented to participate. 20 457 household pesticide storage containers were distributed. In individuals aged 14 years or older, 611 cases of pesticide self-poisoning had occurred by 3 years in the intervention group compared with 641 cases in the control group; incidence of pesticide self-poisoning did not differ between groups (293·3 per 100 000 person-years of follow-up in the intervention group vs 318·0 per 100 000 in the control group; rate ratio [RR] 0·93, 95% CI 0·80–1·08; p=0·33). We found no evidence of switching from pesticide self-poisoning to other forms of self-harm, with no significant difference in the number of fatal (82 in the intervention group vs 67 in the control group; RR 1·22, 0·88–1·68]) or non-fatal (1135 vs 1153; RR 0·97, 0·86–1·08) self-harm events involving all methods.

          Interpretation

          We found no evidence that means reduction through improved household pesticide storage reduces pesticide self-poisoning. Other approaches, particularly removal of highly hazardous pesticides from agricultural practice, are likely to be more effective for suicide prevention in rural Asia.

          Funding

          Wellcome Trust, with additional support from the American Foundation for Suicide Prevention, Lister Institute of Preventive Medicine, Chief Scientist Office of Scotland, University of Copenhagen, and NHMRC Australia.

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          Most cited references34

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          Medical management of paraquat ingestion.

          Poisoning by paraquat herbicide is a major medical problem in parts of Asia while sporadic cases occur elsewhere. The very high case fatality of paraquat is due to inherent toxicity and lack of effective treatments. We conducted a systematic search for human studies that report toxicokinetics, mechanisms, clinical features, prognosis and treatment. Paraquat is rapidly but incompletely absorbed and then largely eliminated unchanged in urine within 12-24 h. Clinical features are largely due to intracellular effects. Paraquat generates reactive oxygen species which cause cellular damage via lipid peroxidation, activation of NF-κB, mitochondrial damage and apoptosis in many organs. Kinetics of distribution into these target tissues can be described by a two-compartment model. Paraquat is actively taken up against a concentration gradient into lung tissue leading to pneumonitis and lung fibrosis. Paraquat also causes renal and liver injury. Plasma paraquat concentrations, urine and plasma dithionite tests and clinical features provide a good guide to prognosis. Activated charcoal and Fuller's earth are routinely given to minimize further absorption. Gastric lavage should not be performed. Elimination methods such as haemodialysis and haemoperfusion are unlikely to change the clinical course. Immunosuppression with dexamethasone, cyclophosphamide and methylprednisolone is widely practised, but evidence for efficacy is very weak. Antioxidants such as acetylcysteine and salicylate might be beneficial through free radical scavenging, anti-inflammatory and NF-κB inhibitory actions. However, there are no published human trials. The case fatality is very high in all centres despite large variations in treatment. © 2011 The Authors. British Journal of Clinical Pharmacology © 2011 The British Pharmacological Society.
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            • Record: found
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            Self poisoning with pesticides.

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              • Record: found
              • Abstract: not found
              • Article: not found

              Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries.

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                Author and article information

                Contributors
                Journal
                Lancet
                Lancet
                Lancet (London, England)
                Elsevier
                0140-6736
                1474-547X
                21 October 2017
                21 October 2017
                : 390
                : 10105
                : 1863-1872
                Affiliations
                [a ]Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, and Centre for Pesticide Suicide Prevention, University of Edinburgh, Edinburgh, UK
                [b ]South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
                [c ]School of Social and Community Medicine, University of Bristol, Bristol, UK
                [d ]Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
                [e ]Department of Community Medicine, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
                [f ]Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
                [g ]Sydney Medical School, University of Sydney, Sydney, Australia
                [h ]Provincial Department of Health Services, Anuradhapura, North Central Province, Sri Lanka
                [i ]Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
                [j ]Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
                Author notes
                [* ]Correspondence to: Prof M Eddleston, Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UKCorrespondence to: Prof M Eddleston, PharmacologyToxicology and TherapeuticsUniversity/BHF Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghEH16 4TJUK m.eddleston@ 123456ed.ac.uk
                Article
                S0140-6736(17)31961-X
                10.1016/S0140-6736(17)31961-X
                5655546
                28807536
                45cfe8e1-4bf2-43c0-852e-68b7b37884a1
                © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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