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      The global distribution of fatal pesticide self-poisoning: Systematic review

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          Abstract

          Background

          Evidence is accumulating that pesticide self-poisoning is one of the most commonly used methods of suicide worldwide, but the magnitude of the problem and the global distribution of these deaths is unknown.

          Methods

          We have systematically reviewed the worldwide literature to estimate the number of pesticide suicides in each of the World Health Organisation's six regions and the global burden of fatal self-poisoning with pesticides. We used the following data sources: Medline, EMBASE and psycINFO (1990–2007), papers cited in publications retrieved, the worldwide web (using Google) and our personal collections of papers and books. Our aim was to identify papers enabling us to estimate the proportion of a country's suicides due to pesticide self-poisoning.

          Results

          We conservatively estimate that there are 258,234 (plausible range 233,997 to 325,907) deaths from pesticide self-poisoning worldwide each year, accounting for 30% (range 27% to 37%) of suicides globally. Official data from India probably underestimate the incidence of suicides; applying evidence-based corrections to India's official data, our estimate for world suicides using pesticides increases to 371,594 (range 347,357 to 439,267). The proportion of all suicides using pesticides varies from 4% in the European Region to over 50% in the Western Pacific Region but this proportion is not concordant with the volume of pesticides sold in each region; it is the pattern of pesticide use and the toxicity of the products, not the quantity used, that influences the likelihood they will be used in acts of fatal self-harm.

          Conclusion

          Pesticide self-poisoning accounts for about one-third of the world's suicides. Epidemiological and toxicological data suggest that many of these deaths might be prevented if (a) the use of pesticides most toxic to humans was restricted, (b) pesticides could be safely stored in rural communities, and (c) the accessibility and quality of care for poisoning could be improved.

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          Most cited references 109

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          Risk factors for suicide in China: a national case-control psychological autopsy study.

          Suicide is the fifth most important cause of death in China, but the reasons for the high rate and unique pattern of characteristics of those who kill themselves are unknown. We pretested, and then administered a comprehensive interview to family members and close associates of 519 people who committed suicide and of 536 people who died from other injuries (controls) randomly selected from 23 geographically representative sites in China. After adjustment for sex, age, location of residence, and research site, eight significant predictors of suicide remained in the final unconditional logistic regression model. In order of importance they were: high depression symptom score, previous suicide attempt, acute stress at time of death, low quality of life, high chronic stress, severe interpersonal conflict in the 2 days before death, a blood relative with previous suicidal behaviour, and a friend or associate with previous suicidal behaviour. Suicide risk increased substantially with exposure to multiple risk factors: none of the 265 deceased people who were exposed to one or fewer of the eight risk factors died by suicide, but 30% (90/299) with two or three risk factors, 85% (320/377) with four or five risk factors, and 96% (109/114) with six or more risk factors died by suicide. Despite substantial differences between characteristics of people who commit suicide in China and the west, risk factors for suicide do not differ greatly. Suicide prevention programmes that concentrate on a single risk factor are unlikely to reduce suicide rates substantially; preventive efforts should focus on individuals exposed to multiple risk factors.
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            Suicide rates in China, 1995-99.

            A wide range of suicide rates are reported for China because official mortality data are based on an unrepresentative sample and because different reports adjust crude rates in different ways. We aimed to present an accurate picture of the current pattern of suicide in China on the basis of conservative estimates of suicide rates in different population cohorts. Suicide rates by sex, 5-year age-group, and region (urban or rural) reported in mortality data for 1995-99 provided by the Chinese Ministry of Health were adjusted according to an estimated rate of unreported deaths and projected to the corresponding population. We estimated a mean annual suicide rate of 23 per 100,000 and a total of 287,000 suicide deaths per year. Suicide accounted for 3(.)6% of all deaths in China and was the fifth most important cause of death. Among young adults 15-34 years of age, suicide was the leading cause of death, accounting for 19% of all deaths. The rate in women was 25% higher than in men, mainly because of the large number of suicides in young rural women. Rural rates were three times higher than urban rates-a difference that remained true for both sexes, for all age-groups, and over time. Suicide is a major public-health problem for China that is only gradually being recognised. The unique pattern of suicides in China is widely acknowledged, so controversy about the overall suicide rate should not delay the development and testing of China-specific suicide-prevention programmes.
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              Patterns and problems of deliberate self-poisoning in the developing world.

              Deliberate self-harm is a major problem in the developing world, responsible for around 600 000 deaths in 1990. The toxicity of available poisons and paucity of medical services ensure that mortality from self-poisoning is far greater in the tropics than in the industrialized world. Few data are available on the poisons most commonly used for self-harm in different parts of the world. This paper reviews the literature on poisoning, to identify the important poisons used for self-harm in these regions. Pesticides are the most important poison throughout the tropics, being both common and associated with a high mortality rate. In some regions, particular pesticides have become the most popular method of self-harm, gaining a notoriety amongst both health-care workers and public. Self-poisoning with medicines such as benzodiazepines and antidepressants is common in urban areas, but associated with few deaths. The antimalarial chloroquine appears the most significant medicine, self-poisoning being common in both Africa and the Pacific region, and often fatal. Paracetamol (acetaminophen) is used in many countries but in few has it reached the popularity typical of the UK. Domestic and industrial chemicals are responsible for significant numbers of deaths and long-term disabilities world-wide. Self-poisoning with plant parts, although uncommon globally, is locally popular in some regions. Few of these poisons have specific antidotes. This emphasizes the importance of determining whether interventions aimed at reducing poison absorption actually produce a clinical benefit, reducing death and complication rates. Future research to improve medical management and find effective ways of reducing the incidence of self-harm, together with more widespread provision of interventions proven to be effective, could rapidly reduce the number of deaths from self-poisoning in the developing world.
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                Author and article information

                Journal
                BMC Public Health
                BMC Public Health
                BioMed Central
                1471-2458
                2007
                21 December 2007
                : 7
                : 357
                Affiliations
                [1 ]Department of Social Medicine, University of Bristol, Bristol, UK
                [2 ]South Asian Clinical Toxicology Research Collaboration (SACTRC)
                [3 ]Scottish Poisons Information Bureau, University of Edinburgh, Edinburgh, UK
                [4 ]Beijing Suicide Research and Prevention Center, Beijing Hui Long Guan Hospital, Beijing, China
                [5 ]Department of Psychiatry, Columbia University, New York, USA
                [6 ]Department of Epidemiology, Columbia University, New York, USA
                [7 ]Department of International Health, University of Copenhagen, Copenhagen, Denmark
                Article
                1471-2458-7-357
                10.1186/1471-2458-7-357
                2262093
                18154668
                Copyright © 2007 Gunnell et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research Article

                Public health

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