A Five Years Retrospective Study of Poisoning Cases Investigated by the Forensic

A five years retrospective study of poisoning cases investigated by the Forensic ChemicalLaboratory in Upper Egypt

Ragaa M. Abdel-Maaboud*, Kamalat A. Aly, Shaaban M.Ahmed, Nady S. Aly and Hossien A. Aly

Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, AssiutUniversity*, Assiut Forensic Laboratory, Ministry of Justice, Egypt

Abstract:

Poisoning is an important health hazard and one of the leading causes of morbidity and mortality worldwide. A five years retrospective study of poisoning cases in seven governorates of Upper Egypt investigated by Assiut Forensic Chemical Laboratory in the period from January 2002 to December 2006 was conducted to investigate the patterns,incidences, mode of poisoning, and types of poisons. The total number of cases was 407. The geographical distribution was; 14.0% from Almenia, 44.0% from Assiut, 19.9% from Sohag, 16.5% from Qena, 2.7% from Aswan, 2.2% from Red sea and 0.7% from New Valley. The highest incidence of poisoning was found in 2006 (29%) followed by 2004 (20.4%) then 2002 (18.7) and 2005 (16.2%), lastly 2003 (15.7%). The highest incidence was in males (61.2%) and the maximum number of cases was recorded in the age group between 21 and 30 years (30.2%). Suicide cases represented 49.6% of the total cases, 59.9% of them were females while cases of abuse represented 32.7% and 95.5% of them were males. Pesticides were the commonest poisons detected (47.3 % of the total), where organophosphates represented (22.1%) and carbamates represented (20.6 %) of the total cases.Also they were the main killer used in suicide cases in addition to hair dye ingestion (18.4%). The use of hair dye for poisoning was common particularly in the south governorates (Qena 81.6% and Aswan 8.2%), either for suicide (83.7%) or trials of suicide (4.1%) and also for murder in 10.2% of the cases. Alcohol was the commonest substance of abuse reported in this study followed by antipsychotics (60.9% and 20.3% respectively). Cannabis and hydrocarbons had similar percentages (5%.3) followed by hypnotics, opoides and other drugs.

On conclusion; this study revealed that there is annual increase in the number of poisoning cases particularly in young adults. Deliberate self- poisoning is a major problem, followed by drug abuse. Pesticides were the main killer followed by hair dye. Alcohol was the commonest abuse substance. There was male predominance except in suicide cases where females predominate.

Key Words: retrospective study, poisoning, Upper Egypt.

Introduction:

Death due to poisoning has been known since time immemorial.Acute poisoning is a medical emergency which poses amajor health problem all over the world. Its type associated morbidity and mortality varies from place to place over a period of time. Easy availability of numerous poisonous substances due to the rapid developmentof science and technology, vast growth of industrial and agricultural set has tremendously increased the incidence of poisoning cases (1).Dangerous products are often introduced into the home, and in addition there has been a multiplication of active therapeutic drugs (2). An ever increasing range of psychotropic and antidepressant drugs are taken in attempted and complete suicides, and there is massive abuse of addictive substances such as alcohol, tobacco, amphetamines, tranquillizers, heroin and cocaine (3; 4). Since 1980, accidents due to toxic exposures have become the most common cause of acute medical illness in many industrialized countries. They are also the second most common cause of death (after infectious disease) in many developing countries (5; 6).Intentional self-poisoning is a major problem worldwide (7; 8).In industrialized countries, itpredominantly occurs in young people impulsively respondingto stressful events who have little desire to die. Deaths arerare, since the medicines ingested are of low toxicity or easilytreated. The situation is different in the developing world,where pesticides are the most popular means of self-poisoning(9) and cause an estimated 300000 deaths each year (8).

According to the legal system, poisoning deaths are recorded as unnatural death and a medico-legal autopsy is routine. Forensic toxicology is required to determine any exogenous chemical agent present in biological specimens made available in connection with medico-legal investigations (10). Analysis of poisoning fatality data is useful in identifying changes in the characteristics of chemical- and drug-related deaths, and to determine what can be changed in terms of exposure sources, drug availability, and prescribing patterns. However non-fatal poisonings also can result in significant morbidity (sometimes long term) with considerable associated costs, and knowledge of their epidemiology is important (11).

In the view of the forgoing observation, this study was conducted to analyze the various aspects of poisoningreported in the cases of sevengovernorates in Upper Egypt in the period 2002-2006; according to age, sex, mode, incidence, pattern andtype of poisoning.

Subjects and methods:

The present study has been conducted on the records of 407 poisoningcases of seven governorates in Upper Egypt (Almenia, Assiut, Sohag, Qena, Aswan, Red sea and New Valley) investigated by Assiut Forensic Chemical Laboratory in the period from January 2002 to December 2006. The cases were brought for post-mortem investigation with alleged history or suspicion of intake of poisonous substances. The study also included criminal cases referred from different inquiries for determination of drug abuse. Poisoning was confirmed by chemical analysis of the visceraand other body fluid samples. Information was obtained from three main sources: inquest reports presented by the legal authority, chemical analysis reports, and autopsy reports.

Statistical Analysis: Data were run on IBM compatible personal computer and analyzed using SPSS (Statistical Package for Social Sciences, SPSS Inc., Chicago, IL, USA) computer program.The data wereanalyzed with respect to age, sex, mode, incidence, pattern andtype of poisoning and presented in the form of percentages.

Results:

The geographical distribution of cases according to sex is demonstrated in table (1). Out of 407 poisoning cases, (61.2%) were males and (38.8%) were females. Assiut Governorate shows the highest incidence of poisoning cases (44.0% of total), with the predominance of males (73.7%), followed by Sohag and Qena (19.9% and 16.5% of total retrospectively) with the predominance of females (50.6% and 53.7%).Almenia, Aswan, Red Sea andNewValleyrepresented 14.0%, 2.7%, 2.2% and 0.7% of total respectively.

Table (2) shows the yearly incidence of acute poisoning cases in the period from 2002-2006 in relation to sex. The maximum number of cases occurred during the year 2006 (29% of total) followed by 2004 (20.4%), 2002 (18.7% of total) then 2005 (16.2% of total) and lastlly 2003 (15.7% of total).

Figure (1) demonstrates gender distribution of poisoning cases in the period 2002-2006.There was male predominance allover the period (51.3%, 56.3%, 62.2%, 59.1% and 70.0% within the years respectively).

The distribution of cases of abuse in relation to the type of poison is demonstrated in figure (2). Alcohol is the commonest substance of abuse followed by antipsychotics (60.9% and 20.3% respectively). Cannabis and hydrocarbons had similar percentages (5.3%) followed by hypnotics, opoides and other drugs.

The distribution of cases of poisoning according to sex and age is shown in table (3). The highest percent of cases was found in the age group 21-30 (30.2% of total) followed by the age group 31—40 (27.0% of total) then the age group 41-50 (19.7% of total) and the age group 11-20 (15.0% of total) and small percentages for the other age groups with the predominance of males in all age groups.

The distribution of mode of poisoning in relation to sex is shown in Table (4). There was male predominence in all modes of poisoning except in suicide and trial of suicide where females predomenate (58.7% and 61.1% respectively).

Table (5) shows the geographical distribution of cases according to the mode of poisoning.The commonest mode of poisoning was suicide (49.4% of total), followed by abuse (32.7% of total) then accidental poisoning (4.7% of cases). The highest percent of cases of suicide occured in Almenia (68.4% of governorate cases) followed by New Valley (66.7% of governorate cases) - with the considration that there were two cases out of three - followed by Sohag (65.4% of governorate cases) followed by Qena (62.7% of governorate cases) then Aswan, Assiut and Red Sea (36.4%, 33.0% and 22.2 % of governorate cases respectively). The highest percent of abuse cases was found in Red Sea Governorate (77.7% of governorate cases) followed by Assiut (51.4% of cases).

Table (6) shows the different types of poisons detected in the samples. Pesticides were the commonest poisons detected (47.3% of the total), where organophosphates represented 22.1% and carbamates represented 20.6 % of the total cases.Alcohol poisoning represented 20.6% of total cases) followed by hair dye poisoning (18.4% of cases) then antipsychotics (9.8%) and zinc phosphide (4.9 %). Each of cannabis and hydrocarbons represented (1.7% of total cases), analgesics & antipyretics (2.0%), opiates and CO (1.5% and 1.2% respectively).

The highest percentage of suicide cases was found in the age group 21-30 years followed by 31-40 years then 41-50 years and 11-20 years with a leaser extent above 50 years as shown in (figure 3).

Figure (4) demonstrates the incidence of different types of pesticides in poisoning cases.Organophosphates were the commonest type (22.1% of total) followed by carbamates (20.6% of the total), zinc phosphide (4.9%), organochlorines (0.7%), Organochlorins& organophosphates (0.5%), Aluminum phosphide (0.5%) and lastely organophosphates & carbamates (0.2% of total cases.

The incidence of cases of hair dye poisoning cases in the period 2002-2006 is demonstrated in figure (5). The highest incidence of cases occurred in 2006 (No. = 19 cases), while in 2005 (No. = 11cases), 2003 and 2004 (No. = 6 cases each) and in 2002 (No. = 7 cases).

Concerning the geographical distribution of hair dye poisoning cases, Qena had the highest incidence of cases (81.6%) and the highest incidence of suicide by this method, followed by both Sohag and Aswan (8.2% each), lastly Assiut (2.0% of total hair dye poisoning cases), while nocases were recorded in Almenia as shown in figure (6).

The total cases of hair dye poisoning was 49 cases (18.4% of total), most of them were suicide (83.7% of hair dye poisoning cases) while suicide trials represented (4.1%). Murder represented (10.2%) and murder trials represented (2.1%) of hair dye poisoning cases. There was female predominance of the use of hair dye in suicide cases (63.3% within mode) and male predominance in murder and murder trials as shown in figures (7 and 8).

The age incidence of suicide cases by hair dye is demonstrated in figure (9). The highest incidence of suicide by the use of hair dye was in the age group 31-40 years (30.6% of cases) followed by the age group 21-30years (34.1% of cases) then the age group 41-50 years (22.0%) and lastly the age group 11-20 years (7.3% of cases).

Tables and figures:

Table (1): The geographical distribution of poisoning cases according to sex

Sex / Governotates / Total
Almenia / Assiut / Sohag / Qena / Aswan / Red sea / New valley
Males
No.
%within sex
%within Gov
%of total / 29
11.6
50.9
7.1 / 132
53.0
73.7
32.4 / 40
16.1
49.4
9.8 / 31
12.4
46.3
7.6 / 11
4.4
100.0
2.7 / 4
1.6
44.4
1.0 / 2
0.8
66.7
0.5 / 249
100.0
61.2
61.2
Females
No.
%within sex
%within Gov
%of total / 28
17.7
49.1
6.9 / 47
29.7
26.3
11.5 / 41
25.9
50.6
10.1 / 36
22.8
53.7
8.8 / 00.0
00.0
00.0
00.0 / 5
3.2
55.6
1.2 / 1
0.6
33.3
0.2 / 158
100.0
38.8
38.8
Total
No.
%within sex
%within Gov
%of total / 57
14.0
100.0
14.0 / 197
44.0
100.0
44.0 / 81
19.9
100.0
19.9 / 67
16.5
100.0
16.5 / 11
2.7
100.0
2.7 / 9
2.2
100.0
2.2 / 3
0.7
100.0
0.7 / 407
100.0
100.0
100.0

Table (2): Yearly incidence of poisoning cases in the period 2002 - 2006 according to sex

Sex / Years / Total
2002 / 2003 / 2004 / 2005 / 2006
Males
No.
%within sex
%within year
%of total / 39
15.7
51.3
9.6 / 36
14.5
56.3
8.8 / 50
20.1
62.2
12.3 / 39
15.7
59.1
9.6 / 85
34.1
70.0
20.9 / 249
100.0
61.2
61.2
Females
No.
%within sex
%within year
%of total / 37
23.4
48.7
9.1 / 28
17.7
43.8
6.9 / 33
20.9
39.8
8.1 / 27
17.7
40.9
6.6 / 33
20.9
28.0
8.1 / 158
100.0
38.8
38.8
Total
No.
%within sex
%within year
%of total / 76
18.7
100.0
18.7 / 64
15.7
100.0
15.7 / 83
20.4
100.0
20.4 / 66
16.2
100.0
16.2 / 118
29.0
100.0
29.0 / 407
100.0
100.0
100.0

Figure (1): The gender distribution of poisoning cases in the period 2002-2006

Figure (2): The distribution of cases of abuse in relation to the type of poison

Table (3): The distribution of cases of poisoning (2002-2006) according to sex and age

Sex / Age groups / Total
0-10 / 11-20 / 21-30 / 31-40 / 41-50 / 51-60 / > 60
Males
No.
% within sex
% within age group
% of total / 00.0
00.0
00.0
00.0 / 32
12.9
52.5
7.9 / 67
26.9
54.5
16.5 / 68
27.3
61.8
16.7 / 59
23.7
73.8
14.5 / 21
8.4
84.0
5.2 / 2
0.8
50.0
0.5 / 249
100.0
61.2
61.2
Females
No.
% within sex
% within age group
% of total / 4
2.5
100.0
1.0 / 29
18.4
47.5
7.1 / 56
35.4
45.5
13.8 / 42
26.6
38.2
10.3 / 21
13.3
26.3
5.2 / 4
2.5
16.0
1.0 / 2
1.3
50.0
0.5 / 158
100.0
38.8
38.8
Total
No.
% within sex
% within age group
% of total / 4
1.0
100.0
1.0 / 61
15.0
100.0
15.0 / 123
30.2
100.0
30.2 / 110
27.0
100.0
27.0 / 80
19.7
100.0
19.7 / 25
6.1
100.0
6.1 / 4
1.0
100.0
1.0 / 407
100.0
100.0
100.0

Table (4): The distribution of mode of poisoning in relation to sex

Mode / Sex / Total
Males / Females
No. / % Within Mode / % of total / No. / %Within Mode / % of total / No. / %Within Mode / % of total
Burn / 4 / 57.1 / 1.0 / 3 / 42.9 / 0.7 / 7 / 100.0 / 1.7
Abuse / 127 / 95.5 / 31.2 / 6 / 4.5 / 1.5 / 133 / 100.0 / 32.7
Suicide / 83 / 41.3 / 20.4 / 118 / 58.7 / 29.0 / 201 / 100.0 / 49.4
Suicide trial / 7 / 38.9 / 1.7 / 11 / 61.1 / 2.7 / 18 / 100.0 / 4.4
Murder / 9 / 56.3 / 2.2 / 7 / 43.8 / 1.7 / 16 / 100.0 / 3.9
Murder trial / 8 / 61.5 / 2.0 / 5 / 38.5 / 1.2 / 13 / 100.0 / 3.2
Accidental / 11 / 57.9 / 2.7 / 8 / 42.1 / 2.0 / 19 / 100.0 / 4.7
Total / 249 / 61.2 / 61.2 / 158 / 38.8 / 38.8 / 407 / 100.0 / 100.0

Table (5): The geographical distribution of cases according to the mode of poisoning

Governorate / % within Mode / Total
burn / Abuse / Suicide / Suicide trials / Murder / Murder trials / Accidental
Almenia
No.
%within Gov
%within Mode
%of total / 1
1.8
14.3
0.2 / 8
14.0
6.0
2.0 / 39
68.4
19.4
9.6 / 2
3.5
11.1
0.5 / 1
1.8
6.3
0.2 / 5
8.8
38.5
1.2 / 1
1.8
5.3
0.2 / 57
100.0
14.0
14.0
Assiut
No.
%within Gov
%within Mode
%of total / 1
0.6
14.3
0.2 / 92
51.4
69.2
22.6 / 59
33.0
29.4
14.5 / 13
7.3
72.2
3.2 / 3
1.7
18.8
0.7 / 7
3.9
53.8
1.7 / 4
2.2
21.1
1.0 / 179
100.0
44.0
44.0
Sohag
No.
%within Gov
%within Mode
%of total / 2
2.5
28.6
0.5 / 11
13.6
8.3
2.7 / 53
65.4
29.4
13.0 / 2
2.5
11.1
0.5 / 4
4.9
25.0
1.0 / 00.0
00.0
00.0
00.0 / 9
11.1
47.4
2.2 / 81
100.0
19.9
19.9
Qena
No.
%within Gov
%within Mode
%of total / 3
4.5
42.9
0.7 / 11
16.4
8.3
2.7 / 42
62.7
20.9
10.3 / 1
1.5
5.6
0.2 / 7
10.4
43.8
1.7 / 1
1.5
7.7
0.2 / 2
3.0
10.5
0.5 / 67
100.0
16.5
16.5
Aswan
No.
%within Gov
%within Moge
%of total / 00.0
00.0
00.0
00.0 / 3
27.3
2.3
0.7 / 4
36.4
2.0
1.0 / 00.0
00.0
00.0
00.0 / 1
9.1
6.3
0.2 / 00.0
00.0
00.0
00.0 / 3
27.3
15.8
0.7 / 11
100.0
2.7
2.7
Red Sea
No.
%within Gov
%within Mode
%of total / 00.0
00.0
00.0
00.0 / 7
77.8
5.3
1.7 / 2
22.2
1.0
0.5 / 00.0
00.0
00.0
00.0 / 00.0
00.0
00.0
00.0 / 00.0
00.0
00.0
00.0 / 00.0
00.0
00.0
00.0 / 9
100.0
2.2
2.2
New Valley
No.
%within Gov
%within Mode
%of total / 00.0
00.0
00.0
00.0 / 1
33.3
0.8
0.2 / 2
66.7
1.0
0.5 / 00.0
00.0
00.0
00.0 / 00.0
00.0
00.0
00.0 / 00.0
00.0
00.0
00.0 / 00.0
00.0
00.0
00.0 / 3
100.0
0.7
0.7
Total
No.
%within Gov
%within Mode
%of total / 7
1.7
100.0
1.7 / 133
32.7
100.0
32.7 / 201
49.4
100.0
49.4 / 18
4.4
100.0
4.4 / 16
3.9
100.0
3.9 / 13
3.2
100.0
3.2 / 19
4.7
100.0
4.7 / 407
100.0
100.0
100.0

Table (6): The distribution of cases according to the type of poison

Type of poison / Cases
No. / %
Alcohol
Alcohol & antipsychotics
Aluminium phosphide
Analgesics & antipyretics
Antibiotics & hypnotics
Antipsychotics
Copper sulphate
Cannabis
Carbamates
Carbolic acid
Co
Corrosives
Hairdye
Hydrocarbons
Opiates
Organochlorines
Organochlorines &organophosphates
Organophosphates
Organophosphates& carbamates
Zinc phosphide / 84
3
2
8
2
40
1
7
84
1
5
1
75
7
6
3
2
90
1
20 / 20.6
0.7
0.5
2.0
0.5
9.8
0.2
1.7
20.6
0.2
1.2
0.2
18.4
1.7
1.5
0.7
0.5
22.1
0.2
4.9
Total / 407 / 100.0

Figure (3): The distribution of suicide cases in relation to age

Figure (4): Incidence of different types of pesticides in poisoning cases.

Figure (5): The incidence of cases of hair dye poisoning cases in the period 2002-2006

Figure (6): The distribution of hair dye cases in different governorates according to the mode of poisoning

Figure (7): The distribution on hair dye poisoning cases according to the mode of poisoning

Figure (8): Gender distribution of hair dye poisoning cases in relation to the mode of poisoning

Figure (9): The distribution of cases of suicide by hair dyein relation to age

Discussion:

Poisoning is an important health hazard and a leading cause of morbidity and mortality worldwide (12). All poisoning death cases are considered as unnatural death and medicolegal autopsy is routine (13). A five years retrospective study of poisoning cases of seven governorates inUpper Egypt investigated by Assiut Forensic ChemicalLaboratory in the period from January 2002 to December 2006 was carried out. The total number of cases was 407. The geographical distribution was; 14.0% from Almenia, 44.0% from Assiut, 19.9% from Sohag, 16.5% from Qena, 2.7% from Aswan, 2.2% from Red sea and 0.7% from New Valley. This distribution was related to population density in a large extent.The highest incidence of poisoning was found in 2006 (29%) followed by 2004 (20.4%) then 2002 (18.7) and 2005 (16.2%) and lastly 2003 (15.7%). Poisoning was more prevalent in males (61.2%) as compared to females (38.3%). This finding is similar to other studies (14; 15). The highest incidence of cases was found in the age group between 21 and 30 years (30.2%).This contradict withIslam and Islam, 2003 (14), in their retrospective study of 273 deaths due to poisoning in Sir Salimullah Medical Collage in Bangladesh from 1988 to 1997, that most of the poisoning cases were in 13-24 years old.The study revealed that the commonest mode of poisoning was suicide (49.4% of total), followed by abuse (32.7% of total) then accidental poisoning (4.7% of cases). This result is in agreement with the result of Singh, et al, 2004 (1) in their ten years study of poisoning cases in a tertiary hospital in India reported that suicide is the most common mode of poisoning accounting (93.09%) followed by accidental poisoning (5.56%). On the other hand their results are contradicted with the present results concerning gender distribution of suicide cases. Their study revealed males predominance which is supported by another study on the epidemiology of intentional self-poisoning in rural Sri Lanka (8), while the present study revealed females (58.7%) of suicide cases and the vulnerable groups of age were between 21-30 years and 31-40 years. This supports the view that women and young people are the commonest victims of suicide as a response to stresses of life.A similarpattern of fatal self-poisoning in young women is seen in ruralareas of China and India (16).

According to data available on the poisons most commonly used for self-harm in different parts of the world, pesticides are the most common poison throughout the tropics and associated with a high mortality rate (17). In some regions, particular pesticides have become the most popular method of self-harm, gaining notoriety amongst both health-care workers and public(5; 16; 17).In the present study pesticides were the commonest poisons detected (47.3% of the total), where organophosphates represented 22.1% and carbamate represented 20.6%,organochlorines (0.7%), Organochlorins& organophosphates (0.5%) of the total cases. The results of this study support the view that organophosphate pesticidesare important causes of fatal self-poisoning (18). In India an estimated 1 million serious accidental poisoningsand 2 million suicide attempts involving organophosphorus compoundsoccur each year (12).

The results of the present study revealed high incidence of suicide deaths as a result of carbamate ingestion and the commonest compound used was aldicarb which is {2-methyl-2-(methylthio)propionaldehyde O-(methylcarbamoyl)-oxime}. Aldicarb is considered to be one of the most acutely toxic pesticides with several incidents of accidental or intentional poisoning being reported (16; 19; 20; 21; 22).

In the present study zinc phosphide and Aluminum phosphide accounted (4.9% and 0.5%) of total cases respectively and all of them were suicide deaths. Aluminum and zinc phosphides are routinely used to repel pests from grain and rice stores. These compounds are commonly known as “rice tablets”. Zinc phosphides are toxic after ingestion because contactwith water in the stomach liberates phosphine gas (16; 20; 21; 22; 23). Aluminum phosphide hasrecently become the commonest mean of self-poisoning in northernIndiaout of 720 patients reported in four studies, 439 (61%)died (24). Many studies from India, showed thatit is also a common mean of self-harm amongst 11 to 15 year-oldadolescents, with mortality rate of 59 %( 25; 26; 27; 28).

Though uncommon in the west, ingestion of paraphenylenediamine (PPD) containing dye is frequently reported in Africa and Asia (29; 30; 31; 32) where it is most often mixed with “Henna” (leaves of Lawsonia alba) and applied to color palms of hands and soles of feet and to dye hair a dark red shade.In agreement with the previous studies, the present results revealed that hair dye - a commercially black hair dye widely used in Upper Egypt and traditionally known as “stone hair dye" (32) -poisoning represented 18.4% of the total cases with stepwise increase in yearly incidence. Hair dye ingestion is a popular way of suicide (83.7% of suicide cases) particularly in Qena, Sohag and Aswan Governorates (82.9%, 9.8% and 7.3% of suicide cases in each governorate respectively), with apredominance of females (68.3% of hair dye poisoning suicides). The highest parentage of suicide by hair dye was found in the age group 31-40 years, followed by 21-30 years then 41-50 years and lastly 11-20 years old (36.6%, 34.1%, 22.0% and 7.3% respectively). The researches emphasized that P-phenylenediamine (PPD) is the main toxic ingredient of permanent hair dyes (33; 34; 35). Many cases of toxicity and mortality either due to accidental or deliberate ingestion of hair dyes were reported in Egypt, Sudan, Israel, Morocco, Saudi Arabia, India and Tunisia (36; 37; 38;39; 40; 41). Paraphenylenediamine poisoning was the firest cause of poisoning in Morocco during the 1990s, while a singlecase of intentional poisoning has been reported inIndia (40; 42).