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Clinical Toxicology

ISSN: 1556-3650 (Print) 1556-9519 (Online) Journal homepage: http://www.tandfonline.com/loi/ictx20

Human poisoning in Thailand: The Ramathibodi


Poison Center's experience (20012004)

Winai Wananukul, Charuwan Sriapha, Achara Tongpoo, Umaporn


Sadabthammarak, Sunun Wongvisawakorn & Sming Kaojarern

To cite this article: Winai Wananukul, Charuwan Sriapha, Achara Tongpoo, Umaporn
Sadabthammarak, Sunun Wongvisawakorn & Sming Kaojarern (2007) Human poisoning in
Thailand: The Ramathibodi Poison Center's experience (20012004), Clinical Toxicology, 45:5,
582-588, DOI: 10.1080/15563650701382789

To link to this article: http://dx.doi.org/10.1080/15563650701382789

Published online: 07 Oct 2008.

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Clinical Toxicology (2007) 45, 582588
Copyright Informa Healthcare
ISSN: 1556-3650 print / 1556-9519 online
DOI: 10.1080/15563650701382789

ARTICLE
LCLT

Human poisoning in Thailand: The Ramathibodi Poison Centers


experience (20012004)

WINAI WANANUKUL, CHARUWAN SRIAPHA, ACHARA TONGPOO, UMAPORN SADABTHAMMARAK,


Human poisoning in Thailand

SUNUN WONGVISAWAKORN, and SMING KAOJARERN


Ramathibodi Poison Center and Division of Clinical Pharmacology and Toxicology, Department of Medicine, Faculty of Medicine,
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Ramathibodi Hospital Mahidol University, Bangkok, Thailand

Objective. To identify poisoning and toxic exposure pattern, severity, and clinical outcome in Thailand during 2001 to 2004. Method.
This is a prospective study. All inquiries were registered, followed up, and verified. Interlocutors, poisons, patients profiles, severity, and
medical outcome after exposure or poisoning were analyzed. Results. A total 14,428 events was suspected as human poisoning or
exposure. After follow-up and verification, 98.9% were confirmed as poisoning or poison exposure. These involved 15,016 patients and
accounted for 6.0 per 100,000 populations per year. The vast majority of calls (92.4%) were from physicians. Pesticides, household
products, and pharmaceutical products were the most common poisons involved in human exposure, which were 41.5%, 19.5%, and 18.9%,
respectively. Patients aged 06 years, teenagers and adults with 2029 years of age had the highest rates of exposure, which were 33.0,
24.5, and 10.5 exposures per 100,000 per year, respectively. Unintentional accidental exposure is the major reason of exposure in children,
but intentional suicide was the main reason of exposure in teenagers and adults. The death rate of all exposure was 5.5%. Pesticides cause
more severe clinical course and the highest death rate (10.0%). Conclusion. Features of poisoning in Thailand were different from those in
Western countries. Pesticide poisoning was the major problem in Thailand. Intentional suicide was the major circumstance of poison
exposure in adults, but accidental exposure was the major reason of exposure in children.

Keywords Poison center; Acute poisoning; Poison; Toxicity; Pesticide; Toxico-vigilance; Thailand

Introduction exposure problems and prevention of toxic exposure. The


centers personnel include two toxicologists and four full-
Poisoning and toxic exposure are worldwide health problems time and six part-time information scientists. International
of great concern. However, magnitude, nature, and character- and self-constructed local databases have been setup for ser-
istics of the problem vary from country to country. This study vices. Though various modes of communication have been
was a toxico-vigilance report of poisoning and toxic exposure established, the telephone is still the most common mode of
in Thailand. It showed the poisoning problems, severity, and communication. It operates 24 hours a day, seven days a
clinical outcome of poisoning and toxic exposure in Thai- week. Service is free of charge. All of the operational costs
land. As Thailand is a developing country and changing from are derived mainly from budgets of the Faculty of Medicine,
an agricultural to an industrialized economy, the findings in Ramathibodi Hospital, Mahidol University.
this report may represent an example of the poisoning and This study was a prospective study based on the routine
toxic exposure problem in a developing country. work of the center and its objective was to identify poisoning
The Ramathibodi Poison Center was established within the and toxic exposure pattern, severity, and clinical outcome in
Faculty of Medicine, Ramathibodi Hospital, Mahidol Univer- Thailand from the year 2001 to 2004.
sity in Bangkok in 1996. The objectives of the center are to
strengthen physicians and health personnel in the manage-
ment of poisoning, as well as to identify poisoning and toxic Materials and methods

This was a prospective study. The definition of terms in the


Received 13 July 2006; accepted 20 October 2006.
system was adopted from the IPCS INTOX data management
Address correspondence to Winai Wananukul, Ramathibodi system (1) and The American Association of Poison Control
Poison Center and Division of Clinical Pharmacology and Toxicol- Center (AAPCC) collection system (2).
ogy, Department of Medicine Faculty of Medicine, Ramathibodi All inquiries to the center were registered for information
Hospital, Mahidol University, Bangkok 10400, Thailand. with regard to toxic substances, patient profile, clinical infor-
E-mail: rawwn@mahidol.ac.th mation, and interlocutors.
Human poisoning in Thailand 583
The information scientists subsequently made follow-up of the center was rendered nationwide. The calls were from
calls for interchanging information of the patients. The calls all regions and provinces of the country.
would be ended either when the patients were discharged
from the hospital, the patient died, or at day 30. Only the
exposure to the definite non-toxic or minimally toxic hazards Poison exposure and poisoning pattern
was exempted for the follow-up call. Substances involved in poison exposure
All records were reviewed and verified by a regular daily
meeting of staff until they were completed and concluded. Among the 15,016 cases, 93.3% were exposed to only one
poison. The other 999 cases (6.7%) were exposed to many
poisons on the same occasion. Eight substances were among
Results the highest we found in this study. If the poisons were in the
same category, all of them would be included in their cate-
This study consisted of four years of cumulative results from gory. Only if the poisons were not in the same category, such
as drug and pesticide, they would be defined as combined
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the year 2001 to 2004, during which 15,739 of inquiries were


initiated with the poison center. It was found that the number chemicals (see Table 3). The combined chemicals cate-
of inquiries was increasing every year (Table 1). A total of gory had accounted for 1.9%. The other 0.1% was exposure
14,428 inquiries were events in which human poison exposure to poisons which could not be defined into any category and
or poisoning was suspected. After follow-up and verification, which were defined as others. The rest of 1.0% did not
163 events (1.1%) were excluded because relevant evidence reveal any clue for identification or to make diagnosis and
revealed that the patients suffered from other causes rather than was thus classified as unknown.
poisoning. These events included cerebrovascular diseases, Pesticides were the most common poisons involved in
convulsive disorder, cardiovascular diseases, and infectious human exposure, which counted for 41.5% of all cases of
diseases. However, a total of 14,265 events (98.9%) were con- exposure (Table 3). Household products and pharmaceutical
firmed as human poisonings and there were 15,016 patients products were the next in common, which accounted for
involved (Table 1). The average poison exposure consulted to 19.5% and 18.7%, respectively. Among the pesticides, insec-
the center was 6.0 per 100,000 populations per year. ticides, herbicides, and rodenticides were found to be 50.0%,
24.7%, and 14.2%, respectively, as shown in Table 4. The
common substances in insecticides, herbicides, and rodenti-
Who were the centers customers? cides are shown in Tables 57.
Table 8 shows a list of some common household products
The vast majority of calls were from physicians and health which were involved in human exposure. Most of them were
personnel, such as nurses and pharmacists, as shown in Table 2. detergents, which caused only gastrointestinal irritation after
Only 0.9% of the calls were from the general public. Service ingestion. However, cleaning agents, such as for the toilet,
which contained hydrochloric acid had accounted for 14.5%
Table 1. Growth of inquiries and confirmed poison exposures from
the year 2001 to 2004
Table 3. Category of substances most frequently involved in human
Human exposures exposures
Number of Confirmed human per 100,000
Year inquiries exposure cases populations* No. of No. of Death
Categories Cases (%) Death rate(%)
2001 2,201 1,981 3.2
2002 3,315 3,052 4.9 Pesticides 6,229 41.5 622 10.0
2003 4,589 4,318 6.8 Household products 2,932 19.5 29 1.0
2004 5,634 5,665 9.1 Pharmaceutical products 2,815 18.7 49 1.7
Over all 15,739 15,016 6.0(average) Technical and occupational 1,372 9.1 32 2.4
products
*Calculated from number of population in each age group. Data from Plant toxins/poisonous plants 562 3.7 23 4.1
Department of Provincial Administration, Ministry of Interior, Thailand; Poisonous animals 409 2.7 24 5.9
the average population in 20012004 was 62.6 million. Thai/Chinese herbs 109 0.7 2 1.8
Recreational and abused agents 81 0.5 7 8.6
Food toxins and contaminants 21 0.1 1 4.8
Table 2. Profession of interlocutors who called the poison center
Health food/cosmetics 14 0.1 0 0.0
Number (%) Food additives 12 0.1 0 0.0
Chemical weapons 9 0.1 0 0.0
Physicians 14,500 92.1 Combined chemicals 287 1.9 8 2.8
Health personnel 1,006 6.3 Others 21 0.1 0 0.0
Other personnel 105 0.6 Unknown 143 1.0 22 15.4
General public 128 0.9 Total 15,016 820 5.5
584 W. Wananukul et al.

Table 4. Pesticides most frequently involved in human exposures Table 8. Household products most frequently involved in human
exposures
Type of pesticide No. of cases (%)
Major/subgroup classification No. of cases (%)
Insecticides 3,217 50.0
Herbicides 1,588 24.7 Cleaning agent for laundry 863 27.7
Rodenticides 911 14.2 Cleaning agent for toilet 742 23.8
Miticides 297 4.6 Cleaning agent for floor 250 8.0
Plant hormone & growth regulators 145 2.3 Dish washing (manual) 287 9.2
Others 262 4.0 Moisture absorbent 195 6.3
Unknown pesticides 17 0.3
Total 6,437*
*The number of cases was higher than those in Table 3 because some Table 9. Pharmaceutical products most frequently involved in
patients took more than one substance in the same category and were human exposures
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counted as one patient.


Major/subgroup classification No. of cases (%)
Tranquillizers 645 16.5
Table 5. Insecticides most frequently involved in human exposures Analgesic & antipyretics 631 16.1
Type of insecticide No. of cases (%) Antidepressants 264 6.7
Respiratory system 241 6.2
Carbamates 829 25.8 Anti-infectives 211 5.4
Organophosphates 783 24.3 Hypnotics & sedatives 195 5.0
Pyrethroids 659 20.5
Combined 401 12.5
Organochlorine (endosulfan) 225 7.0 Paracetamol (acetaminophen) was classified in the analgesic-
Others 169 5.2 antipyretic group and was the main one in this group. Only a
Unknown 151 4.7 small portion of this group was acetylsalicylate (ASA) or
Total 3,217
non-steroidal anti-inflammatory drugs (NSAIDs).
Exposures to toxic plants were small (3.8%) (Table 3).
Plants containing toxalbumins included rosary bean (A.
Table 6. Herbicides most frequently involved in human exposures precatorius), castor bean (Ricinus communis), and curcas
Type of herbicide No. of cases (%) bean (Jatropha curcas). The most common plant containing
alkaloids was thorn apple (Datura metel). Cassava root con-
Glyphosate 710 44.7 tains cyanogenic glycosides, whereas wild yam (Dioscorea
Paraquat 376 23.7 hispida Dennst) was the other most common toxic plant.
Chloroacetanilide 147 9.3 There were a variety of poisonous mushrooms that contained
Chlorophenoxy 147 9.3
both cholinergic and anticholinergic toxins, which produced
Others 158 9.9
Unknown 50 3.1
only non-fatal poisoning. However, unintentional ingestion
Total 1,588 of Amanita spp. during season occurs in the north and north-
east of the country every year. It caused acute liver failure
with a severe clinical course and poor outcome.
Poisonous animals including venomous snakes, wasp, and
Table 7. Rodenticides most frequently involved in human exposures
other insects accounted for 2.7% of all poisonings (Table 3).
Type of rodenticides No. of cases (%) The venomous snakes included hematotoxin and neurotoxin
snakes. The hematotoxin snakes were green pit viper (Trim-
Zinc phosphide 446 49.0 eresurus spp.), Malayan pit viper (Calloselasma rhostoma),
Warfarin 312 34.2 and Russells viper (Vipera russelli siamensis). Cobra (Naja
Long-acting anticoagulant 100 11.0
kaouthia and Naja siamensis) and Malayan krait (Bungarus
Unknown 53 5.8
Total 911 candidas) are neurotoxin snakes that commonly cause human
poisoning in Thailand.

of all household products. The acid concentration ranged Poison exposure and poisoned patient profile
from 6 to 21%. Ingestion of these products caused more severe Table 10 shows the age distribution of the patients. There
gastroesophageal injury than the others in the category. were two separate populations: children and adults.
Table 9 shows a list of pharmaceutical products which Unintentional exposure was the major circumstance of
were commonly involved. Benzodiazepines were drugs clas- exposure in children between the ages of 05 and 612 years
sified in both tranquilizer and hypnotic-sedative groups. old. It was different from teenagers and adults whose
Human poisoning in Thailand 585
Table 10. Number of human poison exposure and rate of human exposure (exposures/100,000 populations/year) in age interval and gender
during 2001 to 2004

Number of human exposures Expsoure/100,000 population/year*


Age (year) Male Female Total Cumulative (%) Male Female Total
05 1,237 1,009 2,246 15.0 35.4 30.6 33.0
6 12 406 232 638 19.3 10.3 6.2 8.3
13 19 780 1,396 2,176 33.9 17.3 32.1 24.5
20 29 1,934 2,459 4,393 63.3 9.2 11.8 10.5
30 39 1,290 1,202 2,492 80.0 6.0 5.4 5.7
40 49 721 666 1,387 89.3 4.0 3.5 3.8
50 59 458 293 751 94.3 4.2 2.4 3.3
60 69 278 191 469 97.5 4.3 2.6 3.4
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70 79 131 106 237 99.0 3.8 2.4 3.0


80 89 31 46 77 99.6 3.3 3.2 3.3
*Calculated from the number of population in each gender and age group. Data obtained from Department of Provincial Administration, Ministry of Inte-
rior, Thailand. One-hundred and fifty cases whose age or gender was not identified were not included.

intentional exposure was the main circumstance (Table 11). stances, followed by household products and pharmaceutical
The patients were merged into two groups according to their products (Table 13). The unintentional occupational and acci-
major circumstances of exposure; children aged less than dental exposure to pesticides was only 8.6%. Exposure to
13 years and teenagers to adults. Table 12 shows substances technical and occupational products was from unintentionally
that were commonly involved in both unintentional and accidentally exposed.
intentional exposures in children aged less than 13 years old.
In teenagers and adults, intentional suicide was the common Clinical severity and outcome
mode of exposure. Pesticides were the most common sub- When interlocutors, who were mainly physicians or health
personnel, called the center, 30.4% (4,567) of cases had a his-
Table 11. Circumstances of exposures among the age groups tory of toxic exposure but no sign or symptom of poisoning
and were defined as poison exposure group in this study
Age Circumstances of exposure (% in row) (Table 14). The other 69.6% (10,444) of cases had clinical
groups manifestations of poisoning and were defined as poisoning
(years) Unintentional Intentional ADRs Others Total
group in this study (Table 14).
05 2,246(98.2) 29(1.3) 5(0.2) 7(0.3) 2,287 Patients in the poisoning group developed a more severe
612 498(77.7) 125(19.5) 7(1.1) 11(1.7) 641 clinical course and clinical outcome when compared to the
1339 1,284(14.1) 7,589(83.6) 54(0.6) 149(1.6) 9,077 poison exposure group (Table 14). The initial severity and
>40 907(30.9) 1,908(65.0) 44(1.5) 77(2.6) 2,936 clinical outcome of patients were tabulated in a separate
*Seventy-five cases in which the circumstances were not identified were
category, especially the three major substances: pesticides,
excluded. ADRs: adverse drug reactions. household products, and pharmaceutical products (Tables 15

Table 12. Substances involved in unintentional and intentional Table 13. Substances involved in unintentional and intentional
exposure in children aged less than 13 years old exposure in teenagers and adults
Category of Category of
substances Unintentional Intentional Others Total substances Unintentional Intentional Others Total
Pesticide 473(93.3) 30(5.9) 4(0.8) 507 Pesticide 490(8.6) 5,139(89.8) 93(1.6) 5,722
Household products 669(98.2) 9(1.3) 3(0.4) 681 Household 308(13.7) 1,933(85.9) 10(0.4) 2,251
Pharmaceutical 751(94.7) 30(3.8) 12(1.5) 793 products
products Pharmaceutical 193(9.5) 1,726(85.4) 103(5.1) 2,022
Technical & 435(99.3) 2(0.5) 1(0.2) 438 products
occupational Technical & 620(66.4) 296(31.7) 18(1.9) 934
products occupational
Poisonous plants 247(75.5) 76(23.2) 4(1.2) 327 products
Others 169(92.9) 7(3.8) 6(3.3) 182 Others 621(53.6) 438(37.8) 100(8.6) 1,159
Total 2,744(93.7) 154(5.3) 30(1.0) 2,928 Total 2,232(18.5) 9,532(78.9) 324(2.7) 12,088
586 W. Wananukul et al.

Table 14. The clinical outcome of patients who initially presented with clinical manifestation of poisoning and only history of poison
exposure

Clinical outcome* (% in row)


No FU Unable to FU Total
(% in row) None Minor Moderate Major Death (% in row) (% in col.)
Poison Exposure 1,439(31.5) 2,560(56.0) 304(6.6) 44(1.0) 25(0.5) 13(0.3) 187(4.1) 4,572(30.4)
Poisoning 1,356(12.9) 5,992(57.2) 1,055(10.1) 702(6.7) 805(7.7) 543(5.1) 10,444(69.6)
All cases 2,795(18.6) 2,560(17.0) 6,296(41.9) 1,009(7.3) 727(4.8) 820(5.5) 719(4.8) 15,016
Definition of each category in clinical outcome is according to Toxic Exposure Surveillance System.

Table 15. The initial severity of the poison exposure patients and poisoning patients who were exposed to the most common substances
which were pesticides, household products, pharmaceutical products, and all kinds of toxic substances
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Initial severity (% in row)


Poison
exposure Poisoning
Category None Minor Moderate Severe Total
Pesticides 2,155(34.6) 2,904(46.6) 367(5.9) 803(12.9) 6,229
Household products 997(34.0) 1,848(63.0) 64(2.2) 23(0.8) 2,932
Pharmaceutical products 926(32.9) 1,446(51.4) 291(10.3) 152(5.4) 2815
All toxic substances 4,572(30.4) 8,103(54.0) 1,082(7.2) 1,259(8.4) 15,016

Table 16. The clinical outcome of the poison exposure patients and poisoning patients who were exposed to the most common substances
which were pesticides, household products, pharmaceutical products, and all kinds of toxic substances

Clinical outcome* (% in row)


No FU Unable to FU
Category (% in row) None Minor Moderate Major Death (% in row) Total
Pesticides 933(15.0) 1,316(21.1) 2,325(37.3) 367(5.9) 407(6.5) 622(10.0) 260(4.2) 6,229
Household products 1,287(43.9) 350(11.9) 1,005(34.3) 66(2.3) 21(0.7) 29(1.0) 174(5.9) 2,932
Pharmaceutical products 428(15.2) 543(19.3) 1,237(43.9) 297(10.6) 112(4.0) 49(1.7) 149(5.3) 2,815
All toxic substances 2,795(18.6) 2,560(17.0) 6,296(41.9) 1,009(7.3) 727(4.8) 820(5.5) 719(4.8) 15,016

and 16). Pesticides and pharmaceutical products caused more Discussion


severe initial severity (Table 15). However, pesticides caused
a much higher percentage of major effects and fatality than Because the number of inquiries to the poison center has been
pharmaceutical products and the overall poisoning (Table 16). increasing continually every year, it suggests that the centers
Table 16 and Table 3 show the death rates of exposure to service is growing. However, the overall number of six poi-
each category. Table 17 lists substances which caused highest son exposures per 100,000 people per year is extremely low
death rate. Most of them were by pesticide. when compared to that in the developed countries; for exam-
ple, 830/100,000 people/year in the United States (2). If the
Table 17. Substances most frequently implicated as causes of death services are continuously developed and expanded, several
hundred instances of inquiries may be expected. The number
Total Number of Death
cases death (%)
of calls from the general public to the center was clearly low;
this might be the case for several reasons. First, the poison
Organochlorine (endosulfan) 225 150 66.7 center is still not well known among the general public,
Paraquat 376 150 39.6 though it is the only functioning center in Thailand. Because
Organophosphates 783 126 16.1 the center does not have enough public relation activities,
Carbamates 829 95 11.5 most of the activities were only by chance or opportunities.
Acid containing cleaning agents 452 23 5.1 Resources for the center are limited and derived solely from
Zinc phosphide 446 16 3.6
the Faculty of Medicine. No direct income is generated by the
Glyphosate 710 18 2.5
main activity of the center and the center provides free
Human poisoning in Thailand 587
service to all. Neither the hospital nor the patient who for exposure to toxic substances (18,19). People should be
receives the benefit from the service is asked to pay. There is advised to keep drugs and potentially toxic substances in a
also no compensation from the government, as is the case in proper place far away from children. Special packaging as
some countries (3). This is one of the current challenges of well as safety caps should be considered. One way uninten-
the center. Second, health hazards from poison exposure tional accidental exposure occurs is that individuals some-
might not be a public concern as much as in the developed time put toxic substances into beverage or food containers
countries. This phenomenon is relevant not only to Thailand, without labeling them. Moreover, they keep these containers
but also to many countries in Asia (46), as well as in differ- and food in the same place. A campaign for safe storage as
ent ethnic groups (7,8). Thus, the center should increase pub- well as labeling the container should be implemented.
lic awareness. The poison center should be a resource and a Regarding intentional suicide, which is the popular mode
leader to provide public education regarding health hazards of self-assault in adults, we found a higher incidence in
from poison exposures, and find opportunities to collaborate females than in males. This was similar to the findings in pre-
with local or national agencies to identify the target and vious suicide studies in Thai people (15,16). Prevention
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important issues in this field. This would be another aspect should focus on psychiatric measurement. To delay or make
that the poison center should aim at (3,9). it more difficult to reach the drugs or toxic substances may
As the calls were mainly from physicians and health per- partially reduce the number of cases. To restrict the availabil-
sonnel, the cases were likely to be a significant exposure or ity of the highly toxic substances, especially pesticides,
those with potentially serious health effects. Minimal risk or should be another measure to decrease toxic exposure. The
mild poisoning was likely to be omitted in this study. There- poison center should have a role in monitoring, registration,
fore, the severity and medical outcome from this study may and informing society regarding this problem.
be more unfavorable than those comprising a large portion of
calls from the general public. This system is sensitive and
effective for response to acute poisoning. In contrast, it is not Conclusions
fit for detecting chronic toxicity or long-term effects, and
these kinds of health effects are also missing in this study. The poison center provides services mainly to physicians and
We realized that a limitation of this study is that it did not health personnel in managing the poisoned patients. Pesti-
represent all of the features of poisoning in Thailand. cides, household products, and pharmaceutical products were
Unfortunately, official reports of poisoning cases from health the most common substances involved in toxic exposures and
facilities are usually underreported. Neither a relevant report- poisoning in Thailand. The overall death rate was relatively
ing system of poisoning cases nor a monitoring system has high because pesticide poisonings were associated with a
been developed in Thailand. An actual feature of toxic expo- higher death rate and a more severe clinical course than other
sure and poisoning in the country is not available. This report poisonings. Most of the exposures were intentional suicide,
may partly reflect poisoning problems of the country. especially in teenagers and adults. Accidental exposure was
Pesticide poisoning is the most common and important in the main reason of exposure and poisoning in children. Public
Thailand. It contributed to nearly half of all poisonings. This relation activities including education, provoking awareness,
finding was different from that of Western countries, where and poisoning prevention should be implemented.
pesticide poisoning is a minor problem. Poisoning from
household products and pharmaceutical products, which are
most common in Western countries, is second after pesticide Acknowledgments
poisoning (2,10). However, our finding is similar to those
found in China, Taiwan, Sri Lanka, and India which are in the This study was partially supported by the Royal Thai Gov-
same continent and have similar cultures (4,1114). Pesticide ernment World Health Organization Collaborative Program
poisoning is one of the popular modes of self-assault in these and Syngenta Crop Protection Limited. The authors grate-
countries (6,1517). As it caused higher morbidity and death fully acknowledge all part-time scientists and the assistance
than other kinds of poisoning, it was an important factor that of Professor Amnuay Thithapandha in editing and preparing
contributed to a higher death rate in our study compared to this article.
those in developed countries. As highly toxic organophos-
phates such as methylparathion and methamidophos as well
as endosulfan were banned in the year 2003 2004, clinical References
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