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ACMT FIT Luncheon Lecture:Global Toxicology

Ra i s Vo h ra MDZi a d Ka z z i MD

Co- Ch ai rs , ACM T I nte r n at i o na l Co m m i ttee

Global Toxicology trends,gaps, & opportunities

Objectives• 1. Describe the magnitude and contributing factors of the global poisoning epidemic• 2. Summarize initiatives where ACMT is working with international organizations to address the problems of global toxicology• 3. Describe ways in which toxicology fellows-in-training and junior faculty can be part of the solution

Global Toxicology: Trends, Gaps and Opportunities

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• Background: The Situation in the US/ Europe• Roughly 3.5 million calls/yr are made to U.S. PCCs• > 50% of exposures occur in children under 6yrs old• 75% of exposures are managed at home• Effective, total care delivered from EMSED ICU• Well developed pharmaceutical/resuscitation processes• Regulatory oversight/ feedback• Fatalities are uncommon

• 1,106 reported in 2003• .046% of all cases reported• 54% are suicides

R u r a l N e p a l

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Farmer, HimalayanFoothills

Poisonings Around the World• 2-3 million poisonings per year• 5M Snakebites(1M deaths)/ year• 1 million suicide deaths • 300,000 Pesticide deaths/ year• Recreational/ illegal drug use: underreported• Most occupational exposures not reported• Air pollution causes 6 million preventable deaths/year • Poisoning outbreaks (briefly) direct media/government attention • Poisoning mortality is much higher in rural tropics• 10-20% versus 1% in US/UK• Morbidity (DALYs) comparable to Neglected Tropical DiseasesWhat are the factors contributing to this epidemic? How is ACMT helping to address international tox issues?

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TRENDS

WORLD’S MAJOR POISONS

organophosphates

misc.

phosphide

snakes pharmaceuticalsParaquat

“farmaceuticals”

EtOH + tobacco

herbals and plants

OccupationalEnvironmenaland Industrial Toxins

Street Drugs

ORGANOPHOSPHATES: 300,000 Deaths/ year= APPROXIMATELY 1000 Deaths / day!!

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Agrochemicals are the top poisoning killers• AVAILABILITY of toxins• Social/economic factors• Poor Storage practices• Lack of first aid/ 911• Limited EM/ ICU care• No epidemiology• Low gov’t accountability• Complex problem which will require a multifaceted solution

Botanical Gardens, Sri Lanka

• Limited EM/ ICU care• AVAILABILITY of toxins• Poor Storage mechanisms• Low farmworker education regarding toxicity and first aid• Complex problem which will require a multifaceted solution

Br J Clin Pharmacol. 2009 Dec;68(6):916-9.

AGROCHEMICALS ARE THE TOP POISONING KILLERS

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Toxic Plants and MushroomsLots of regional variability in patterns

• Yellow Oleander/ Sea Mango (cardiac glycoside/ digoxin)• Glory Lily (colchicine)• Datura/ Belladonna (atropine)• Mushrooms (various)• Cassava/Yam bean (cyanide)• Rosary bean (abrin, like ricin)• Sandbox tree (hurin, an irritant)• Cleisthanus (toxin unknown)• MANY OTHERS REPORTED

Household, Environmental and Occupational ToxinsCooking Stove FuelCleaning AgentsAcids and CorrosivesCosmeticsTradtionalmedicinesAir/ Water PollutionOccupational Toxins

Summary Points• Organophosphorus cmpds are most common and deadly toxins worldwide• Snakebites affect mainly the rural poor• Urban overdose mortality is lower than rural

• Less dangerous ingestions?• Access to EM/ICU care and antidotes?

• Traditional meds & plants require research• Some interventions are possibly harmful• Regulatory action is needed worldwide

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GAPS

Asymmetric Burden of Poisoning• Poor access to care• Poor access to antidotes• Lake of specialized workforce• Lack of policies to protect the public from certain chemicals and exposures• Lack of data systems that are necessary to identify and characterize hazards and threats to public health

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Toxicology is Under-Developed Worldwide• Inpatient care•Outpatient care•Academic•Private practice•Research

•Government• Industry•Global Health•Legal consulting•Telehealth

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Pubmed “Biopsy”

A new view on all of thisGlobal Toxicology represents diseases that are neglected as well as emerging• “Neglected Tropical Diseases”

• Classically a domain of Infectious Diseases• Snakebite was recently named as a NTD• Allows mobilisation of WHO and other agencies

• “Emerging” Tropical Problems• Newer concept which should include poisoning • Building momentum as EM matures globally• Implies solutions based on new data/ technology

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POISONING NEEDS TO BECOME RECOGNIZED AS AN EMERGING,NEGLECTED TROPICAL DISEASE

o p p o r t u n i t i e s

How can ACMT members help?•Poison control center development worldwide

•International collaborations to optimize research resources•Critical appraisal of effective remedies in low-resource areas•Restriction and bans on highly toxic agents by governments

•Web based education and poisoning data collection

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ACMT International Committee’s motto: Medical Toxicologists have an important role in Global HealthWe can positively impact the health of populations:

• By advocating for poison prevention in high risk areas• By supporting steps to optimize care of poisoned pts• By educating health care professionals from a diversity of backgroungs, specialties and skill levels

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Solutions: Prevention•Preventing exposures to chemicals

• Root cause analysis: Assessing and characterizing circumstances and sources of exposure for future prevention• Raising awareness among community change agents• Exporting the concept of “Poison Prevention Week”• Reaching out to parents, farmers and other high risk groups• Directing pesticide regulation and banning most toxic cmpds• Campaigning at WHO level for NTD status (such as with snakebites)

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The Full Scope of Tox Practice Has Global Implications• Environmental• Occupational• Intentional Overdose from Pharmaceuticals and Chemicals• Envenomation and plant toxins• Terrorism preparedness and response• Ionizing Radiation • Addiction medicine• Forensic and Analytical (less common)

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PREVENTION AT WORK in the US: Impact of Lead Poisoning Prevention Policy on Reducing Children’s Blood Lead Levels18

2

10121416

0

8

‘76 ‘80 ‘82 ‘84 ‘86 ‘88 ‘90 ‘92 ‘94 ‘96 ‘98Year‘72

Blood

Lead Le

vels (µ/d

L)

‘00‘74

Lead Gasoline Phase-out 1973

Lead-based Paint Poisoning Prevention Act 1971

‘78

Residential Lead Paint Ban 1978

Lead Title X 1992 Housing units with lead based paint hazards reduced by 40% since 1990

Lead Contamination Control Act Virtual Elimination of Lead in Gasoline1988Ban on lead solder in food cans 1995

2.7 %≥ 10 µg/dL

Lead in Plumbing banned 1986

‘02 ‘04

1.2 %≥ 10 µg/dL

‘06

0.8 %≥ 10µg/dL

‘10‘08 ‘12

Lead in Children’s Products Reduced to 600 ppm2009

Lead in Children’s Products Reduced to 100 ppm2011

Renovation and Repair Rule2010

Clean Water Act1972

Solution: Bedside and Remote Clinical Care• Telemedicine

• American University of Beirut Medical Center• Outbreak response

• Emory-Georgia Poison Center-CDC Medical Toxicology Fellowship Program (2001)

35http://www.cdc.gov/NCEH/HSB/chemicals/fellowship.htm

Solution: Education• In country seminars and conference• Online training programs and webinars• International training programs and fellowships in medical toxicology

• Emory International Postdoctoral Medical Toxicology Fellowship

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Ahmedabad, India 2006

Satellite Broadcast 2012

MENATOX Annual Meeting Qatar 2015

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ACMT Symposia and Hands-On WorkshopsACMT members regularly teach cutting edge content at major international meetingsAnnual ACMT Symposium at Asia-Pacific Association of Medical ToxicologyNewer collaborations with Middle East and North Africa Toxicology Society (MENATOX) as well as Mediterranean Emergency Medicine Congress and World Congress of Emergemcy Medicine (Mexico)2015: Creation of the International Speakers’ List: A pool of polished and academically respected ACMT members that can be recruited for International Speaking engagementsTox Lab Workshop: ACMT members curate and deploy a case-based hands on workshop to teach common clinical problems, diagnostic tips, and treatment pearls in a casual, small group setting.

Spanish Language Tox Curriculum• Essentials of Toxicology review guide• Translated and peer reviewed in Spanish• Basis for lecture series and for independent review materials• Used to teach EM residents and faculty in Dominican Republic• ACMT International Committee is planning to expand the project into more Spanish-speaking sites

ACMT GETUP Project: Video Conferences for Tox Education Aim is to connect countries/centers with and without toxicology services for case-based education on practical issuesAlso we hope that this will build long term bridges between health care providersOver 20 sites now connected and meeting with 1-2 other sites on average once a month; video archives on ACMT.net

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Coming Soon: ACMT’s 1-day GlobalTox Course1-day, interactive toxicology curriculum for low resource settings• Audience response clickers• Pre-built Hands-on problem based workshops• Tech Clinic to get users into GETUP/ FOAM• Now recruiting authors/ presenters– join us!

Summary: The Global Poisoning Epidemic Needs Your Skills!• Poisonings are a burden to health globally with an asymmetric effect on underdeveloped nations• Medical toxicologists can mitigate this negative effect using various strategies:

• Poisoning Prevention• Research• Optimizing systems of care• Sustainable professional education

• Junior faculty and toxicology fellows can make a huge impact on global toxicology--participate either online or in person • ACMT International Committee can help guide your experience and provide advice about proper planning and time commitments

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