Cluster of Deaths Due to Consumption Of QuiNalphos in Sironko District, Uganda-November 2017

Summary

Quinalphos is an organophosphate chemical chiefly used as a pesticide. It is ranked moderately hazardous in the World Health Organization’s acute hazard ranking and its use is either banned or restricted in most nations. We describe a case of alleged intentional poisoning of four members of the same household in Sironko District, Uganda. All the four case- persons developed similar symptoms of stomach ache, vomiting, neck pain and perceived fever (all temperatures recorded in the health facilities were within normal ranges).

They all developed symptoms on the same day (9 November 2017) and almost at the same time (onset time for 3 case-persons was 9am and 1 case-person 7pm), and three died within 24 hrs. All the 4 case-persons shared a usual meal with 4 others at 9pm on 8^th November 2017 however, the 4 that got ill ate 5 rice balls earlier in the day at 2pm. The severity of symptoms was dependant on the quantity of rice balls eaten. Eight chicken that died ate pieces of rice that fell down during sharing. The only survivor tested positive for quinalphos. This cluster of illness and deaths most likely was caused by consumption of rice balls laced with Quinalphos. We recommended police investigation as triple homicide, and stricter control of pesticides in the district and countrywide.

Background

Quinalphos is an organophosphate chemical chiefly used as a pesticide. It is a reddish brown liquid and is ranked moderate- ly hazardous in the World Health Organization’s (WHO) acute hazard ranking. The use of quinalphos is either banned or restricted in most nations [1]. Acute pesticide poisoning accounts for significant morbidity and mortality worldwide, especially in developing countries [2].

The WHO estimates three million cases of pesticide poisoning occurring every year resulting in an excess of 250,000 deaths, temporary or permanent disability [3]. And yet pesticides are produced in an un- regulated manner and sold by unregistered vendors on the streets and in market places in Sub-Saharan Africa [4]. We de- scribe a case of alleged intentional poisoning of four members of the same household in Sironko District, Uganda.

Case presentations:

At 14:00hours, on the 8^th November, an eight-year old child (SP) of primary two level came neck home from school with five rice balls (locally called bolingo). The school is approximately 400 metres away. The rice balls (RB) were shared among the children and their grandmother [NB (9-year old)-2 RB, SP (8-year old)-1RB, NP (6-year old) -1/2RB, AW (58-year old)-1 ½RB]. Pieces of the RB fell down as the grandmother shared them. 8/10 chicken that were being reared by the grandfather ate the pieces that fell down.

On the same day at 21:00 hours, the family of 8 shared a meal of sweet potatoes, yams, and egg plants and drunk water from a common pot. On 9^th November, as the family awoke at 6:00hours, eight chicken (4 adults and 4 chicks) were found dead. And by 0900hrs the three children (NB, SP and NP) had started developing symptoms. NB developed stomach-ache, neck pain, fever (self reported), vomiting and convulsion. She was taken to a clinic A and referred to Hospital B but the mother preferred to take her to her father who stays in the next district.

While there, she was taken to clinic C and given normal saline, dexamethasone and hydrocortisone & referred again to Hospital B but died on the same day on her way to hospital at 5pm. SP developed stomach-ache, neck pain, confusion, convulsion, perceived fever, general body weakness, nasal bleeding, headache and vomiting. She was taken to clinic D and died at 3:15am on 10^th November. Only a malaria test (result: negative) and Haemoglobin (Hb: 10g/dl) was done. AW collapsed at 19:00hours, and taken to clinic E.

Other symptoms included neck pain, stomach-ache, chest pain, general weakness, and loss of consciousness. Tests that were run included; Temperature (35.8), malaria (negative), typhoid (negative), brucella (negative), Random blood sugar (100.3mg/dl: ranges 72-108mg/dl), Blood pressure (100/70mmHg). She was managed with diclofenac, normal saline, ceftriazone plus quinine and died at 11:00hours on 10 November. NP developed vomiting and stomach-ache. She was taken to a drug shop for first aid however medication given could not be traced for.

A blood sample was collected and taken to the Government Analytical Laboratories (GAL) for toxicology analysis. Quinalphos was qualitatively detected in her blood by Liquid Chromatography-Mass Spectrometry Triple quadruple (LC-MS/MS). She recovered and is well.

Discussion And Conclusions

Organophosphate compounds are possibly the most widely used insecticides in the world [5]. While Uganda is a signatory to several conventions and agreements related to the management of chemicals, the national implementation of the principles of these agreements are not excellent [6]. The easy access to these hazardous products might result in serious health threats [7]. Diagnosis of mild to moderate organophosphate poisoning is frequently difficult [8, 9], as was the case with the case-persons described above, since symptoms are non-specific and mimic other common disorders.

The acute toxicity of organophosphates is due to the inhibition of the enzyme acetylcholinesterase by phosphorylation, resulting in an accumulation of acetylcholine at postganglionic parasympathetic nerve endings (muscarinic receptors), parasympathetic ganglia (nicotinic receptors) and neuro- muscular junctions (nicotinic receptors). All the organohosphates inhibit both red cell acetyl cholinesterase and plasma cholinesterase and this provides the basis for biological monitoring of toxicity [10].

Early symptoms of acute exposure to organophosphates are non-specific but lead to more characteristic features. In mild to moderate poisoning there may be headache, blurred vision, miosis, excessive salivation, nausea, vomiting, lacrimation, sweating, wheezing and lethargy. Severe poisoning may cause coma, convulsions, respiratory muscle paralysis, bradycadia and hypotension [10, 11]. The four case-persons described in this paper presented with similar symptoms.

The first step in management of acute poisoning is to maintain a clear airway and ensure adequate ventilation, after which atropine should be given until atropinization is achieved. Pralidoxime (a specific cholinesterase reactivator) should also be started within four hours of exposure [10]. Supportive measures include oxygen support, intravenous fluids, and maintaining electrolyte balance [12]. None of the case- persons in this paper received ideal care and management of poisoning. First, there was a delay in seeking care from a health facility. Secondly, the case-persons were taken to clinics probably because of financial implications or access.

These clinics possibly do not have health workers who are experienced enough, so the illness was not diagnosed as poisoning and symptoms were managed as any other infection. A review of literature showed that many patients recover if they report to a health facility within a short time following exposure to organophosphates, whether orally or through inhalation, followed by a correct diagnosis using patient history and correct clinical management [4, 7, 11-14]. The mismanagement of this poisoning led to loss of lives of the three case-persons. The one case-person who survived was probably because of the low dose that she ate.

Organophosphate poisoning in this case occurred because these pesticides are easily accessed in the open market from unregistered vendors with no strict regulation of their use. Additionally, was a lack of recognition of the clinical features of organophosphate poisoning by the attending health workers at the health care facilities. As a result, institution of appropriate care and management of poisoning was not done.

We recommended police to take on this investigation as triple homicide. Also there should be strict control in the handling of pesticides in the district and country.

References

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