Final Project Report

SAICM QSP project no.: X.04.G.ZMB

Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region

Final Project Report Written by JN Edwards and JH Tempowski January 2014


This project was funded under the Quick Start Programme of the Strategic Approach to International Chemicals Management, project number X.04.G.ZMB

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Contents Contributors ...................................................................................................................................... iv Preamble ............................................................................................................................................ vi 1. Executive summary .................................................................................................................... 1 2. Introduction .................................................................................................................................. 8 2.1 Burden of disease from poisoning ................................................................................ 8 2.2 The role of poisons centres .............................................................................................. 8 2.3 The impetus for establishing poisons centres .......................................................... 9 2.4 Current situation in Africa regarding poisons centres .......................................... 9 2.5 Poisons centres in the sub-region .............................................................................. 10 3. Background to the feasibility study .................................................................................. 12 3.1 Origin of the project ......................................................................................................... 12 3.2 Objectives of the project................................................................................................. 12 3.3 The study area.................................................................................................................... 13 3.4 Project activities ................................................................................................................ 13 4. Literature review ..................................................................................................................... 13 4.1 Methods ................................................................................................................................ 13 4.1.1 Pattern and epidemiology of poisoning in the sub-region ....................... 13 4.1.2 Health financing and country profiles for study countries ...................... 14 4.1.3 Models of poisons centre structures and organisation ............................. 14 4.1.4 Economic evaluation studies ............................................................................... 14 4.2 Results ................................................................................................................................... 14 4.2.1 Pattern and epidemiology of poisoning in the sub-region ....................... 15 4.2.2 Health financing and country profiles for study countries ...................... 21 4.2.3 Models of poisons centre structures and organisation ............................. 26 4.2.4 Economic evaluation studies of poisons centres ......................................... 29 4.2.5. Existing cross-border initiatives ....................................................................... 35 4.3 Conclusions ........................................................................................................................ 36 Stakeholder consultation ........................................................................................................... 38 5. Survey of stakeholders ........................................................................................................... 38 5.1 Methods ................................................................................................................................ 38 5.1.1 The questionnaire survey recipients ................................................................ 38 5.1.2 Denominator data for the survey ....................................................................... 39 5.2 Results ................................................................................................................................... 40 5.2.1 Questionnaires distributed and response rate ............................................. 40 5.2.2 Responses to questions .......................................................................................... 41 5.3 Conclusions from the survey ........................................................................................ 60 6. Discussions at the close-study country national meetings and the international multi-stakeholder meetings...................................................................................................... 60 6.1 Description of meetings ................................................................................................. 60 6.1.1 First international multi-stakeholder meeting ............................................. 61 6.1.2 National meetings .................................................................................................... 61 6.1.3 Final international multi-stakeholder meeting ............................................ 61 6.2 Meeting outcomes ............................................................................................................ 63

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region 6.2.1 First international multi-stakeholder meeting ............................................. 63 6.2.2 National multi-stakeholder meetings ............................................................... 63 6.2.3 Final international multi-stakeholder meeting ............................................ 65 6.2.4 Costs of setting up and running services......................................................... 74 6.3 Conclusions from the stakeholder consultation ................................................... 75 7. Discussion ................................................................................................................................... 75 7.1 What has the study shown about the countries in the sub-region? .............. 75 7.2 What has the study shown about the nature of poisoning/burden of disease in the sub-region? .................................................................................................... 76 7.3 Role of poisons centres in the healthcare delivery system in the African region ............................................................................................................................................ 78 7.3.1 Role of poisons centres in public health and chemical safety ................. 78 7.3.2 Role of poisons centres in clinical healthcare delivery.............................. 80 7.4 What has the study shown about the available infrastructure to support a poisons centre? ......................................................................................................................... 81 7.5 Is a sub-regional poisons centre feasible?............................................................... 83 7.5.1 Requirements for a sub-regional poisons centre ......................................... 84 7.6 How can national poisons centres be established? ............................................. 85 7.7 The Hub concept – what is it, how could it help, how could it be set up? ... 86 7.8 What is the role of regional economic communities?......................................... 87 7.9 Technical guidance for establishing poisons centres ......................................... 88 8. Conclusions................................................................................................................................. 89 9. Recommendations ................................................................................................................... 91 References ....................................................................................................................................... 94 Appendix 1..................................................................................................................................... 110 Literature Review of Poisoning in the Eastern Africa sub-region: Summary of reports found ........................................................................................................................... 110 Appendix 2..................................................................................................................................... 122 Toolkit to assist in setting up a Poisons Information Service ............................... 122 Appendix 3..................................................................................................................................... 135 Proposed cost model for setting up and running a poisons information service ....................................................................................................................................................... 135 Appendix 4..................................................................................................................................... 144 Possible sources of funding for poisons centres ........................................................ 144 Appendix 5..................................................................................................................................... 162 EAPCCT Self-assessment checklist for minimum and optimum standards .... 162

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Contributors The following people contributed to the implementation of the project and the preparation of this report. Mr J Nicholas Edwards Project Consultant Mr David Kapindula Ms Hawa Senkoro Ms Joanna Tempowski

Zambia Environmental Management Agency (project applicant). SAICM African Regional Focal Point (2009-2012) World Health Organization Regional Office for Africa (implementing agency) World Health Organization, Headquarters (implementing agency)

Steering Group Members Mr Christopher Kanema Dr Freddie Masaninga Ms Carine Marks Mr Mulonda Mate Mr Tom Menge

Robert Nyarango Caesar Nyadedzor Clare Roberts Dexter Tagwireyi

Zambia Environmental Management Agency, Lusaka, Zambia

World Health Organization Country Office for Zambia

Tygerberg Poison Information Centre, Cape Town, South Africa Ministry of Health, Lusaka, Zambia

Poison Information and Management Centre, Nairobi, Kenya

Gertrude’s Garden Children's Hospital, Nairobi, Kenya

Poisons Information Centre, Accra, Ghana; Network of African Poisons Centres and Applied Toxicologists Poisons Information Centre, Rondebosch, South Africa

Drug and Toxicology Information Service, Harare, Zimbabwe Page | iv

Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region Evaluator Dr Mark Personne

National Poisons Information Centre, Stockholm, Sweden, on behalf of the European Association of Poisons Centre and Clinical Toxicologists

The contributions of participants in national and international workshops and of those who completed survey forms is gratefully acknowledged.

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Preamble The problems caused by chemicals and toxins in Africa are at least as bad as those on other continents. Yet Africa has very few poisons centres to advise clinicians or the public, to provide training or laboratory services or to lead poisons prevention efforts. The number of poisons centres has not changed in more than three decades. However, the chemicals industry has continued to grow, and the potential need for poisons information has risen in parallel. Looking ahead, the predicted annual growth rate for the chemicals industry in Africa and the Middle East is over 6% for 2013, then over 5% until 2021. Nowhere else in the world, except parts of Asia, will the chemicals industry grow faster (UNEP 2012). Despite this, Africa's ability to manage the effect of chemicals on health remains minimal.

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1. Executive summary 1.1 Introduction

The problems caused by chemicals and toxins in Africa are at least as bad as those in other continents. Estimates suggest that the burden of unintentional poisoning in Eastern Africa is significant, with 13,000 deaths and 734,000 Disability-Adjusted Life Years (DALYs) in 2010. Moreover, unintentional poisoning ranks 30th in importance as a cause of years of life lost due to premature death in Eastern Sub-Saharan Africa, compared with 43rd globally and 65th in Western Europe.

Africa has very few poisons centres to advise healthcare workers or the public. Furthermore, the paucity of such centres means a lack of laboratory services, training and the ability to lead poisons prevention efforts. While the number of poisons centres has barely changed in more than three decades, the chemicals industry has continued to grow, and the potential need for poisons information has risen in parallel. An additional impetus is provided by the International Health Regulations (2005) under which countries must put in place a number of core capacities, including having an adequatelyresourced poisons centre.

The establishment and strengthening of poisons centres was identified as a regional priority at the first African regional meeting on the Strategic Approach to International Chemicals Management (SAICM) in June 2006. The possibility of a sub-regional poisons centre, i.e. a centre in one country serving multiple countries, was suggested. This project is the result of a request by the SAICM Africa Core Group, at its fifth meeting in January 2010, that proposals be developed to address the lack of progress in establishing poisons centres. The overall objective of the project was to find a means for improving the provision of poisons centre services in Africa and, specifically, to: • • • •

document the incidence of poisoning in the Eastern Africa sub-region; establish the existing provision of poisons centre services in the sub-region; identify available models of poisons centre service provision and the requirements for their establishment; and present options on how to improve the availability of poisons centre services in the sub-region.

1.2 Project activities

The project has involved the synthesis of information drawn from two major activities: a literature review and an extensive stakeholder consultation. The countries included in this study were: Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Mozambique, Rwanda, Seychelles, Uganda, United Republic of Tanzania, Zambia and Zimbabwe. Prior to the start of the project, three poisons centres were known of in the sub-region: two in Nairobi, Kenya and one in Harare, Zimbabwe. The aim of the literature review was to obtain background information on the 16 countries included in this project, particularly on the epidemiology of poisoning and on Page | 1

Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region health system characteristics, and also to collect information on poisons centres more generally, as well as on any relevant cross-border arrangements in the sub-region

The stakeholder consultation involved a survey and international and national workshops. Its purpose was to gather information about resources in the sub-region relevant to the management of poisoning and chemical events, and also to find out about the attitudes of stakeholders to various aspects of a sub-regional poisons centre. Stakeholders in all 16 study countries were consulted by questionnaire and in four countries (Kenya, Zambia, the United Republic of Tanzania and Zimbabwe) stakeholders were also consulted through national workshops. International workshops took place at the beginning and towards the end of the project. At the final workshop the outcomes of the project were discussed, together with options for providing poisons centre services.

1.3 Project outcomes 1.3.1 Literature review Epidemiology of poisoning The literature review revealed that data on the epidemiology of poisoning in the Eastern Africa sub-region are scarce and countries are unevenly represented in the published literature. Commonly-reported forms of poisoning include pesticide poisoning, kerosene ingestion by children, and poisoning with natural toxins, including snakebite, and with traditional medicines. One striking finding is the relatively high case fatality rate for poisoning from chemicals and drugs, even for accidental poisoning in children. This is in contrast to developed countries where accidental poisoning rarely causes deaths in children. National characteristics The review also showed that there is a wide variation among countries in the subregion in terms of indicators relevant to the establishment and work of poisons centres. The amount spent on health per capita in the study countries varies considerably, and even in the highest spending country, Mauritius, expenditure is low in comparison with OECD countries. Moreover, only nine countries spend the minimum amount considered by WHO to be sufficient to provide essential healthcare, and only two countries (Mauritius and Seychelles) have the minimum number of healthcare workers judged sufficient by WHO to provide essential interventions.

Other indicators of interest in the context of the delivery of poisons information services include limited access in many countries to telephone services and the Internet, and also relatively low adult literacy levels in many countries. Once again, there is considerable variation in these indicators with, for example, Eritrea having an extremely low level of mobile telephone subscriptions and the Seychelles having a level that is on a par with many developed countries. On the positive side, access to telecommunications services is improving rapidly in many countries. Poisons centre models The most common model for a poisons centre is a telephone-based information service in a single country. In some countries poisons information services are combined with

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region drug-information services. Very few examples of cross-border poisons centre services were identified in the study. A small number of formal arrangements between two countries were found whereby a poisons centre provided services to another country to supplement that country’s existing national service e.g. by providing out-of-hours cover. In this case there were procedures for documenting and reporting the enquiries from the other country. Many poisons centres answer ad hoc enquiries from other countries, however, there is no mechanism for follow-up or for reporting back to health authorities. There has also been a growth in Internet and other electronic poisons information databases, including the AfriTox® database available in the African region, and TOXINZ (from New Zealand) available to low-income countries through HINARI 1. Studies on cost-effectiveness have shown that, whatever the configuration of the poisons centre, they provide a positive cost-benefit.

Existing Cross-border initiatives There are three regional economic communities covering the countries in the Eastern Africa sub-region: the Southern African Development Community (SADC), the East African Community (EAC), and the Common Market for Eastern and Southern Africa (COMESA). These communities have initiatives relevant to cross-border collaboration on poisons centre services, for example, the SADC Protocol on Health and the EAC East Africa Public Health Laboratory Networking Project (EAPHLNP). In addition the three communities are collaborating in a tripartite approach to build infrastructure, including for telecommunications, and to harmonize policy on health and environmental protection. 1.3.2 Stakeholder consultation During this consultation a drug and poisons information centre was identified in Madagascar, increasing the known poisons centres in the sub-region to four.

Stakeholders recognised the need to improve poisons centre services. While there was general support for a sub-regional poisons centre there was a notable preference for national centres. Indeed four countries (Ethiopia, Uganda, United Republic of Tanzania and Zambia) have started developing plans to set up their own centres. During the second international multi-stakeholder meeting there was a detailed discussion of possible options for improving poisons centre services, including both large-scale and smaller-scale sub-regional poisons centres, an entirely Internet-based service, standalone national centres, and national poisons centres linked together through a coordinating hub. The last of these was the preferred option, followed by standalone national poisons centres.

1.4 Discussion and conclusions

While the Eastern Africa sub-region suffers a number of severe health burdens there is an argument for investing in poisons centre services as a means for improving the prevention and cost-effective management of poisoning, as well as to fulfil other public health and chemical safety roles. 1

http://www.who.int/hinari/en

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region This report presents concrete examples of the contribution of poisons centres to improving public health, chemical safety and the clinical management of poisoning. Poisons centres achieve this by being both providers and collectors of information on hazardous substances and products, and on the effects of exposures. Poisons centres also provide a focus for research, training and preventive activities. However, to be able to do this work effectively poisons centres need to be adequately resourced.

This study sought to evaluate the feasibility of a sub-regional poisons centre and to propose ways for improving the availability of poisons centre services in the sub-region. With regard to a sub-regional centre, the study has shown that there are a number of practical matters that would have to be dealt with, for example, concerning the sharing of confidential information, issues of medical liability, an agreed mechanism for reporting events and poisoning data from each country, and agreement on the basis for cost-sharing. There would also need to be political support in the countries concerned, as well as support from the professionals and members of the public who would be using the service. Based on the limited available experience with such a service, a sub-regional centre would work best for countries with a shared language, similar levels of medical resources and funding, as well as a good telecommunications infrastructure. While a shared poisons centre service might work between two countries, a service shared between more countries is an untested concept and its ability to fulfil the required public health and chemical safety roles is uncertain.

During the consultation, stakeholders showed a strong preference for national centres over a sub-regional centre and supported the concept of national centres networked or linked through a hub. The hub concept was explored in project discussions and the following functions were suggested: • • •

• • • •

coordination of training of poisons centre staff; standard setting for poisons centre services; promoting standardisation between centres e.g. in treatment advice, documentation of enquiries etc.; mentoring of poisons centres and staff in the network; sign-posting, i.e. directing members to other resources and sources of assistance etc,; advocacy on behalf of the network at national and international fora; and assistance in handling difficult enquiries.

From a practical perspective establishing national poisons centres rather than a subregional centre is more straightforward. It also has the benefit that national authorities would have immediate ownership and access to, data on chemical exposures in their own countries. In addition a national centre would promote the development of national capacities in clinical toxicology. Networking poisons centres through a hub would provide advantages in terms of sharing training resources, harmonising data collection, providing mutual support, and, potentially, facilitating the development of cross-border surveillance and early warning of events of international concern.

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A hub could be a physical entity, e.g. based at an existing poisons centre, or it could be a virtual entity e.g. provided by the Network of African Poisons Centres and Applied Toxicologists (NAPCAT) if the association were resourced to do this.

1.5 Challenges and opportunities

The challenges to establishing poisons centres in the sub-region include lack of trained personnel, under-developed ICT infrastructure, limited access to toxicology references and obtaining sustainable financial support. The extent of these challenges varies from country to country.

There are also, however, a number of opportunities that can mitigate these challenges. Firstly, the project has shown that there is definite interest on the part of governments in setting up poisons centres, as evidenced by plans already developed by Ethiopia, Uganda, United Republic of Tanzania and Zambia. A regionally-relevant database on toxic substances, the AfriTox® poisons information database, is available for use by anglophone countries. In addition, the existing poisons centres in the sub-region, as well as those in South Africa, are willing to provide technical support and training. The emergence of NAPCAT as a regional body could, if enabled to develop, provide a focus for advocacy, and mutual support as well as, possibly, a hub function.

Improving telecommunications infrastructure is already allowing many sectors of the community to access services, and this could be extended to poisons information services. This is a time of considerable innovation in telecommunications in Africa, as exemplified by m-Pesa (mobile money) and the use of SMS (Short Message Service) for conveying information of different kinds. Moreover, new developments and projects are seeking to revolutionise both data provision and collection in the health sector.

1.6 Recommendations

1. The plans for establishing poisons centres already drafted by Ethiopia, Uganda,

the United Republic of Tanzania and Zambia should be further developed by the responsible authorities to ensure that they are based on a robust and sustainable cost model that takes account of existing services and the funding mechanisms for the health system into which the poisons centre service will be integrated. These plans can then be used as the basis for requesting support from development partners for the establishment of the centres. In addition, technical support, in the form of training and practical guidance, should be sought from the poisons centres in the sub-region, in Kenya, Madagascar and Zimbabwe, as well as the poisons centres in Cape Town, South Africa. WHO and other international organizations should be asked to assist with the development of proposals and should facilitate other technical assistance.

2. Governments of countries that would prefer to share poisons centre services

rather than establish their own centres should agree on a framework that includes policies and agreements addressing the ethical, quality standard and liability considerations of a cross-border service, as well as procedures for

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region sharing information, alerting about events and reporting numerical data on poisoning cases. Robust financial arrangements should be put in place to ensure the sustainability of the cross-border service.

3. The existing centres within the sub-region should be further strengthened

through increased financial support from their governments. Moreover, formal recognition of existing centres by their governments as national centres should be sought. Centres are encouraged to actively seek additional funding sources provided these do not threaten the operational independence of the centres. Technical and in-kind support could be sought from other African and nonAfrican poisons centres and this could be facilitated by WHO.

4. Consideration should be given to establishing poisons centre hubs that link

together centres in different countries that share linguistic and cultural characteristics. The hub could serve the following functions to members of the network: coordination, training, standard-setting, mentoring, signposting and advising, as well as advocacy and negotiations with state, regional and international bodies on behalf of the network.

The role of hubs could be provided by any of the existing poisons centres in the African region, i.e. not only within the Eastern Africa sub-region. Alternatively hub functions could be provided by NAPCAT.

5. In order to strengthen the provision of poisons centre services within the sub-

region, and more widely in Africa, poisons centres should be encouraged to network. It is recommended that NAPCAT should be strengthened through increased financial support so that it can further develop its intended roles in promoting professional development, standard-setting and advocacy for poisons centres in the region. While some funds for the network come from membership dues, NAPCAT should seek additional funding from national authorities, donors and international bodies. With adequate resources NAPCAT could provide hub functions for a group of poisons centres.

6. To assist in the early development of standardised data collection and data

exchange as well as consistent reporting of data about poisoning and toxicology within the sub-region, it is recommended that all centres operating within the region consider the use of the WHO-developed tools for harmonized data collection as used in the IPCS INTOX Data Management System2.

7. A comprehensive survey should be carried out to identify the location, activity and availability of expertise on different aspects of toxicology within the sub-

2 http://www.who.int/ipcs/poisons/package/en/index.html

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region region. This information should be kept in a database. Information about experts within a country should be made available to the appropriate national health authorities and institutions. The survey and construction of the database could be carried out by NAPCAT if it was provided with sufficient resources to perform this task.

8. A regular audit of analytical capacity and services in the sub-region should be undertaken and a listing maintained of relevant laboratories.

1.7 Moving forward

The project report provides additional guidance in a set of Annexes to assist countries in planning and setting up a poisons centre.

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2. Introduction 2.1 Burden of disease from poisoning

Poisoning with chemicals, both synthesized and natural, presents a significant public health problem in developing countries and those in economic transition. According to WHO estimates, in 2004 unintentional poisoning caused 346,000 deaths worldwide, 91% of which occurred in low- and middle-income countries (WHO 2008a). There were an estimated 59,000 deaths in the WHO regions for Africa and Eastern Mediterranean (these equate to the UN region for Africa). In addition, in the same year, unintentional poisoning caused the loss of over 7.4 million years of healthy life (disability adjusted life years, DALYs), of which over 1.5 million were in Africa and the Eastern Mediterranean. Intentional ingestion of pesticides causes approximately 350,000 deaths per year worldwide (WHO 2009a). Looking more regionally, the Global Burden of Disease Project, has estimated that in 2010 poisoning accounted for 13,000 deaths and 734,000 DALYs in Eastern Africa (Institute for Health Metrics and Evaluation 2012) 3.

2.2 The role of poisons centres

The appropriate diagnosis and management of poisoning is an area of specialist knowledge for which few health care professionals are trained. Moreover, the sheer range of substances and products that can be the cause of poisoning means that even an experienced health care professional will sometimes need additional information and advice. In most developed countries this assistance is available from a poisons centre. A poisons centre is a centre of technical expertise about chemicals and toxins and their harmful effects. As a minimum it is a poisons information service, but some centres also include a toxicology laboratory and/or a clinical treatment unit. The main tasks of a poisons centre are to: • provide advice about the diagnosis and management of poisoning • develop protocols for the management of poisoning • maintain databases of chemical products and substances • collect data on enquiries to the centre to establish the epidemiology and causes of poisoning • carry out toxicovigilance / surveillance of new hazards • engage in poisons prevention activities • provide training to health professionals on the diagnosis and management of poisoning

The databases compiled by a poisons centre on the chemicals and chemical products in use in the country (including on their toxicology and the diagnosis and treatment of exposure) may become a unique source of information on these substances. Similarly, the data collected on poisoning enquiries may also be a unique source of information on

3 It should be noted that the definition of Eastern sub-Saharan Africa from the GBD and IHME report (Horton 2012) does not map exactly on the UN-defined Eastern Africa sub-region; notable is the exclusion of Zimbabwe from the GBD and IHME definition and that Sudan is not in the UN Eastern Africa subregion, but is included in the GBD and IHME definition.

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region the number and type of human exposures to chemicals nationally or sub-nationally, and can be used to inform national authorities on the poisoning problems in the country that need attention. Typically, a poisons centre provides a 24-hour service to advise healthcare professionals about treatment, most commonly in cases of emergency. Globally, the majority of poisons centres also provide advice to the public.

2.3 The impetus for establishing poisons centres

The United Nations Conference on the Environment and Development (UNCED) highlighted the important role of poisons centres in chemical safety in its programme of action, Chapter 19 of Agenda 21. The establishment and strengthening of poisons centres is relevant to a number of the objectives of the Strategic Approach to International Chemicals Management (SAICM) Overarching Policy Strategy, namely: Risk Reduction; Knowledge and Information; Governance; and Capacity-Building and Technical Cooperation. The continuing need of countries for poisons information and control centres and for increased capacities to deal with poisonings and chemical incidents is recognized in the SAICM Global Plan of Action.

The International Health Regulations (2005) provide a legal and operational framework for WHO Member States to better protect the health of their populations (WHO, 2008b). The IHR (2005) specifically require all Member States to develop core capacities for surveillance, preparedness and response towards all public health threats, including chemicals. Countries should also have the capacity to rapidly share and access relevant information within the country and with the global community. Having an adequately resourced poisons centre is considered to be an indicator of surveillance and response capacity for public health events involving chemicals (WHO, 2010).

2.4 Current situation in Africa regarding poisons centres

Over the years, many countries have established or strengthened poisons centres to improve the management of poisoning, thereby reducing deaths and disability, and to provide data to support and focus preventive and chemical safety measures. The African region, however, remains very poorly provided for. According to WHO data 4 only nine of the 53 countries in the UN African region have a poisons centre, namely: Algeria, Egypt, Ghana, Kenya, Morocco, Senegal, South Africa, Tunisia and Zimbabwe.

In the Eastern Africa sub-region, the area for this study, only two countries have poisons centres, Kenya and Zimbabwe. Information about these centres is given below.

Interim results of global survey of poisons centres, unpublished. Data for two WHO regions: Africa and Eastern Mediterranean

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2.5 Poisons centres in the sub-region 2.5.1 Kenya There are two poisons centres in Kenya, both in Nairobi. They are the Poison Information and Management Centre based at Kenyatta National Hospital, and the Drug and Poison Information Centre (DPIC) based at Gertrude's Garden Children’s Hospital. 2.5.1.1 Poison Information and Management Centre (PIMC) The host institution, Kenyatta National Hospital is a national referral and teaching hospital. It has 50 wards, 22 out-patient clinics, 24 operating theatres (16 specialized) and an Accident & Emergency Department, with a total bed capacity of about 2000. On average the hospital caters for over 80,000 in-patients and over 500,000 out-patients annually. The PIMC is located within the hospital and receives significant in-kind support. This includes staff costs, premises, use of telecommunications infrastructure and access to published references through the medical library. The overall coordination and direction of the centre is provided by the Chief Pharmacist of the hospital.

There are three staff who provide a 24-hour, 7-day a week service. Out of normal office hours on-call staff carry a mobile telephone. Staff include a toxicologist (who is in charge of the centre), drug and poison information pharmacists, and hospital clinical pharmacists with support from pharmacists from the University of Nairobi School of Pharmacy. There are also secretarial support staff. The PIMC offers a drug and poisons information service to both medical staff and the general public, though mainly the former. Users can contact the service using two tollfree numbers. The centre documents its enquiries using the WHO INTOX Data Management System.

The centre also develops guidelines for the management of poisoning and collects national data on poisoning. The centre undertakes training outreach to hospitals (with a target to reach all Level 5, i.e. provincial, hospitals), health care professionals, and professional associations, offering continuing professional development and continuing medical education sessions, including the management of poisoning. In addition the centre offers training to industry, including the agrochemical industry.

The PIMC collaborates with the Kenyan Pharmacy and Poisons Board, the Agrochemical Association of Kenya, the Pest Control Products Board, the Kenya Association of Manufacturers, the Kenya Association of Pharmaceutical Industries and other institutions, and with the Drug and Poison Information Centre at the Gertrude’s Garden Children’s Hospital. In addition to in-kind support from the Kenyatta National Hospital the PIMC receives some funding from the Agrochemical Association of Kenya through a levy paid by manufacturers and importers of agrochemicals.

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region 2.5.1.2 Drug and Poison Information Centre (DPIC) The DPIC is based in the pharmacy department at the Gertrude's Garden Children’s Hospital, a private hospital. It provides a 24-hour emergency and technical information service available by telephone to anyone with a concern about a poison or a drug. The centre offers drug information, poisons information and training for parents and caregivers on general principles of poisons management and first-aid when poisoning occurs, and poisons prevention in the home. These services are provided by pharmacists.

2.5.2 Zimbabwe There is only one poisons centre in Zimbabwe, the Drug and Toxicology Information Service (DaTIS) 5. This is a unit in the School of Pharmacy at the University of Zimbabwe and is situated in Parirenyatwa Hospital, Harare, the largest teaching hospital in the country. DaTIS was established in 1979 in response to the health service challenges in Zimbabwe. These included a low practitioner to patient ratio and a recognition that there was a need for independent drug information and for poisons information.

The centre has dedicated office space and, as part of the University of Zimbabwe, it has good access to the university library facilities. The Ministry of Health provides a small annual grant, otherwise the only funding that the centre receives is through in-kind support from the University of Zimbabwe, which pays the salaries for two full-time lecturer-pharmacists to carry out university work. Other than this there are no salaried staff employed by DaTIS. The centre benefits from three community-service pharmacists (i.e. pharmacists who have completed their pre-registration training and serve the government for a year before full practice certification) and a pre-registration pharmacist for six months. Un-paid interns also carry out some of the centre’s work. The centre answers enquiries from health-care professionals on poisoning diagnosis, management and prevention. Enquiries are answered by pharmacists. The service is available 24 hours a day, 7 days a week, with staff in the office in normal working hours and the out of hours service being provided through a roster of on-call pharmacists/toxicologists contacted on their cell phones. DaTIS is also involved in drafting national treatment guidelines.

DaTIS is engaged in education and training of health-care students (pharmacists, nursing science and doctors), both undergraduate and postgraduate, as well as teaching to paediatricians, physicians and public health practitioners. The staff of the centre teach on a Masters in Public Health course and offer continuing education and other outreach courses and seminars.

The centre produces a drug information bulletin and has an active website. The centre carries out research, in particular in toxico-epidemiology, and analytical and experimental toxicology. DaTIS has limited laboratory facilities but lacks equipment and is currently trying to build up its analytical services.

5

http://www.datis.uz.ac.zw/index.php

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region The centre collaborates with, and has associations with, several other agencies including the Medicines Control Authority of Zimbabwe, the Ministry of Health – Directorate of Pharmacy Services, WHO, the Red Cross and CropLife.

The strategic goals of the centre are to ‘normalise’ the centres functions and to generate income for the centre. In addition the centre would like to increase its profile, to be more widely recognised and to increase community services.

3. Background to the feasibility study 3.1 Origin of the project

The establishment and strengthening of poisons centres was identified as a regional priority at the first African regional meeting on the Strategic Approach to International Chemicals Management (SAICM) in June 2006. The possibility of a sub-regional poisons centre, i.e. a centre in one country serving multiple countries, was suggested. At its fifth meeting in January 2010, the SAICM Africa Core Group, which comprises representatives from all sub-regions, noted a continuing lack of progress on this issue and requested that proposals be developed to address this. The project proposal was developed and funding was secured from the SAICM Quick Start Programme (QSP) Trust Fund. The applicant organisation was the Zambia Environmental Management Agency (ZEMA) and the implementing agency was the World Health Organization (WHO).

The project has been guided by a Steering Group comprising representatives from the poisons centres in Kenya, South Africa and Zimbabwe, a representative of the Network of African Poisons Centres and Applied Toxicologists (NAPCAT), who works at the poisons centre in Ghana, the SAICM Regional Focal Point (outgoing and incoming), ZEMA and WHO.

3.2 Objectives of the project

The overall objective of the project was to find a means for improving the provision of poisons centre services in Africa. While this project has focused on one sub-region, Eastern Africa, it is expected that other sub-regions could utilize the findings. The specific objectives were to: • document the incidence of poisoning in the Eastern Africa sub-region; • establish the existing provision of poisons centre services in the sub-region; • identify available models of poisons centre service provision and the requirements for their establishment; and • present options on how to improve the availability of poisons centre services in the sub-region

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3.3 The study area

The study area for this project comprised the countries in Eastern Africa, as defined by the UN 6, that had a SAICM National Focal Point (NFP), i.e. Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Mozambique, Rwanda, Seychelles, Uganda, United Republic of Tanzania, Zambia and Zimbabwe. Excluded countries were Somalia and South Sudan, which had no SAICM NFP, and Reunion and Mayotte, which are French overseas departments.

3.4 Project activities

The project has involved the synthesis of information drawn from two major activities: a literature review and an extensive stakeholder consultation. The stakeholder consultation involved a survey and international and national workshops. Additional information and perspective has been provided through regular discussions with the project Steering Group.

4. Literature review The purpose of the literature review was to obtain background information on the 16 countries in the sub-region included in this project, and also to collect information on poisons centres more generally, as well as any existing cross-border health arrangements in the sub-region.

The literature review forms part of the project but is also a separate study in its own right. Full details of the search methods used and the results obtained are provided in the report of the literature review in Annex LR. A summary is provided below.

4.1 Methods

The review involved a search of the published scientific literature for information on the pattern and epidemiology of poisoning and chemical exposure in the sub-region, as well as a search of official and grey literature sources on the health systems and their funding. In addition the review described a number of different models of poison centre operations, and considered reports of economic evaluations of poison centre operations anywhere in the world. Finally the review sought information on any existing crossborder arrangements in Africa that might be relevant for this study. 4.1.1 Pattern and epidemiology of poisoning in the sub-region Data on the epidemiology of poisoning in countries in the sub-region were sought through a wide-ranging literature search of both the peer-reviewed and grey literature, with no date or language restrictions. Other sources included WHO disease estimations and WHO health profile documents. Members of the Steering Group were also asked to 6

http://unstats.un.org/unsd/methods/m49/m49.htm

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region provide any data or references available to them. In addition, respondents to the survey (see below) were asked if they could provide any data on poisoning in their countries. Epidemiological parameters such as case fatality rates, mortality rates, prevalence and incidence were identified and reported. Case reports were also considered as they provided an indication of the type of poisoning hazards in the country.

4.1.2 Health financing and country profiles for study countries Information on the country profiles, health systems and funding structures of the study countries was sought. The resources available for health will influence the ability of a country to fund and support any poisons centre activities. This part of the review relied mainly on UN agency information sources, including the following: • •

•

National Chemical Profiles http://www.unitar.org/cwm/nphomepage/ Situation Analysis & Needs Assessments (SANAs) (available for Ethiopia, Kenya and Madagascar on http://www.afro.who.int/en/clusters-aprogrammes/hpr/protection-of-the-human-environment/highlights/secondinter-ministerial-conference-on-health-and-environment-inafrica/articles/2468-sana-reports.html) WHO country cooperation strategies and health profiles (available for each country at http://www.afro.who.int/en/countries.html)

4.1.3 Models of poisons centre structures and organisation The WHO publication, Guidelines for Poison Control was a key resource for this part of the review (WHO 1997). In addition, published descriptions of specific poisons centres and their operations were considered, together with abstracts and full papers on Internet-based delivery systems for poisons information. The Steering Group was also asked for input to this part of the review.

4.1.4 Economic evaluation studies This section of the literature review sought studies evaluating the economic impact of poisons centres. Once again, the review involved a search of the peer-reviewed and grey literature, including congress abstracts. The outcomes of interest were economic evaluation results, including incremental cost-effectiveness ratios, cost savings, incremental costs, and cost-benefit ratios.

4.2 Results

Information was obtained about all the countries in the study area, although there were large variations in the amount and quality of the information available on the pattern of poisoning. The review also found very wide variations in the amount spent per capita on health in the countries of the sub-region – from $14 (Eritrea) to $510 (Mauritius) – although a significant proportion of this, and other differences, is accounted for by the widely different GDP between the countries in the sub-region. Page | 14

Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region 4.2.1 Pattern and epidemiology of poisoning in the sub-region 4.2.1.1 Availability of published reports on poisoning The literature review found relatively few published reports on poisoning for the Eastern Africa sub-region, with a general increase in the number of publications after 1990 compared with earlier years (Figure 4.1). There was a wide variation in the number of published reports by country, ranging from 25 reports on poisoning in Zimbabwe to no reports for Burundi, the Comoros, Eritrea or Rwanda. These reports – where numbers are given – represent a cohort of some 36,000 people (see Appendix 1 for case numbers in individual studies), although this is a low estimate as some reports were for ‘families’ or other groups.

Figure 4.1 – Bibliometric analysis of the numbers of papers found in literature review

The number of publications is influenced by many factors and it is unlikely that the small number is due to lack of incidents of poisoning. It is more likely a result of the ability of health researchers to collect data from national statistical authorities or elsewhere and the availability of time to do such work in the face of other priorities. Information on poisoning found for each country is summarised below. Additional information can be found in a summary table in Appendix 1. 4.2.1.2 Summary of information on poisoning in each country

BURUNDI According to WHO estimates there were 7.8 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). No published studies of the epidemiology of poisoning in Burundi were found. COMOROS According to WHO estimates there were 1.7 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). Poisonings account for 0.2% of

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region disability adjusted life years lost (DALYs) (WHO AFRO 2010). No published studies describing poisoning in Comoros were found.

DJIBOUTI According to WHO estimates there were 3.9 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). Only four published reports were found describing poisoning in the country. These described accidental childhood poisoning with kerosene (paraffin); two papers on snakebite; and a prospective study of stingray stings. In the study of kerosene ingestion, 41% of cases developed pneumonia, highlighting the potential severity of this form of poisoning (Benois et al., 2009). ERITREA According to WHO estimates there were 3.7 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). No published studies describing poisoning in Eritrea were found.

ETHIOPIA According to WHO estimates there were 3.5 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). Poisoning was found to be the second most common method of attempted suicide after hanging according to a communitybased study. Strong detergents and rodenticides were the most frequently used poisons (Alem et al., 1999). Five hospital-based studies identified organophosphate pesticides as an important cause of poisoning, with a case fatality rate as high as 20% in one study (Abebe 1991; Selassie 1998; Melaku et al., 2006; Abula & Wondmikun 2006; Desalew et al., 2011). A mass accidental poisoning with Datura stramonium was also described (Aga & Geyid 1992). KENYA According to WHO estimates there were 3.4 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). A relatively large number of papers were found describing poisoning in Kenya. These included reports of mass poisonings caused by the food-borne toxins botulinum toxin and aflatoxin. Indeed, aflatoxin poisoning associated with consumption of mouldy maize is a recurring problem (CDC, 2004a). Three studies of snakebite were also identified. One of these estimated an annual rate of snakebite of 150 per 100,000 population (Snow et al., 1994), while another estimated 13.8 per 100,000 population (range 1.9-67.9) with an annual mortality of 0.45 per 100,000 population (Coombs et al., 1997). Five hospital-based studies highlighted pesticides, household products, and kerosene poisoning in children as causes of significant morbidity and mortality (Kahuho 1980; Guantai et al., 1993; Mbakaya et al., 1994; Lang et al., 2008; Nyamu et al., 2012). A number of mass methanol poisoning events have also been described, associated with consumption of informally produced alcoholic drink (Akida, et al., 2011). MADAGASCAR According to WHO estimates there were 2.9 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). The only publications found on poisoning in Madagascar involved poisoning with natural toxins, namely: puffer fish (tetrodotoxin), snakebite, spider bite, and ciguatera toxin. Ciguatera toxin has caused a number of mass poisonings, and has usually involved ingestion of contaminated shark

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region and turtle meat (Habermehl et al., 1994; Ramialiharisoa et al., 1996 & 1997; Ranaivoson et al., 1994; Champetier de Ribes et al., 1998).

MALAWI According to WHO estimates there were 0.9 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). Epidemiological and other data concerning poisoning in Malawi are very limited. The review identified a case report of a baby who survived organophosphate poisoning (O’Reilly & Heikens, 2011), two hospital-based studies of childhood poisoning and one study of suicide. Of note in a prospective study of paediatric admissions for poisoning was the rather high case fatality rate of 7.6%, with the most common cause of death being poisoning from traditional medicines (Chibwana et al., 2001). Yu and colleagues (2009) reported that poisoning accounted for 15.1% of child injuries admitted to a central referral hospital in Malawi. Dzamalala and colleagues (2006) reported that the most common method of suicide was pesticide poisoning. MAURITIUS According to WHO estimates there were 0.1 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). Only one published report of poisoning was found, describing ciguatera toxin poisoning in some tourists (Glaizal et al., 2011) MOZAMBIQUE According to WHO estimates there were 3.4 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). In Mozambique the only published reports found concerned chronic cyanide poisoning resulting from ingestion of inadequately processed cassava, a condition also known as konzo. This is characterised by neurological abnormalities, particularly a spastic paraparesis. Reports of these outbreaks spanned the years 1986 to 2002 (for example, Cliff et al., 1986; Cliff et al., 1997; Ernesto et al., 2002).

RWANDA According to WHO estimates there were 1.3 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). No published reports of poisoning were found, only a media report of food poisoning.

SEYCHELLES There is no WHO estimate for deaths due to unintentional poisoning (WHO, 2009b). Only one published report on acute poisoning was found, which concerned poisoning by a fish toxin (Lagraulet 1975). The only other publications found related to pre- and postnatal exposure to methylmercury and the Seychelles Child Development Study e.g. Myers et al., 2009.

UGANDA According to WHO estimates there were 11.4 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). Three hospital-based studies were found. A review of paediatric admissions for accidental poisoning between 1963 to 1968 identified 130 cases of whom 7 died (case fatality rate of 5.4%) (Bwibo, 1969). Household chemicals accounted for the largest proportion of admitted cases, and of these kerosene was the most significant. All but one of the deaths were due to

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region medicines. Cardozo and Mugerwa (1972) carried out a retrospective survey of all poisoning admissions in 1970, excluding alcohol and venomous bites and stings. Children under ten years accounted for 69% of cases, which mainly involved kerosene ingestion and pesticides. In adults, almost half of all the cases resulted from pesticide exposure. In a further retrospective study of acute poisoning admissions to two hospitals, poisoning with agrochemicals was responsible for most of the cases followed by household chemicals, carbon monoxide, snakebite and food poisoning (Malangu, 2008). A study of deliberate self-harm found that poisoning was the most important method used, mainly involving organophosphate pesticides and medications (Kinyanda et al., 2004). Mass methanol poisoning is also a problem in Uganda, associated with informallyproduced alcoholic drink (Uganda Office of the President, 2009).

UNITED REPUBLIC OF TANZANIA According to WHO estimates there were 6.6 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). Only a small number of published studies on poisoning were found. One study concerned accidental poisoning with Datura stramonium from contaminated millet (Rwiza, 1991). The second was a prospective study of snakebite, which identified 85 cases, half of whom received antivenom (Yates et al., 2010). The case fatality rate was 1%. A hospital-based case review described 736 cases of poisoning with organochlorines between 1988 and 1990 (Mbakaya, et al., 1994). Konzo, associated with cassava ingestion is also a recurring problem in the United Republic of Tanzania (e.g. Howlett et al., 1990 & 1992; Mlingi et al., 2011). Poisoning was found to be a common method of committing suicide, particularly involving anti-malarials (mostly chloroquine) and pesticides (Ndosi et al., 2004).

ZAMBIA According to WHO estimates there were 4.8 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). In a retrospective analysis of paediatric admissions for accidental poisoning, kerosene poisoning accounted for the largest proportion of admissions, followed by food poisoning, household products, and medicines (Bhushan et al., 1979). The case fatality rate was 0.5%. Another combined retrospective and prospective four-year study of children admitted to a hospital in north-east Zambia found that snake bite was a significant cause of injury in 4-14 year olds (Gernaat et al., 1998). Organophosphate poisoning has been identified as one of the key causes of non-traumatic coma in Zambia (Sinclair et al.,1989). A case series of mushroom poisoning in the Zambian copper belt has also been described, with a case fatality rate of 14% (Gill 1979). ZIMBABWE According to WHO estimates, there were 8 deaths per 100,000 population due to unintentional poisoning in 2004 (WHO, 2009b). Multiple studies of poisoning in Zimbabwe have been published, many of them by staff of DaTIS. Three retrospective studies of the epidemiology of poisoning have been published. The first, by Nhachi and Kasilo (1992), looked at all poisoning admissions to six major referral hospitals in the country over a ten-year period, 1980 to 1989. Of a total of 6018 cases of poisoning evaluated, the main agents involved were traditional medicines, household chemicals

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region (mostly kerosene), venomous bites and stings, pharmaceuticals and insecticides. The overall case fatality rate was 15%, with the main agents responsible being pesticides, traditional medicines and pharmaceuticals in descending order. A later study during 1998-1999 found that the spectrum of agents responsible for most admissions had changed with pesticides and pharmaceuticals accounting for most admissions, though household chemicals, venomous bites and stings and natural toxins remained important causes of poisoning (Tagwireyi et al., 2002a). In this study the case fatality rate was 4.4%.

Three studies looked specifically at poisoning in children. Two studies of hospital admissions, ten years apart, found that accidental poisoning with household products, particularly kerosene, was the most common cause, usually affecting children under five years (Kasilo & Nhachi 1992a; Tagwireyi et al., 2002b). In the earlier study, traditional medicines were the next most common cause, followed by venomous bites and stings, and pharmaceuticals. In the later study, pesticide poisoning was the second most common cause of admission, though traditional medicines and venomous bites and stings still featured. The case fatality rate in the first study was 4.9% and 3.1% in the second study. In a two-year retrospective study of intensive care admissions, Chitsike (1994) identified 42 cases of acute poisoning. Once again, household products, particularly kerosene, were the most common cause of poisoning, followed by traditional medicines and pharmaceuticals. The case fatality rate was 21%, however, this was a more severely poisoned group of children than in the other studies. A number of specific studies of pesticide poisoning have been reported. In a comparison of organophosphate poisoning cases admitted to an urban and a rural hospital, Nhachi (1988) found that the majority of cases admitted to the urban hospital were due to intentional self-poisoning, while accidental poisoning predominated in the rural hospital. No deaths were recorded at the rural hospital, while the case fatality rate at the urban hospital was 14%. Other studies of organophosphate poisoning cases admitted to urban hospitals again found a high incidence of intentional self-poisoning, with case fatality rates around 8% (Kasilo et al. 1991; Dong & Simon 2001). Dong and Simon noted a 320% increase in admissions for organophosphate poisoning over the period 1995 to 2000. Tagwireyi and colleagues (2006a) looked more broadly at admissions for pesticide poisoning and found that almost half resulted from oral ingestion of rodenticides, followed by organophosphates. Intentional self-poisoning accounted for more than half of cases, and the case fatality rate was 6.8%. Of note, they found that many of the cases resulted from ingestion of illegal rodenticides, popularly known as "mushonga yemakonzo", sold on street corners in Zimbabwe.

Studies looking at poisoning with pharmaceuticals have particularly drawn attention to the problem of chloroquine overdose. A retrospective review of hospital admissions over the period 1987 to 1995 revealed a steady annual rise from zero cases to 33, with a case fatality rate of 40% (Queen et al., 1999). There was a preponderance of females taking chloroquine in overdose, compared to other overdoses and toxic exposures. This preponderance was again seen in a second study by McKenzie (1996), with a high case fatality rate of 20.7%. Chloroquine can be used to induce abortion, which could account for the relatively high numbers of women taking overdoses compared to men. Ball and colleagues (2002) investigated this through a retrospective cohort study of hospital admissions for pharmaceutical poisoning. They found that patients admitted with

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region chloroquine poisoning were twice as likely to be found pregnant than similar women admitted due to overdose of other medicines.

Poisoning with household products has been shown to be a common cause for poisoning admissions in the under-fives, mainly through accidental exposure (Nhachi & Kasilo 1994a). In their retrospective review Nhachi and Kasilo (1994a) reported a case fatality rate of 13% with most of the deaths being suicides. Kerosene was the most common poisoning agent, followed by rodenticides, bleach and caustic soda. In a separate study of kerosene ingestions by Tagwireyi and co-workers (2006b), almost all were accidental and they occurred mainly in the under-five age group. The case fatality rate was 0.3%.

A small number of studies of snakebite and scorpion sting have been carried out. Case fatality rates for snakebite have varied from 0.4% (Blaylock, 1982) to 5% (Muguti et al., 1994). The higher case fatality rate in the second study was attributed to the lack of available antivenom. Some studies have noted the use of inappropriate treatments such as antibiotics and traditional remedies (Kasilo & Nhachi, 1993a; Nhachi & Kasilo 1994b). Cobras and puff adders accounted for most of the snakebites, with the summer months of November to April being a particularly high risk period (Tagwireyi et al., 2004). Scorpion stings are described less frequently, however, severe poisoning can sometimes occur, and one study reported a case fatality rate of 0.3% (Bergman, 1997).

Poisoning with traditional medicines has been identified as a problem in a number of the general studies of the epidemiology of poisoning in Zimbabwe described above. Nyazema (1984) identified 297 cases admitted to Harare hospital for the period 1971 to 1982, with a year-on-year increase in numbers. In their sub-analysis of a ten-year retrospective study of all poisonings, Kasilo and Nhachi (1992b) found that most poisonings were associated with the use of traditional medicines to treat an ailment, such as depressed fontanelle and fever in children, and diarrhoea and abdominal pain in adults. In this series, the case fatality rate was 6%. In a further cases series of poisonings Tagwireyi and colleagues (2002c) found that the traditional medicines were taken to treat abdominal pains or for aphrodisiac purposes. A range of adverse effects were noted, in particular nephrotoxicity. The case fatality rate in this series was 9.5%, however, the identity of the agents causing deaths was not known.

Poisoning with toxic plants and fungi has also been described in Zimbabwe. Examples include Elephant’s Ear ingestion by children (Tagwireyi & Ball, 2001), which is usually relatively benign, and ingestion of Amanita species, which is often fatal (Flegg, 1981). A small number of poisonings from heavy metals has also been described, with the highest proportion being caused by copper (Kasilo & Nhachi, 1993b).

4.2.1.3 Death rates from unintentional poisoning – 2004 Table 4.1 shows the range of death rates from unintentional poisoning in the 16 countries as estimated by WHO (WHO, 2009b). There are wide variations, from Mauritius, with 0.1 death per 100,000 population, to Uganda with 11.4 deaths per 100,000 population. There are no estimates for intentional, suicidal or homicidal, poisoning deaths. The lack of mortality data on suicidal self-poisoning is a particular

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region gap. That such poisonings occur in significant numbers is suggested by some of the studies quoted in section 4.2.1 and Appendix 1. The studies carried out in Zimbabwe, for example, have shown that a high proportion of admissions for poisoning for substances such as pesticides are the result of deliberate self-poisoning. Table 4.1 – Number of deaths per 100,000 population from unintentional poisoning in 2004 (WHO 2009b) Country Burundi Comoros Djibouti Eritrea Ethiopia Kenya Madagascar Malawi Mauritius Mozambique Rwanda Seychelles Uganda United Republic of Tanzania Zambia Zimbabwe

Death rate / 100,000 pop 7.8 1.7 3.9 3.7 3.5 3.4 2.9 0.9 0.1 3.4 1.3 Not reported 11.4 6.6 4.8 8.0

4.2.2 Health financing and country profiles for study countries The review found that most of the 16 countries in the sub-region were struggling with an inadequately-resourced health sector coupled with a heavy burden of disease. Within the sub-region, however, there was quite a wide range in terms of available financial and human resources (Tables 4.2 and 4.3). In Eritrea, for example, the per capita expenditure on health was USD 14, compared with USD 510 in Mauritius. The WHO Commission on Macroeconomics and Health has estimated that countries need to spend USD 34 at the 2007 value, (approximately USD 36 at the 2011 value 7), per capita per year in order to provide essential healthcare (WHO 2007a); in 2011 only nine of the 16 countries in the sub-region were meeting this requirement. There were also wide ranges in the proportion of Gross Domestic Product (GDP) spent on health, from only 2.6% in Eritrea to 10.7% in Rwanda. Furthermore, the proportion of total expenditure on health covered by the government ranged from 26.3% (Uganda) to 92.1% (Seychelles). The amount of funding for health that came from external sources ranged from as little as 3.7% in Mauritius to 69% in Eritrea and Mozambique (WHO 2013a).

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region Table 4.2: Summary of Financing Structure for Study Countries Country data for 2011 (WHO, 2013)

Per capita total expenditure on health USD

Per capita total expenditure on health PPP int $ 8

Total expenditure on health as a % of GDP

General government expenditure as a % of total expenditure on health* 34.7 57.8 68.1 48.8 57.3 40.1 63.1 73.1 40.3 41.5 57.4 92.1 26.3 38.2 61.9 46.3

Private expenditure on health as a % of total expenditure on health*

General government expenditure on health as a % of total government expenditure 8.1 13.4 14.1 3.6 14.6 5.9 15.3 18.5 9.7 7.7 23.7 9.3 10.8 11.1 16.0 8.9

Burundi 22 48 8.3 65.3 Comoros 43 58 5.3 42.2 Djibouti 105 193 7.7 31.9 Eritrea 14 17 2.6 51.2 Ethiopia 17 52 4.7 42.7 Kenya 36 74 4.4 59.9 Madagascar 19 40 4.1 36.9 Malawi 31 76 8.5 26.9 Mauritius 510 868 5.9 59.7 Mozambique 35 66 6.7 58.5 Rwanda 62 137 10.7 42.6 Seychelles 439 932 3.6 7.9 Uganda 42 127 9.4 73.7 UR Tanzania 39 110 7.5 61.8 Zambia 84 96 5.9 38.1 Zimbabwe No data 20 8.9 53.7 (2007 data) 9 *In some cases the sum of the ratios of general government and private expenditures on health may not add to 100 because of rounding

Most countries in Africa have severe shortages of healthcare workers resulting from a combination of a limited capacity for their training and the migration of skilled workers to other countries (WHO AFRO, 2012). This is no less true in the sub-region (Table 4.3). The WHO minimum density of healthcare workers to deliver essential interventions is 23 physicians, nurses and midwifery staff per 10,000 population (WHO AFRO, 2012); only two countries (Mauritius and Seychelles) meet this standard. A further problem is that there is a skewed distribution of healthcare workers between urban and rural areas, with most working in urban areas. By contrast, in most of the countries in the sub-region the majority of the population continues to live in rural areas.

Other indicators of interest, in the context of delivery of a poisons information service, are the relatively low availability of mobile telephone subscriptions and the very limited access to the Internet in most countries (Table 4.3). Most poisons information services are telephone-based but, as the literature review has shown, some poisons centres also deliver an Internet-based information service. Within the Eastern Africa sub-region, however, there are clear differences in access to mobile telephones, with Eritrea having an extremely low level of subscriptions at 5.5 per 100 inhabitants and Seychelles having a level that is on a par with many developed countries (ITU, 2013). Access to mobile telephony is increasing rapidly in some countries (Figure 4.2). Indeed the growth in PPP International dollars: derived by dividing local currency units by an estimate of their Purchasing Power Parity (PPP) compared to the US dollar, i.e. the measure which minimizes the consequences of differences in price levels between countries. 9 WHO Zimbabwe 2010 8

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Feasibility Study for a Sub-Regional Poisons Centre in the Eastern Africa Sub-Region mobile telephone subscriptions is greatly outstripping that of fixed line telephones, which remain extremely limited in most countries (Figure 4.3). With regard to the Internet, even in the best served country, Seychelles, less than half of the population uses the Internet. By contrast in most developed countries over 80% of the population use the Internet (ITU, 2013). With the exception of Djibouti, Internet usage mirrors fairly closely the proportion of the population living in urban areas. The adult literacy level is poor in many countries in the sub-region, particularly amongst women (Table 4.3), and this is of importance when thinking about using written means for disseminating poisons information.

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Table 4.3 Summary of selected indicators for 16 countries in the Eastern Africa sub-region

Burundi Comoros Djibouti Eritrea Ethiopia Kenya Madagascar Malawi Mauritius Mozambique Rwanda Seychelles Uganda UR Tanzania Zambia Zimbabwe

No. mobile phone subscriptions per 100 inhabitants 10

% population using Internet10

% population living in urban areas 11

Literacy levels in men / women (%) 12

Civil registration of deaths (%)11

No. physicians, nurses & midwives per 10,000 pop11

75.8 96.9

13.5 17.1

34 37

71.9 / 58.5 87.8 / 80.1