Available online on 15.09.2022 at http://jddtonline.info

Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

Copyright  © 2022 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited

Open Access   Full Text Article                                                                                                                                                                               Review Article 

A Review on Household Poisoning and its Management

S Daniel Sundar Singh¹* , Alka M Das², A. Harshini², Irene Mariya Kishore², S.M. Subanandhiny²

¹ Department of Pharmacy Practice, C.L. Baid Metha College of Pharmacy, Chennai, Tamil Nadu, India

² Department of Pharmacy Practice, C.L. Baid Metha College of Pharmacy, Chennai, Tamil Nadu, India

Abbreviations: World Health Organization (WHO), Health Resources and Services Administration (HRSA).

INTRODUCTION

Harmful materials have become a customary home item in many developing countries in past few decades. It has become a considerable health problem worldwide and that is due to their effortless availability, marketing, accessibility, and people’s lack of knowledge regarding the harmful effects of such products. ¹ The larger number of poisonings that is about79% occur in low- and middle-income nations like India, with oral intake of dangerous substances being the most common mode of poisoning. ² WHO appraised that, in 2016, unintentional poisoning caused 106 683 deaths and a loss of about 6.3 million years of healthy life (disability-adjusted life year) ³. The worldwide occurrence of poisoning is unknown. It may be hypothesized that up to half a million people die each year as a result of wide variety of poison exposures, including poisoning by natural toxins.⁴ WHO ccautiously estimates that during the past 10 years the incidence of pesticide poisoning, which is high in developing countries, has doubled; however, a total sum up of cases that occur each year across the globe, and the severity of reported cases, are not known. In 1982 it was estimated in that developing countries accounted for only 15% of the worldwide use of pesticides. In that 50% of cases of pesticide poisoning occurred were largely avoidable in these countries as they were mainly due to misuse of the chemicals.⁴

In many nations, poisoning is one of the main cculprits of emergency attention at hospitals. “Poisoning is a time-dependent emergency and, like infectious diseases, may require a specialist for appropriate diagnosis and treatment” -says WHO.³ Unintentional and intentional exposures continue to be a substantial cause of morbidity and mortality in the US.⁵ NPDS 2000-2020 Data on encounter volume clearly show a general downward trend in exposure cases. This drop, which has been seen since the middle of 2007, is due to fewer people using PCs for exposures that are less dangerous. Exposures with more significant outcomes (death, major, moderate) and HCF instances, however, have remained marginally up during this time.⁵ Poison is defined as any substance, when it comes into contact with any part of it, causes harm or death by local or systemic action, or both. ³ A chemical is considered poisonous if it causes harm or death through local, systemic, or both effects when it is ingested by a living being or comes into contact with any part of it.³ Household poisoning is described as the hazardous effect induced owing to the exposure to household products and chemicals such as cosmetics, pesticides, detergents, sanitizers, cleansers etc... Because many household toxins cannot be felt, seen, smelled, or tasted when they come into contact with us, it is vital to be aware of the most frequent household poisons and to take proactive efforts to minimize or reduce our exposure to them^. 6 

According to current statistics, unintentional and domestic poisoning is the 13th biggest cause of mortality in India (45.5%) among adults (>18 years) and children (1 to 18 years).⁷. Males outnumbered females by a margin of 62.4% to 37.5%. Unintentional poisoning was the most common mode of poisoning (66.8%), followed by intentional poisoning (33.2%). Oral exposure was the most common method of infection (95.6%). Household pesticides were the most frequently implicated (43.7%), followed by household cleansers (21.8%), thermometer mercury (5.2%), naphthalene balls (5%), antiseptics (3%), kerosene (2%), and paint thinner (2%). Poisoning was also caused by a variety of goods such as camphor, silica gel, cosmetics, and adhesives (17.1%). ^8,9 The most commonly used household poisonous substances are listed in Table: 1.

Home products were shown to be the most frequent poisoning agents in an urban area in India, according to Patil et al. (2014). ¹⁰ In recent years, not only in India but all throughout the world, poisoning has increased as a subject of worry. Due to a lack of comprehensive scientific data on home poisoning and its variation with age and region, preventive, therapeutic, and rehabilitation interventions are not applied to their full potential in India. Different regions of the nation experience poisoning in various ways. Finding risk factors depends on being aware of a nation's geographic pattern of poisoning. ¹¹ 

A home accident could involve a staggering number of chemicals. As a result, there was no attempt to finish the topic.^[12] The remarks were restricted to some of the more general aspects of the situation, as well as illustrations of some of the most frequent and notable incidents. The numerous texts on general toxicology, industrial toxicology, pharmacology, and specialized articles in the medical literature contain a wealth of information about poisons, but they frequently fall short of offering solutions to the particular issues that a doctor faces in the event of a household accident. Despite the abundance of local evidence, a global meta-analysis of data on household poisoning is still missing.¹²

Table 1: Commonly used Harmful Household Ingredients

POISONING MECHANISM

Both local and systemic effects can be caused by poisons. They work by affecting the body's secretions or bodily activities, such as urine, lacrimation, salivation, and perspiration. Additionally, poison alters the biochemistry of cells, which in turn alters the physiology. Certain neurotoxic poisons, such as lead, ethanol, nitric oxide, botulinum toxin, tetanus toxin, etc., cause damage to neurons. The majority of toxins alter the oxygen route, which eventually leads to respiratory issues

12. The inspiratory oxygen fraction is decreased by asphyxiant gases (carbon dioxide, methane, butane, and nitrogen).
13. Cyanide and hydrogen sulphide interfere with the cytochrome enzyme chain, impairing oxidative metabolism and lowering tissue oxygen consumption.
14. Organophosphates, strychnine, and the botulinus toxin all produce respiratory syndrome by paralyzing or spasming the respiratory muscles. Both local and systemic effects can be caused by poisons. They work by affecting the body's secretions or bodily activities, such as urine, lacrimation, salivation, and perspiration. Additionally, poison alters the biochemistry of cells, which in turn alters the physiology. This lowers the arterial oxygen tension.
15. By lowering alveolar oxygen tension and impairing breathing, opioid, sedative-hypnotic, and barbiturate use leads to respiratory depression.
16. Hemolysis is brought on by carbon monoxide, nitrites, arsine, and stibine. As a result, hemoglobin function declines.
17. Beta-blockers and tricyclic antidepressants decrease the amount of oxygen that gets to the heart, which causes myocardial depression.¹³

TOXICOKINETICS

Since the body tends to get rid of the wrong things when poison is consumed, the majority of it is lost through vomiting and diarrhea. The liver performs a biotransformation on any toxicity that is still present in the body. Urine can get rid of poisons or their byproducts. Bile, perspiration, saliva, mucus, and exhaled air are other means of excretion. The epidermis, nails, and hair hold onto poisons like arsenic, much as bone can hold onto substances like lead or radioactive metal.¹³

HOUSEHOLD POISONING ACROSS THE GLOBE

Poisoning is one of the most common reasons for illness and death in children. According to WHO data from 2008, unintentional poisoning is a global health risk for the paediatric population, with a death rate of roughly 45000 per year and an incidence rate of 1.8/100,000 inhabitants. 1 Children under the age of five are involved in most accidents; factors contributing to this are kids' inherent curiosity, their inability to recognise danger ahead, and toddlers' propensity for mouthing. Around 2 million kids under the age of 6 reportedly have a history of poisoning and visit emergency rooms every year. 3 While intentional poisoning is fairly common in the adolescent age group, the vast majority of cases, particularly those involving children, were unintentiona¹⁴

According to World Health Organization (WHO) estimates, three million severe pesticide poisoning episodes occur globally each year, with at least 300,000 people dying as a result, with low- and middle-income countries accounting for 99 percent of cases. Long-term pesticide exposure has yet to be precisely estimated in terms of health effects. One of the most pressing global public health issues is how to protect people from the harmful effects of pesticides while also ensuring local agricultural production and food security in low- and middle-income countries.¹⁵

HOUSEHOLD POISONING IN INDIA

Pesticides, household cleaners, mercury for thermometers, antiseptics, kerosene, paint thinners, and other various household items are frequently utilized for domestic purposes. Any of these products, if overused or mismanaged can cause poisoning. In India, the National Poisons Centre (NPIC) at the All-India Institute of Medical Sciences, New Delhi, provides information on management of poisoning to treating physicians. A significant prevalence of poisoning from home items, followed by medications, agricultural pesticides, and industrial chemicals, has been identified by analysis of data based on telephone calls received by the NPIC (April 2006–March 2016). Because not all poisoning calls are reported to the Center, the trend and pattern of poisoning differs across the nation. Therefore, the data as a whole could not accurately reflect the situation in India. However, the results do reveal a rising prevalence of poisoning owing to home chemicals notably among children¹⁶.

Also Pooled analysis of studies revealed that pesticides were the main cause of poisoning in adults, with an incidence of 63%, while miscellaneous agents were the main cause of poisoning in children, with an incidence of 45.0%, among those presenting to hospitals. Pesticide poisoning was the most prevalent in North India (79.1%), followed by South (65.9%), Central (59.2%), West (53.1%), North East (46.9%) and East (38.5%). The second most common cause of poisoning was miscellaneous agents (18%, %), followed by drugs (10%), venoms (6%) and corrosives (2%).¹⁷

HOUSEHOLD POISONING ACROSS SOUTH INDIA

According to the World Health Organization and the Centers for Disease Control and Prevention in the United States, accidental poisoning is one of the leading causes of morbidity and mortality worldwide, accounting for 18-19% of total poisoning cases in India. According to available statistics, accidental poisoning was the 13th leading cause of death in India from 2001 to 2003, with accidental pesticide intake ranging from 8695 (2001), 7777 (2002), and 8064 (2003).¹⁸

From October 2018 to October 2019, a 12-month prospective observational study was conducted in a teaching hospital on 278 cases of acute poisoning reported to the emergency department. Data on patient demographics, poisoning agent type, hospital stay duration, and outcome were collected and analyzed. Organophosphate compounds (41%), drug overdose (36%), rodenticide (9%), house cleaning agents (6%), mosquito repellents (4%), corrosives (1%), and kerosene were the most commonly consumed poisoning agents (1%). Sedatives were the most common drug overdose cause of poisoning (9%), followed by nonsteroidal anti-inflammatory agents (4%). Of the 278 patients, 87 (31%) were males under the age of 30. The majority of the patients were illiterate and worked as laborer’s (27%) or farmers (17%). (36 %). Suicide (79%) was discovered to be the leading cause of poisoning. Acute poisoning is a major public health concern, particularly among the younger and less educated populations.¹⁹

In our article, literature review was conducted on Pubmed, Google scholar, Dove press, Science direct etc., by using the search terms such as household poisoning, review article on household poisoning. Filters applied during the search was Year (Jan 2017- Dec 2021), Type of article (Full text review article) from which we obtained an overall of 32 full text review articles, in that 7  articles were found closely related to our review which is mentioned in Table: 2.

Table: 2 Studies conducted on household poisoning in India for the recent five years

GRADING SYSTEM 

 WHO categorized poisoning severity as grading system (Table:3), based on clinical presentation upon exposure towards household poisoning. A standardized and universally applicable classification scheme for the severity of poisoning allows a qualitative assessment of incidence and facilitates comparability of data.²⁰

 Table: 3 Poison severity scale

  (Available from: https://www.who.int/ipcs/poisons/pss.pdf)

 TOXICITY/POISONING MANAGEMENT

Poisoning is treated by stabilizing the patient, evaluating them, removing the poison, and administering an antidote. During patient stabilization, the patient's condition is thoroughly assessed, and vital signs are kept track of. Convulsions, electrolyte imbalances, acid-base disorders, hyperthermia, hypothermia, and movement problems are identified during the patient's evaluation. There are several strategies used in decontamination to lessen the effects of toxins. When a poison needs to be eliminated, methods such forced dieresis, hemodialysis, hemoperfusion, and hemofiltration are used. When an antidote needs to be supplied to a patient, the right agent is given to them to block the poison's effects.¹³

Pre -Hospital care 

First Aid

Monitoring is done for respiration, airway, and circulation, and manual cardiopulmonary resuscitation is initiated.

If required, promptly. If cardiac arrest occurs, this stops it and restores blood flow while protecting brain function. any. Early breakdown of the toxin is crucial to preventing the spread of serious intoxication. When the patient arrives at the hospital, the emergency department is contacted right away, and the patient is positioned on their left side for easier airway clearance and slower poison absorption. As first aid, the following procedures are used.

When a toxin is inhaled, the patient needs to be transported to a room with fresh air, the windows and doors need to be opened, and if the patient isn't breathing, artificial respiration needs to be given.

12. For the immediate effects on skin, contaminated garments should be taken off, and the affected region should be covered with fresh water. With soap and water, the polluted area is cleaned.
13. For poisoning in the eye, rinse the open eyes with cold, fresh water many times over the course of 15 minutes. Remove your contact lenses.
14. If a poison was ingested, further therapy and water are administered unless the patient is unconscious or convulsing.¹³

Hospital care

Depending on the clinical status and symptoms of the patient when they arrive at the hospital, supportive and symptomatic care is crucial. It is crucial to pay close attention to the body's vital indicators, including the heart rate, blood pressure, respiration, oxygenation, circulation, blood sugar, ECG, and other cardiac activities. If any of these are improper, appropriate medical care must be given, such as mechanical ventilation, oxygenation, orotracheal or nasotracheal intubation. Pressor agents, cardiac stimulants, defibrillation, and pacing are used to keep blood pressure and heart functions in check. Infusions of dextrose solution are used to keep blood sugar levels in check. Similar to this, further supportive care is provided to address seizures, acid-base and electrolyte abnormalities, and fluid imbalances. In order to assure fluid supplementation and urine output, IV and urinary catheters are installed.¹³

Emesis & gastric lavage

Ipecac syrup, a non-prescription drug, has been used to cause vomiting for centuries. However, because to the lack of a toxic consequence and the difficulties in diagnosing it, its usage is no longer advised. There is no need to induce if beneficial emesis has already happened on its own. If he feels better using the appropriate procedure, a toxicologist will induce emesis. Gastric lavage is the procedure of removing the ingested poisons by delivery and aspiration of fluid through a gastric tube. When a harmful substance has been consumed, this treatment is used. The fluid contains 2-4 liters of heated (370 C) saline. But there are specific consequences of gastric lavage that include laryngospasm, hypothermia, electrolyte and fluid imbalance, aspiration pneumonitis, and mechanical injury.¹³

Activated charcoal 

Administration of activated charcoal can lessen the absorption of toxins. It is carbon-based, dark in color, and blocks poison absorption by joining with the poison. Because of emesis and aspiration, it is typically less effective for substances like iron, lead, alcohol, lithium, and corrosives and is not recommended for substances like aliphatic hydrocarbons. It is administered within the first hour following toxin consumption. Adults should take 25-100 g of activated charcoal, while children up to 2 years old should take 25-50 g. It is delivered via a nasogastric tube after being slurry-fied with water. This treatment is utilized if a patient has consumed a dose of phenobarbital, carbamazepine, dapsone, theophylline, or quinine that poses a life-threatening risk. Additionally, this is employed in the treatment of cimetidine, digitalis, NSAIDs, Opiates, phenothiazines, strychnine, tetracycline, antidiabetic medications, as well as kerosene, paracetamol, phenol, alcohol, carbamates, heavy metals, hydrocarbons, cyanide, etc.¹³

Laxatives and purgatives

To remove the poison and the charcoal poison complex from the gastrointestinal tract, laxatives like sorbitol magnesium citrate and liquid paraffin are used right away after the delivery of charcoal. However, their value has not been established, and their usage is not usually recommended. They are only employed after their efficacy has been established. before doing a colonoscopy and undergoing intestinal surgery to eliminate toxins, whole bowel irritants like polyethylene glycol electrolyte solutions. They clean the digestive system.¹³

Diuresis 

Using diuretics helps the body eliminate toxins even more effectively. The majority of the time, diuretics is used to push the urine's forced elimination of the toxin. The fluid balance, blood pressure, electrolyte balance, and acid base balance are all closely watched while using diuretics. Commonly prescribed medications for this purpose include furosemide and mannitol. Due to several unfavourable effects, this method is not always advantageous.¹³

Hemodialysis and hemoperfusion 

Hemodialysis is a procedure that eliminates toxins as well as waste products like urea and creatinine from your blood. Hemoperfusion is a technique for purifying blood outside the body to get rid of toxins. Only when there are serious poisoning instances and symptoms are getting worse are hemodialysis and hemoperfusion employed. It is also employed when the typical toxin removal pathway is jeopardized. Drugs that are to be eliminated must have a low molecular weight, be loosely linked to proteins, and be less dispersed throughout tissues in order for a suitable device called a dialyzer to be used. If poisoning with ethylene glycol, ethanol, theophylline, or salicylate is suspected, this approach is effective. The risks of thrombosis, blood element loss, fluid and electrolyte imbalances, air embolism, and infection are present with this approach, just like with other treatments. Additionally, a patient with unstable hemodynamics cannot tolerate this approach.¹³                                                                                      

Antidotes

Antidotes are substances that neutralize the toxin. These medicines or chemicals counteract the effects of poison and their symptoms. Important antidotes often used are listed in table 4. They are created when a tiny amount of poison is given into animals and antibodies are drawn from the blood of the animals. Antivenom, for instance, is created from antibodies and used to combat venom secreted by specific snakes and spiders. Antidotes operate using the following mechanisms.

The production of inert complexes, such as those containing chelating agents for heavy metals, dicobalt edentate for cyanide, and Prussian blue for thallium

12. Accelerated detoxification: For instance, thiosulfate hastened the transformation of poisonous cyanide into non-toxic thiocyanate, while acetylcysteine detoxifies paracetamol metabolites to lessen hepatotoxicity.
13. Competition for receptor sites, such as when naloxone works at the opioid receptor site to counteract the effects of opiates.
14. Receptor site blockade: Organophosphates are blocked by atropine at the muscarinic receptor site, for example.
15. Reduced hazardous conversion: By competing with the same enzyme, ethanol prevents the metabolism of harmful metabolites from methanol (alcohol dehydrogenase)
16. Bypassing toxic effects, such as oxygen in cyanide poisoning.¹³

Table 4:  List of Antidots Commonly Used

PREVENTION

12. Keep any medications and possibly hazardous items (laundry supplies, toiletries, cosmetics etc..) out of children's reach or in locked cabinets.²⁰
13. Keep medications properly labelled and store them in their original containers, also discard them if they are expired or no longer in use. 
14. To ensure safe and efficient use, always adhere to the directions on the product label, for example: Bleach is particularly harmful and should only be combined with water.
15. To safely dispose of spent button batteries (such as those found in watches), store any that are not in use out of the reach of children.²¹
16. Please adhere to any specific storage directions (for example, keeping flammable liquids away from heat, keeping medicines in a cool place, and keeping acids away from alkaline products).²²
17. To protect skin and eyes, put on gloves and safety goggles when using harsh cleaners like drain cleaner, bleach, and oven cleanser.²³ Regardless of whether you know what is inside, avoid sniffing chemical containers.²⁴
18. Call the local poison control center or the emergency number if you or someone you are with has been exposed.²⁵

CONCLUSION

Pesticides and chemicals (phenol, bleaches, kerosene, and their derivatives) were the two most common agents of poisoning. Pesticides were the second most common cause of overall high mortality after chemical poisoning. In various investigations conducted in India, pesticides, particularly organophosphates and aluminum phosphide, were the most frequent causes of poisoning Fan et al (2013). found that home items were one of the main sources of poisoning in New Zealand among children and teenagers under the age of 19. Additionally, a study conducted in Brazil by Presgrave Rde et al (2015). discovered that ingesting pesticides, household cleaners, or caustic substances caused the majority of unintentional poisoning in youngsters. Researchers have rightly noted that the pattern of poisoning in a place depends on a number of factors, including the accessibility, and availability of poisonous substances, socioeconomic position, cultural aspects of the population, Age, the amount taken, early hospitalization, and proper therapy are only a few of the variables that affect poisoning-related mortality.²⁶ 

To lower the prevalence of poisoning in urban settings, it is crucial to educate and raise awareness among the general public about chemical poisoning from home chemicals. Early diagnosis of suspected poisoning symptoms, implementing effective preventive measures, counselling, creating standard management protocols, and providing fast, focused treatment will all help to win the war against poisoning in India.²⁷

 CONFLICT OF INTEREST:

The Authors declare no conflicts of interest regarding the publication of this paper.

AUTHORS CONTRIBUTION:

All the authors contributed equally to prepare this article, read, and approved the final Manuscript.

REFERENCES:

[1]. RamananKarunakaran S, Muthunarayanan L, Ramraj B. Prevalence of accidents and poisoning due to household hazardous materials in a rural area of Kancheepuram, Tamil Nadu. Int J Community Med Public Health. 2019 Apr 27; 6(5):2047. https://doi.org/10.18203/2394-6040.ijcmph20191816

[2]. Mittal C, Singh S, Kumar-M P, Varthya SB. Toxicoepidemiology of poisoning exhibited in Indian population from 2010 to 2020: a systematic review and meta-analysis. BMJ Open. 2021 May; 11(5):e045182 https://doi.org/10.1136/bmjopen-2020-045182

[3] .WHO Guidelines for establishing a poison centre [Internet]. Who.int. Available from: https://www.who.int/news/item/18-01-2021-who-guidelines-for-establishing-a-poison-centre

[4] .[Internet]. Who.int. [cited 2022 Jun 28]. Available from: http://apps.who.int/iris/bitstream/10665/41966/1/9241544872_eng.pdf

[5] Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Bronstein AC, Rivers LJ, et al. 2020 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 38th Annual Report. Clin Toxicol (Phila) [Internet]. 2021; 59(12):1282-501. https://doi.org/10.1080/15563650.2021.1989785

[6]. Batt AL, Bruce IB, Aga DS. Evaluating the vulnerability of surface waters to antibiotic contamination from varying wastewater treatment plant discharges. Environ Pollut. 2006; 142(2):295-302 https://doi.org/10.1016/j.envpol.2005.10.010

[7]. Bannur V, Jirli PS, Honnungar RS, Koulapur VV, Pujar SS. Pattern of Poisoning Cases at a Tertiary Health Care Centre-A Cross Sectional Study.. Medico-Legal Update. 2019; 19(1):124 https://doi.org/10.5958/0974-1283.2019.00025.2

[8]. Adepu R, Churi S, Jesslin J. Assessment of prevalence and mortality incidences due to poisoning in a South Indian tertiary care teaching hospital. Indian J Pharm Sci. 2010; 72(5):587. https://doi.org/10.4103/0250-474X.78525

[9] Justin S, Shobha C. Impact of Educational Intervention on Knowledge, Attitude and Practice among General Public Regarding Accidental Poisoning. Indian Journal of pharmacy Practice.2014Jan; 7(1):52.

[10]. Patil A, Peddawad R, Verma VCH, Gandhi H. Profi le of acute poisoning cases treated in a tertiary care hospital: a study in Navi Mumbai. Asia Pac J Med Toxicol. 2014; 3:36-40.

[11]. Chelkeba L, Mulatu A, Feyissa D, et al. Patterns and epidemiology of acute poisoning in Ethiopia: systematic review of observational studies. Arch Public Health 2018; 76:34. https://doi.org/10.1186/s13690-018-0275-3

[12] Justin S, Shobha C. Impact of Educational Intervention on Knowledge, Attitude and Practice among General Public Regarding Accidental Poisoning. Indian Journal of PharmacyPractice. 2014; 7(1):52.

[13]. Researchgate.net. [cited 2022 Jun 28]. Available from: https://www.researchgate.net/publication/341609961_General_Principles_Types_Diagnosis_and_Management_of_Poisoning .

[14]. Ramawat P, Jain N. A study about clinic-epidemiological pattern of acute poisoning in pediatric age group. Asian J Med Sci [Internet]. 2021; 12(4):48-53. Available from: https://www.nepjol.info/index.php/AJMS/article/view/30701/27959 https://doi.org/10.3126/ajms.v12i4.30701

[15]. Boedeker W, Watts M, Clausing P, Marquez E. The global distribution of acute unintentional pesticide poisoning: estimations based on a systematic review. BMC Public Health [Internet]. 2020; 20(1):1875. https://doi.org/10.1186/s12889-020-09939-0

[16]. https://www.researchgate.net/publication/326321710_Poisoning_due_to_household_prod ucts_A_ten_years_retrospective_analysis_of_telephone_calls_to_the_National_Poisons_Information_Centre_All_India_Institute_of_Medical_Sciences_New_Delhi_India

[17]. Mittal C, Singh S, Kumar-M P, Varthya SB. Toxicoepidemiology of poisoning exhibited in Indian population from 2010 to 2020: a systematic review and meta-analysis. BMJ Open [Internet]. 2021; 11(5):e045182. Available from: https://bmjopen.bmj.com/content/11/5/e045182 https://doi.org/10.1136/bmjopen-2020-045182

[18] Behera A, Singla N, Sharma N, Sharma N. Paradigm shift in pattern and prevalence of poisoning during COVID-19 pandemic. J Family Med Prim Care [Internet]. 2022; 11(1):208-14. Available from: https://journals.lww.com/jfmpc/Fulltext/2022/01000/Paradigm_shift_in_pattern_and_prevalence_of.34.aspx https://doi.org/10.4103/jfmpc.jfmpc_916_21

[19] Nadeem MN, Maqdoom M, Akif ME. A prospective observational study on pattern of poisoning cases reported to emergency department of a teaching hospital in south India. Biomed Pharmacol J [Internet]. 2020; 13(4):1863-9. https://doi.org/10.13005/bpj/2061

[20] Persson H, Sjöberg G, Haines J, Garbino J. Poisoning Severity Score: Grading of acute poisoning. J Toxicology - Clinical Toxicology. 1998; 36:205-13. https://doi.org/10.3109/15563659809028940

[21] Prevention tips [Internet]. Hrsa.gov. 2019 [cited 2022 Jun 28]. Available from: https://poisonhelp.hrsa.gov/what-you-can-do/prevention-tips

[22] Household safety: Preventing poisoning [Internet]. Kidshealth.org. [cited 2022 Jun 28]. Available from: https://kidshealth.org/en/parents/safety-poisoning.html

[23] Chemicals in the home [Internet]. Gov.au. [cited 2022 Jun 28]. Available from: https://www.betterhealth.vic.gov.au/health/healthyliving/Chemicals-in-the-home

[24] .Household poisons [Internet]. Ohsu.edu. [cited 2022 Jun 28]. Available from: https://www.ohsu.edu/oregon-poison-center/household-poisons

[25] Poison prevention tips [Internet]. Nationwidechildrens.org. Available from: https://www.nationwidechildrens.org/specialties/central-ohio-poison-center/poison-prevention-tips

[26] Patil A, Peddawad R, Verma VCS, Gandhi H. Profile of Acute Poisoning Cases Treated in a Tertiary Care Hospital: A study in Navi Mumbai. Asia Pac J Med Toxicol [Internet]. 2014 ; 3(1):36-40. Available from: https://apjmt.mums.ac.ir/article_2469.html

[27]. Journal of the association of physicians of India - JAPI [Internet]. Japi.org. Available from: https://www.japi.org/q2d46464/analysis-of-poisoning-in-urban-setting-a-single-centre-study

[28] Nyayakar S, Singh SD, Christan M, Joseph MK. A Review on Alcohol Based Hand Sanitizer (ABHS) Poisoning During COVID-19 Pandemic Among Young Children. Journal: PARIPEX Indian Journal of Research. 2021:34-7