Case Fatality as an Indicator for the Human Toxicity of Pesticides—A Systematic Scoping Review on the Availability and Variability of Severity Indicators of Pesticide Poisoning

Abstract

Objective: To investigate if case fatality and other indicators of the severity of human pesticide poisonings can be used to prioritize pesticides of public health concern. To study the heterogeneity of data across countries, cause of poisonings, and treatment facilities. Methods: We searched literature databases as well as the internet for studies on case-fatality and severity scores of pesticide poisoning. Studies published between 1990 and 2014 providing information on active ingredients in pesticides or chemical groups of active ingredients were included. The variability of case-fatality-ratios was analyzed by computing the coefficient of variation as the ratio of the standard deviation to the mean. Findings: A total of 149 papers were identified of which 67 could be included after assessment. Case-fatality-ratio (CFR) on 66 active ingredients and additionally on 13 groups of active ingredients were reported from 20 countries. The overall median CFR for group of pesticides was 9%, for single pesticides 8%. Of those 12 active ingredients with a CFR above 20% more than half are WHO-classified as “moderately hazardous” or “unlikely to present acute hazard”. Two of seven pesticides considered “unlikely to present hazard in normal use” showed a CFR above 20%. The cross-study variability of reported case fatality was rather low. Studies most often utilized the Glasgow Coma Score for grading the severity of poisoning. Conclusion: Although human pesticide poisoning is a serious public health problem, an unexpectedly small number of publications report on the clinical outcomes within our study period. However, CFRs of acute human pesticide poisoning are available for several groups of pesticides as well as for active ingredients showing moderate cross-study variability. Our results underline that CFR is an indicator of the human toxicity of pesticides and can be utilized to prioritize highly hazardous pesticides especially since there is limited correspondence between the animal-test-based hazard classification and the human CFR of the respective pesticide. The reporting of available poisoning data should be improved, human case-fatality data are a reasonable tool to be included systematically in the periodic statutory review of pesticides and their regulation.