Guidelines for poison control
The issue of this document does not constitute formal publication. It should not be reviewed, abstracted, or quoted without the written permission of the Manager, International Programme on Chemical Safety, WHO, Geneva, Switzerland.
This report contains the collective views of an international group of experts and does not necessarily represent the decisions or the stated policy of the United Nations Environment Programme, the International Labour Organisation, or the World Health Organization.
First draft prepared at the National Institute of Health Sciences, Tokyo, Japan, and the Institute of Terrestrial Ecology, Monk's Wood, United Kingdom
Published under the joint sponsorship of the United Nations Environment Programme, the International Labour Organisation, and the World Health Organization
The International Programme on Chemical Safety (IPCS) is a joint venture of the United Nations Environment Programme, the International Labour Organisation, and the World Health Organization. The main objective of the IPCS is to carry out and disseminate evaluations of the effects of chemicals on human health and the quality of the environment. Supporting activities include the development of epidemiological, experimental laboratory, and risk-assessment methods that could produce internationally comparable results, and the development of manpower in the field of toxicology. Other activities carried out by the IPCS include the development of know-how for coping with chemical accidents, coordination of laboratory testing and epidemiological studies, and promotion of research on the mechanisms of the biological action of chemicals.
WHO Library Cataloguing in Publication Data
1.Poisoning - prevention & control
2.Poison control centres
ISBN 92 4 154487 2 (NLM Classification: QV 600)
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I. Policy overview
1. Poison information centres: their role in the prevention and management of poisoning
Conclusions and recommendations
II. Technical guidance
2. Information services
Organization and operation
Location, facilities, and equipment
3. Clinical services
Clinical toxicology units
4. Analytical toxicology and other laboratory services
Functions of an analytical toxicology service
Location, facilities, and equipment
5. Toxicovigilance and prevention of poisoning
Toxicovigilance and prevention programmes
6. Response to major emergencies involving chemicals
Education and training
Collaboration between centres
7. Antidotes and their availability
Registration and administrative requirements
Considerations of time and geography
Special problems of developing countries
Antidotes for veterinary use
8. Model formats for collecting, storing, and reporting data
9. Library requirements for poison information centres
Publications of international organizations
1. Summary description of the IPCS INTOX Package
2. Classified lists of antidotes and other agents
3. Example of a substance record: chemical
4. INTOX product record
5. INTOX communication record and miniform
6. Proposed format for a poison centre annual report
7. Environmental Health Criteria series
The International Programme on Chemical Safety (IPCS) was established in 1980 as a collaborative programme of the International Labour Organisation (ILO), the United Nations Environment Programme (UNEP), and the World Health Organization (WHO) in order to provide assessments of the risks to human health and the environment posed by chemicals, so that all countries throughout the world might develop their own chemical safety measures. The IPCS provides guidance on the use of such assessments and seeks to strengthen the capacity of each country to prevent and treat the harmful effects of chemicals and to manage emergencies involving chemicals. In its different activities, the IPCS collaborates with various international organizations and professional bodies. Its work on prevention and treatment of poisoning is undertaken in collaboration with the World Federation of Associations of Clinical Toxicology Centres and Poison Control Centres1 and its member associations. The aims of the European Commission (EC) in the field of poison control are similar to those of the IPCS and many activities are undertaken jointly by the two bodies.
Poisoning by chemicals is a significant risk in all countries where substantial quantities and increasing numbers of chemicals are being used in the development process. Some countries already have well established facilities for the prevention and control of poisoning, many wish to establish or strengthen such facilities, and others have not yet fully recognized the extent of the risk.
The need for advice on poison control, particularly with a view to encouraging countries to establish poison information centres, was recognized at a joint meeting of the World Federation, the IPCS, and the EC, held at WHO headquarters, Geneva, from 6 to 9 October 1985. At this meeting it was recommended that guidelines be prepared on poison control and particularly on the role of poison information centres. It was also recommended inter alia that antidotes and other substances used in the treatment of poisoning should be evaluated, comparable information needed for diagnosis and treatment of poisoning collected and recorded in a standardized manner, toxicovigilance and poison prevention programmes developed, mechanisms for exchanging experience of dealing with major chemical accidents established, and specialized training in poison control encouraged.
A consultation of experts from poison information centres, from developed and developing countries, was held in London, England, from 24 to 25 February 1986, to advise on the structure and content of the proposed guidelines on poison control. It was agreed that the guidelines would be in two parts, the first concerned with national policy, and the second with technical aspects of establishing and running the various elements of a poison control programme. A drafting
1 Hereafter referred to simply as the World Federation.
group was established and charged with the preparation of the guidelines. This group met twice - from 25 to 26 November 1986 in Brussels, Belgium, and from 16 to 20 February 1987 in London, England - and concentrated on the drafting of the policy overview.
The initial draft was examined by an extended editorial group, meeting from 9 to 14 November 1987 in Salvador, Bahia, Brazil, during the Fifth Congress of the Brazilian Society of Toxicology. Work on the drafting of Part II was also initiated at that time.
Additional contributions were made by a number of experts, acknowledged below. Besides the extensive experience of poison control published in the literature, the results of the following activities were used in assembling material: the Joint IPCS/EC/World Federation survey on poison control centres and related toxicological services;1 the Joint IPCS/EC Project on Antidotes; the IPCS Poisons Information Package project - IPCS INTOX - being undertaken jointly with the Canadian Centre for Occupational Health and Safety (CCOHS) and the Centre de Toxicologie du Québec (CTQ), with financial assistance from the International Development and Research Centre of Canada (IDRC); the joint WHO (EURO)/IPCS/EC meetings held in Munich, 16 to 20 December 1985, on public health response to acute poisonings2 and in Munster, 8 to 12 December 1986, on prevention of acute chemical poisonings;3 and the IPCS seminar on training for poison control programmes in developing countries,4 held in London in February 1987.
Subsequently, a complete draft text was circulated for comment to members of the World Federation and selected IPCS focal points in various countries. The text was examined at a joint IPCS/EC secretariat meeting with the General Assembly of the World Federation, held at WHO headquarters in Geneva, 31 October to 2 November 1988; it was the opinion of the meeting that the guidelines reflected experience in Europe and North America, but should be tested in a number of other regions of the world before being finalized and published.
The guidelines were first presented at the Joint IPCS/WHO/World Federation Workshop on Prevention and Management of Poisoning by Toxic Substances, held in Kuala Lumpur, Malaysia, 29 November to 2 December 1989, in which representatives from 27 countries took part. They were also presented and discussed at two regional IPCS workshops on development of poison control programmes, held in Montevideo, Uruguay, in March 1991 and February 1992, organized by the Centro de Información y Asesoriamento Toxicológico and with partial financial support from the International Union of Toxicology (IUTOX). The guidelines were further used as the basis for national workshops on poison control held in Ciloto, Indonesia, in November 1992, Bangkok, Thailand, in November 1992, and New Delhi, India, in December 1992.
Due account having been taken of experience of their use in different parts of the world, the guidelines are now issued as a WHO publication to encourage their wide distribution and use throughout the world.
Attention is drawn to the report5 of the United Nations Conference on Environment and Development (UNCED), held in Rio de Janeiro, Brazil, in June 1992, in Agenda 21, Chapter 19, of which all countries are called upon to promote the establishment and strengthening of poison control centres to ensure prompt and adequate diagnosis and treatment of poisoning, including networks of centres for chemical emergency response.
Following the recommendations of UNCED in relation to sound management of chemicals, an Intergovernmental Forum on Chemical Safety (IFCS) was established in April 1994. One of the priority activities recommended to all governments by IFCS is the establishment of poison centres with related clinical and analytical facilities and the promotion of harmonized systems for recording data in different countries. These guidelines provide policy and technical advice to those responsible for setting up poison centres and related facilities, and give recommended approaches for harmonized data recording among countries.
1Report of the survey of poison control centres and related toxicological services 1984-1986. Journal de toxicologie clinique et expérimentale, 1988, 8(5):313-371.
2 Public health response to acute poisonings: poison control programmes: report on a joint working group, Munich, 16-20 December, 1985. Copenhagen, World Health Organization Regional Office for Europe, 1986 (Environmental Health Series, No. 11).
3 Prevention of acute chemical poisonings: high-risk circumstances: report on a joint WHO/IPCS/CEC meeting. Copenhagen, World Health Organization Regional Office for Europe, 1987 (Environmental Health Series, No. 28).
4 Report of IPCS Seminar on Training for Poison Control Programmes in Developing Countries. Geneva, World Health Organization, 1987 (unpublished document ICS/87.33, available on request from Programme for the Promotion of Chemical Safety, World Health Organization, 1211 Geneva 27, Switzerland).
5Adopted by the United Nations General Assembly at its 47th Session in New York, in December 1992, Resolution GA47/719.
The following are the members of the drafting group and experts who prepared specific sections of these guidelines:
Dr B. Fahim, Director, Poison Control Centre, Ain Shams University, Cairo, Egypt
Dr R. Flanagan, Toxicology Laboratory, Medical Toxicology Unit, Guy's and St Thomas's Hospital Trust, London, England
Dr M. Govaerts, formerly Director, Belgian Poisons Centre, Brussels, Belgium
Dr J.A. Haines, IPCS Secretariat, World Health Organization, Geneva, Switzerland (Chairman of the drafting group)
Dr V. Murray, Honorary Consultant, Medical Toxicology Unit, Guy's and St Thomas's Hospital Trust, London, England (Rapporteur of the drafting group)
Dr H. Persson, Director, Swedish National Poisons Information Centre, Karolinska Hospital, Stockholm, Sweden
Dr J. Pronczuk de Garbino, IPCS Secretariat, World Health Organization, Geneva, Switzerland
Dr E. Wickstrom, Director, Poisons Information Centre, Oslo, Norway
Ms H. Wiseman, Medical Toxicology Unit, Guy's and St Thomas's Hospital Trust, London, England
The following experts took part in consultations and review working groups for the guidelines:
Dr A. Berlin, Secretariat, Directorate General V, European Commission, Luxembourg
Dr I.R. Edwards, Director, WHO Collaborating Centre for International Drug Monitoring, Uppsala, Sweden, formerly Director, National Toxicology Group, University of Otago, Dunedin, New Zealand
Dr N. Fernicola, Toxicology Consultant, Pan American Health Organization, Bogota, Colombia
Dr E. Fournier, formerly Director, Toxicology Service, Fernand Widal Hospital, Paris, France
Dr J. Garbino, formerly Assistant, Intensive Care Unit, Hospital de Clínicas Dr Manuel Quintela, Montevideo, Uruguay
Dr A.N.P. van Heijst, formerly Director, Dutch Poisons Control Centre, Utrecht, Netherlands
Dr J. Indulski, formerly Director, Nofer's Institute of Occupational Medicine, Lodz, Poland
Dr A. Jaeger, Director, Poisons Centre, Strasbourg, France
Dr J.P. Lorent, Swiss Toxicological Information Centre, Zurich, Switzerland
Dr S. Magalini, Director, Poisons Centre, Rome, Italy
Dr F. Oehme, Veterinary College, University of Kansas, Manhattan, KS, USA, formerly President, World Federation of Associations of Clinical Toxicology Centres and Poison Control Centres
Dr M. Repetto, Director, National Toxicology Institute, Seville, Spain
Dr L. Roche, Lyon, France, formerly Secretary General, World Federation of Associations of Clinical Toxicology Centres and Poison Control Centres
Dr B. Rumack, formerly Director, Rocky Mountain Drug and Poisons Information Center, Denver, CO, USA
Dr N.N. Sabapathy, formerly Zeneca Agrochemicals, Hazelmere, England
Dr S. Shabeer Hussain, Director, National Poison Control Centre, Karachi, Pakistan
Dr W.A. Temple, Director, National Toxicology Group, University of Otago, Dunedin, New Zealand
Dr M. Thoman, Associate Editor, Veterinary and Human Toxicology, Des Moines, IA, USA
Dr M.T. van der Venne, Directorate General V, European Commission, Luxembourg
Dr C. Vigneaux, Anti-Poisons Centre, Lyon, France
Dr J. Vilska, Director, Poison Information Centre, Helsinki, Finland
Dr G. Volans, Director, Medical Toxicology Unit, Guy's and St Thomas's Hospital Trust, London, England
Dr R. Wennig, Director, National Health Laboratory, Luxembourg
The massive expansion in the availability and use of chemicals, including pharmaceuticals, during the past few decades has led to increasing awareness - on the part not only of the medical profession but also of the public and various authorities - of the risks to human health posed by exposure to those chemicals. Moreover, each country has a variety of natural toxins to which its population may be exposed. Authorities need only to consult local hospital accident and emergency departments for confirmation that toxic risks exist in every country and, in many cases, are increasing.
Tens of thousands of man-made chemicals are currently in common use throughout the world, and between one and two thousand new chemicals appear on the market each year. In industrialized countries, there may be at least one million commercial products that are mixtures of chemicals, and the formulation of up to one-third of these may change every year. A similar situation exists in the rapidly industrializing developing countries. Even in the least developed regions, there is growing use of agrochemicals such as pesticides and fertilizers, of basic industrial chemicals, particularly in small- scale rural cottage industries, and of household and other commercial products, as well as pharmaceuticals.
Every individual is exposed to toxic chemicals, usually in minute, subtoxic doses, through environmental and food contamination. In some instances, people may be subjected to massive, or even fatal, exposure through a chemical disaster or in a single accidental or intentional poisoning. Between these two extremes there exists a wide range of intensity of exposure, which may result in various acute and chronic toxic effects. Such effects clearly lie in the public health domain, particularly in cases of chemical contamination of the environment that may result in exposure of an unsuspecting public. The situation is similar to, but subtler than, exposure to infectious diseases: although chemicals may be absorbed in small quantities, they do not induce pathological signs until toxic concentrations are reached in the tissues of exposed individuals.
The global incidence of poisoning is not known. It may be speculated that up to half a million people die each year as a result of various kinds of poisoning, including poisoning by natural toxins. WHO conservatively estimates that the incidence of pesticide poisoning, which is high in developing countries, has doubled during the past 10 years; however, the number of cases that occur each year throughout the world, and the severity of cases that are reported, are unknown. It was estimated in 1982 that, while developing countries accounted for only 15% of the worldwide use of pesticides, over 50% of cases of pesticide poisoning occurred in these countries and, being due mainly to misuse of the chemicals, were largely avoidable. The worldwide frequency of major incidents involving chemicals, i.e. incidents that could cause multiple deaths, has been rising during the past two decades. There is growing concern about the possible health consequences of chronic exposure to naturally occurring toxic substances and to man-made chemicals and waste. In addition, poisonings of domestic animals are a cause for concern in certain countries, because of their economic impact on animal husbandry.
The principal toxic risks that exist in any country may be readily identified by surveys of hospital accident and emergency wards, forensic departments, and rural hospitals in agricultural areas. The growing incidence of poisoning from accidental exposures to chemicals, and recent examples of acute poisoning in local populations as a result of industrial and transport accidents involving chemicals have highlighted the importance of countries having special programmes for poison control and, in particular, the facilities for diagnosis, treatment, and prevention of poisoning.
Although the risks of poisoning by chemicals are not yet universally recognized, some countries have already established poison control programmes that provide the framework for both prevention and management of poisoning. These newly emerging programmes are important elements of chemical safety. Such programmes will vary in their structure according to local circumstances, but they all need clear direction and coordination in order to ensure the efficient use of resources, appropriate patient care, and effective preventive measures. There is a wide variety of starting points for any country wishing to initiate a poison control programme, and it is essential to identify the existing capabilities and facilities on which a programme may be built. The main elements of such programmes are identification of the toxic hazards existing locally (in order to establish preventive measures), diagnosis of poisoning, and treatment of poisoned patients.
These guidelines are intended to help countries that wish to establish or strengthen facilities for the prevention and management of poisoning. They are concerned with the identification of relevant existing facilities, of needs, of potential resources (including human resources), and of other bodies whose collaboration is essential to the implementation of successful poison control. Based on the experience of established poison information centres throughout the world, the guidelines provide advice rather than a unique model, and should be adapted in accordance with the socioeconomic and cultural conditions prevailing in each country.
Part I is written primarily for the administrator and decision- maker; it provides a policy overview of the problems of poisoning and the types of programmes and facilities that will be effective in preventing and dealing with them. Particular emphasis is given to the key role to be played by poison information centres.
Part II provides technical guidance for those with direct responsibility for the establishment and operation of specific poison control facilities and covers the following topics:
*clinical services (including lists of antidotes and other agents used in the treatment of poisoning)
*analytical toxicology services
*toxicovigilance and prevention of poisoning
*response to major emergencies involving chemicals
*antidotes and their availability
*standardized formats for the collection and storage of essential data by poison information centres
*documentary and library support for poison information centres.