Dr M M Jahangir Alam
Associate Professor
Department of Medicine
Sylhet M A G Osmani Medical College
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Poisoning is a medical emergency, results in
morbidity and mortality
TESS of the American Association of poison
control center records more than 2 million
exposures and more than 700 deaths
annually
Poisoning records around 300000 episodes
and around 2000 death per year in
Bangladesh
Billal Alam et al, Factors associated with travel related poisoning
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Mode and pattern of poisoning vary from
region to region and country to country
Recent trends of poisoning favors travel
related poisoning. Hospital registry of SOMCH
revealed that 43.27% of total poisoning
patients were admitted in medicine unit due
to travel related poisoning
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Travel related poisoning is an emerging social
and public health concern in Bangladesh
Few years back it was observed to be
introduced by Dhatura and allied compound
Now different benzodiazepines are used with
different food items for this purpose
Poisoning is a man made incident, which can
be preventable
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Bangladesh is one of the developing countries
where basic data regarding travel related
poisoning are not available as there is no
remarkable study done in this issue
On average, 1-2 patients/day with induced
poisoning on journey used to get admitted
during festival time
Bari et al, Emerging trend of commuter (Street) poisoning in Bangladesh:
4 years (2008- 2011) experience from Hospital archive
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Since 2008 to 2011, a total of 4435 cases of
acute poisoning were admitted in the
Medicine ward of Sylhet M. A. G. Osmani
Medical College Hospital
Of them commuter poisoning (1919; 43.27%)
was the most commonly occurring type
(p<0.05) both in male and female & this
trend remained same in almost all study years
Study year
Type of poisoning
Total
OPC
Commute
r
(unknow
n agents)
poisonin
g
Sedativ
e
Harpic
Rat-killer
Corrosi
ve
Alcohol
Kerosen
e
Paracet
amol
Snake
bite
Others
2008
260
438
122
86
35
31
9
6
6
4
25
1022
2009
223
487
113
95
33
25
12
4
9
5
35
1041
2010
336
451
130
65
45
40
12
7
5
15
50
1156
2011
321
543
117
67
60
32
11
6
9
6
44
1216
Total
1140
1919
482
313
173
128
44
23
29
30
154
4435
Percentag
e
25.7
43.27
10.87
7.06
3.9
2.89
0.99
0.52
0.65
0.68
3.47
Bari et al, Emerging trend of commuter (Street) poisoning in Bangladesh:
4 years (2008- 2011) experience from Hospital archive
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Most of the circumstances of travel related
poisoning occur within bus, bus stands, taxi,
tampoo, auto-rickshaw, train, launch, railway
station, local markets
The incidence of this type of induced
poisoning in cities like Dhaka, Chittagong,
Sylhet, Rajshahi, Khulna is increasing during
festival time like Eid ul fitr, Eid ul azha, Durga
Puja, etc
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The miscreants use tea, coffee, biscuit, 'dab
water', cold drinks, fruit, fruit juice, betel nut,
'jhal muri', etc
Sometimes they offer medication of low cost
for some disease like skin disease, asthma,
hemorrhoids
Circumstances/Transport of travel related poisoning
180
168
160
140
120
100
80
60
36
40
10
20
20
30
36
Train
Others
0
Bus
Bus stand
CNG
Launch
Billal Alam et al, Factors associated with travel related poisoning
Use of substances in travel related poisoning
80
72
66
70
60
60
50
40
42
30
30
18
20
12
10
0
Dab water
Drinks
Tea
Betel nuts
Biscuits
Fruit juice
Others
Billal Alam et al, Factors associated with travel related poisoning
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Majority (70%) of people were made stuporus
with dab water, soft drinks and tea, betel leaf
with nut
Smaller percentage of victims is offered
cream biscuits, fruit, fruit juice
These agents are chosen as they are popular
fast food, cheaper to buy and easily available
and widely accepted.
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Majority of victim travels through bus. More
incidence of induced poisoning occurred
when they are returning home from office
Usually these patients are found unconscious
on buses or other places of the public
transport system, and are brought to hospital
by police
Pattern of Rescue by different persons
180
160
153
140
120
100
70
80
54
60
40
20
3
8
12
Travelmate
Relative
0
Police
Vehicle staff
Public
Others
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There is exclusively male sex pre-ponderance
in induced poisoning cases, male: female=
98:2=49:1
Majority of the victims are at 21 to 30 years
age group
Most of the victims had lost their valuables
including money
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Sometimes the people are robbed of their
mobiles, wristwatches, wedding rings,
credit-cards, official documents
The miscreants act as small groups in
different places taking it as a profession,
making the people and police fool and rob
their valuable in regular basis
Age pattern of travel related poisoning patient in medicine
department of DMCH from January to June (2010).
140
120
100
80
60
40
20
0
116
103
38
39
4
11-20 yrs
21-30yrs
31-40 yrs
41-50 yrs
51-6 0 yrs
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They may be linked with larger chain of
miscreants and this needs to be identified by
the law-enforcing agencies of government to
disrupt the chain and to protect the people of
being robbed off during journey.
These patients are admitted throughout the
year but interestingly more during summer
possibly people are usually thirsty due to
excessive hot weather and easily deceived
with an offer of cold drink from other person
(Hospital records)
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The interesting aspect of change of pattern of
poisoning happened in the nature of patients of
unknown poisoning from Datura to sedative
which can be differentiated by skin condition,
pupil size, relatively calm patient with uneventful
recovery.
Majority of victims were unconscious within 30
minutes of time after ingestion of offered
substance and remaining were unconscious
within 60 minutes because hypnotics used were
absorbed quickly from gut, acted rapidly on
central nervous system and made the person
stuporous.
Symptoms of travel related poisionig patients
250
200
150
228
100
192
168
156
50
3
6
30
m
at
em
es
is
iti
ng
ae
H
da
ch
ea
H
Vo
m
e
n
d
ur
re
Bl
ro
w
si
vi
si
o
ne
s
n
D
C
on
fu
si
o
ss
iz
zi
ne
D
s
0
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Patient are usually brought by police in a
drowsy or stuporous conditions. Systemic
examination is usually normal with no focal
neurological deficit.
Laboratory investigations including
haemogram, liver & Kidney function tests,
ECG examination are unremarkable in most
cases
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Full toxicological screening was performed
for urine samples obtained from the 15
patients of May 2006, using an LC–TOF MS
lorazepam was identified in all 15 cases but
additional ingestion of diazepam five cases
and nitrazepam (three cases) was also
detected However, in eight cases with
lorazepam only
M.M.A. Majumder, et al., Criminal poisoning of commuters in Bangladesh,
Forensic Sci. Int. (2008), doi:10.1016/j.forsciint.2008.06.016
M.M.A. Majumder, et al., Criminal poisoning of commuters in Bangladesh,
Forensic Sci. Int. (2008), doi:10.1016/j.forsciint.2008.06.016
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The patients are usually managed in a very
busy admitting unit. Many patients are
managed in hospital floor.
Few patients had accompanying relatives with
them. Hospital facilities, logistics and staff
cannot cope with such number of admitted
patients.
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Young trainee doctors and nurses managed
the patients with resource limitations
In the absence of a specific diagnosis, care of
these patients has been limited to
observation and supportive measures egmaintenance of nutrition, fluid replacement
and nursing care
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Fortunately most of the patients are discharged
within 24 hours after admission uneventfully.
Almost all patients are given stomach wash as a
part of management of general poisoning, which
did not reveal any significant gastric aspirate
colour.
Usually almost all patients are recovered fully.
Some of them absconded probably due to social
and medico-legal cause. Absence of mortality
among suspected induced poisoning is
reassuring for us
Duration of Hospital stay in travel related poisoning patients
160
144
140
120
96
100
80
60
48
40
12
20
0
0
<12 hrs
12 to 18 hrs
18 to 24 hrs
24 to 48 hrs
48 to 72 hrs
Mode of outcome
160
138
140
120
96
100
80
66
60
40
20
0
0
life threatening
Death
0
Complete
recovery
treatment needed Minor symptoms
but no resudual
with rapid
disability
resolution
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The incidence of Travel related poisoning is
increasing and pattern is changing day by day
as urbanization is going on.
The facility of chemical identification of the
induced poisoning should be made available
for more effective, specific treatment of the
patients rather relying on supportive
treatment only
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Special measures should be taken by the hospital
administration for urgent management of these
unaccompanied victims.
Steps should be taken by law-enforcing agencies
to identify the offending agents and culprit by
vigilance.
Advice should be given to the public not to take
food items on the travel particularly from an
unknown person.
Social awareness for safe travel needs to be
created
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A team of healthcare professionals including
doctors, nurses, and paramedics is needed to
build up.
A separate day care room close to emergency
department can be set up which can be
utilized by all admitting adult medicine units
If the people, the mass media, the police, the
bus driver and conductors become alert, the
incidence can be reduced.
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Much co-ordinate work is needed to tackle
the situation such as:
◦ Community-based study to identify the problem on
nationwide basis and uniform guidelines about
treatment
◦ Awareness of the public for its prevention,
immediate first-aid measures and quick hospital
admission
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Awareness of the doctors by giving adequate
importance of poisoning in undergraduate
curriculum as well as by continued medical
education
Facilities for intensive care with artificial
respiration, adequate drug supply and by
improving diagnostic method of chemical
analysis
M.M.A. Majumder, et al., Criminal poisoning of commuters in Bangladesh,
Forensic Sci. Int. (2008), doi:10.1016/j.forsciint.2008.06.016
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Majumder MMA, Basher A, Faiz MA, Kuch U, Pogoda W, Kauert GF, et al.
Criminal poisoning of commuters in Bangladesh: prospective &
retrospective study. Forensic Sci Int 2008 August 25; 180(1):10-16.
Sarker ZM, Khan RK. Acute poisoning– scenario at a district hospital.
Bangladesh J Med 2002 July; 13(1):49-52.
Uddin MJ, Shahed FH, Bhowmik SK, Rashid R, Ghose A, Rahman MR, et al.
‘Transport related poisoning’—an untapped public health problem. The
Healer. 2002; 9: 40-42.
Rahman M, Rahman M, Chowdhury AH. Pattern of poisoning in Rangpur
Medical College Hospital. Northern Med J 1994 January; 3(1): 15-18.
Howlader MAR, Hossain MZ, Morshed MG, Begum H, Sardar MH, Uddin
MZ, et al. changing trends of poisoning in Bangladesh. J Dhaka Med Coll
2011 April; 20(1): 51-56.
Bari MS, Chakraborty SR, Alam MMJ, Qayyum JA, Hassan N, Chowdhury
FR, Emerging trend of commuter (Street) poisoning in Bangladesh: 4
years (2008- 2011) experience from Hospital archive
Alam MB, Ahasan HAMN, Bari MS, Chowdhury FR, Factors associated with
travel related poisoning