Pesticide poisoning – we still do not know    

In 1987, the House of Commons Agriculture Committee, chaired by Sir Richard Body MP, produced a draft report1 The Effects of Pesticides on Human Health. The first recommendation of the Body Report noted ‘we deplore the lack of a centralised system of coordinating all reports on pesticide poisoning.’ John Harvey and Peter Beaumont report on changes over the following 13 years.

Background: then and now
One of the witnesses that gave evidence to the Body Report was the National Poisons Unit based at Guy’s Hospital, London – which is now the London regional centre of the National Poisons Information Service (NPIS). The Unit made a powerful plea: ‘The government should intervene in order to achieve, quickly, a nationwide pooling of standardised information on all cases of acute or suspected acute poisoning from agrochemicals: the evaluation, confirmation and long term follow up of each case should be carried out by an independent team of experts following an agreed protocol which must guarantee patient confidentiality.’
    This aspiration has not been realised. Michael Meacher, Minister of State for the Environment, Transport and the Regions, responded to a Parliamentary Question from Paul Tyler, the Liberal Democrat MP2, earlier this year. ‘Comprehensive information on the number of people who are poisoned by pesticides each year is not available.’
    This article reflects concern about three issues particularly: the lack of any coordinated system of pesticide poisoning reporting; the lack of transparent management and accountability of the NPIS by the Department of Health (DoH); and the fact that the centres are not adequately structured or resourced by the DoH to follow up cases or to deal with chronic cases.

NPIS
Six regional centres now make up NPIS, located in London (the biggest), Belfast, Birmingham, Cardiff, Edinburgh and Newcastle. The centres aim to provide a year-round, 24-hour a day service for health care staff on the diagnosis, treatment and management of patients who may have been poisoned3. Enquiries were until recently made by doctors only by telephone to NPIS centres but new arrangements have been introduced to augment the current telephone-only access to health professionals by use of the online database (TOXBASE) and NHS Direct staff in addition. It is also aimed to move to a more regionally based service with stronger local links.
    It is difficult to get NPIS as a whole to produce information on the incidence of pesticide poisoning. But in the Body Report as long ago as 1987, Dr Volans the Director of the London Unit, offered the view that acute cases of pesticide poisoning in England and Wales were of the order of 5-6,000 cases per year.
    The 1997 NPIS Annual Report4 – the latest available – shows that the regional centres received a total of 274,247 calls, of which 200,575 (73%) were taken by the London centre. Dr Virginia Murray, Deputy Director of the London NPIS, points out that pesticides represent only a small part of NPIS work. Between April 1995 and April 2000, the London NPIS received 1,006,550 emergency case inquiries – about 200,000 per year. 6,472 of these concerned insecticides: information about herbicides and fungicides may be available in the system but has not been analysed. About 20-30 patients are referred to the London centre out-patient clinic every year with symptoms that may be due to pesticide poisoning. 
    Although they are not a major proportion of calls, pesticides do however create considerable work for the centres. There are a great number of different pesticide active ingredients. Both doctors and patients often will not know what the patient has been exposed to. Even if the chemical is known, there are few antidotes – and still fewer ways to treat the patient and help them recover.
    The job of recording calls on a country-wide basis would have to be done by the Department of Health, as none of the centres is equipped to do this.

A public service?
Another aspiration of the National Poisons Unit at the time of the Body Report was to extend the outreach of the Unit to a wider public. This has not been entirely successful.
    At present, the service takes referrals from the health practitioners – principally doctors and recently NHS Direct. It remains a tool of the medical profession only.
    According to Dr Murray, the service was from the outset told it was not to be available to the public.
    In other countries – such as France and Belgium – national poisons centres are listed in the telephone directory. Many other poisons services respond to queries from the general public. In Boston, USA, for example 80% of inquiries are from the public and 20% are from medical professionals. However, NPIS London now has an arrangement with NHS Direct, which went live this year. Now if someone rings NHS Direct with a poisoning query, they should be put in touch with trained nurses who can describe what resources are available*. 

No transparency
Gareth Jones, head of the DoH’s Sustainable Development Unit which funds the English NPIS centres, is a member of the NPIS Board which is run by the DoH to determine policy and strategy for the centres. But when PAN UK asked the DoH who else was on the Board, the information was refused because: ‘it is an internal management committee and its agendas and minutes are not published.’
    The Department subsequently emphasised that it is not attempting to hide the identity of NPIS Board members, which is made up of DoH managers rather than named individuals. When a manager moves to a new post, the replacement will take up the place on the Board.
    This does not, however, meet the concerns. The lack of transparency in the policy, management and accountability of a public institution is unacceptable.

No chronic OP diagnoses
Over-exposure to many pesticides can cause chronic health effects, but the issue of organophosphate pesticides is particularly contentious.
    Following the report of the Joint Working Party of the Royal College of Physicians and Royal College of Psychiatrists on the clinical management of organophosphates (OP) in 1998, the Chief Medical Officer of Health wrote to all GPs in November of that year5 ‘I have asked officials at the Department of Health to open immediate discussions with the Directors of the National Poisons Information Service on the report’s recommendations … and for improving the level of support to GPs who have patients who may be suffering the effects of OP poisoning.’ 
    But it is not clear whether the NPIS centres individually or as a whole accept or have ever diagnosed chronic OP poisoning. This is serious because to most GPs and hospital doctors NPIS is the only consultant-led resource available. NPIS does not publish figures on referrals or diagnoses. Although the London centre says it accepts the existence of chronic OP poisoning as evidenced in the literature over 30 years, the fact remains that NPIS and the individual centres exist principally to provide an acute service. 
    Members of PAN UK’s Action on Pesticide Exposure (PEX) have been led to believe that the London centre sought and received funding for research into chronic poisoning of OP victims, but it is not clear whether any such research has been conducted or published, nor whether the London centre nor any of the other NPIS centres has undertaken any research into chronic OP poisoning.

Conflict of interest?
A further concern is that outpatients at the Medical Toxicology Unit (MTU) Outpatients Clinic (the London centre forms part of the MTU) may see Dr Martin Wilks, one of the four consultants. He works part-time for the MTU: for three days a week he is the Medical Advisor to the agrochemical company Zeneca (now Syngenta). Although he may see pesticide exposure patients at an initial stage, when it may not be clear that their illness is pesticide-related, or if there is an emergency, Dr Wilks does not deal with long-term pesticide cases. Patients are not informed at the outset that he also works for an agrochemical company and neither Dr Wilks nor the MTU regard it as appropriate to disclose what many may see as a potential conflict of interest.
    Dr Sarah Myhill is a GP with a practice on the Welsh borders and sees many farmers and others she considers have been poisoned by OPs. She has identified a diffuse pattern of symptoms temporally related to OP exposure which she regards as indicating chronic OP poisoning. She voiced the suspicion of many sufferers in an editorial published this year in the Journal of Nutritional and Environmental Medicine6 when she alleged that the London centre of the NPIS had failed to diagnose a single case of [chronic] OP poisoning over the past decade, despite seeing the most seriously afflicted sufferers, and that cynics among those sufferers believed that the funding of Guy’s Poisons Unit by Zeneca had affected their judgement.
    Dr Murray disagreed; but accepted that Zeneca does fund the centre to the sum of about £3,000 pa for paraquat surveillance. She insisted that no direct industry funding was received for any work related to OP pesticides. By contrast Yvette Cooper, in response to a Parliamentary Question stated that ‘The Medical Toxicology Unit [of which the centre is part] provides post-marketing surveillance for one company and advice on safety information for one company – a total of two companies with an annual average income of £3,000.’
    Dr Glyn Volans, the Director of the London centre rejects allegations of industry influence claiming that its clinical approach is very much in line with the Royal Colleges’ report. In his response7 to Dr Myhill in October, he said: ‘Rather than concentrating on the causal relationship between OP exposure and symptoms, the report advocates an open-minded and pragmatic approach to the management of the illness, similar to that used in other poorly understood medical disorders… We have for many years advocated a multidisciplinary approach to the diagnosis and management of illnesses which may be related to chemical exposure. If we have failed individual patients, that is a matter of regret and an incentive to try even harder.’
    Gareth Jones of the DoH said that the Department would not know if London NPIS was being funded by chemical companies. ‘All we are paying for is the service they are providing for NHS professionals in the diagnosis and management of people who have been poisoned,’ said Mr Jones. This includes the London centre’s telephone service, the TOXBASE database available to doctors on the internet so they can obtain information about poisoning without having to rely so much on the telephone service, and training NHS staff in poisoning diagnosis.

The need for a proper service
There are five areas of urgent concern for victims of pesticide poisoning.

A clinical database
In the Committee on Toxicology (COT) report8 published last year, one of the conclusions read: ‘It was a matter of particular concern to some members of the working group that the present schemes for monitoring human adverse effects had yielded so few relevant data and that little progress had been made in establishing a relevant clinical database.’ This is not something that the NPIS has been able so far to provide. 
    The Ministry of Agriculture Fisheries and Food (MAFF) has at last been persuaded to invest in research to develop this. A MAFF-funded research project will look at existing NGO databases including PAN UK’s PEX project, the OP Information Network (OPIN) and the Northern Ireland Organophosphorus Sufferers Association (NIOPSA). NPIS should contribute, subject to confidentiality and consent, the information it holds on OP victims to enable the research to use the largest and most accurate data set.

Poisons monitoring
The DoH needs to produce an annual nationwide report on the incidence of acute and chronic pesticide poisoning. Without basic statistics, we cannot tell if things are getting worse or better. Perhaps this need has at last been recognised. One small sign has been the outcome of an HSE consultation on ill-health monitoring9 following pesticide exposure. It is a request for research proposals10 for a pilot system of monitoring to answer a number of vital questions:

• the annual national incidence of illness presented to GPs (local doctors) and diagnosed as related to pesticides;
• the main health effects, exposures and pesticides, and the cost of setting up a permanent system to collect pesticide related data from GPs.

Access to information
Another priority must be a properly funded NPIS that not only provides information to health professionals but also to the public. It also needs to be publicly accountable and to publish data in the public domain. Membership of the Board of the NPIS centres and their policy and strategy are also public concerns: most similar Boards now include a lay representative and there is no reason why NPIS should be different.
    Access to information also includes disclosure of funding and elimination of conflicts of interest. Public confidence in poisons management can only be engendered if the source of that advice is independent from any real or perceived conflict of interest with the agrochemical industry.

Action on chronic OP poisoning
Has NPIS diagnosed a single case of chronic pesticide poisoning or done any research on the issue? We need all the experts involved to pool their expertise in the interests of those who have been poisoned to achieve the best consensus on what is chronic OP poisoning and how people can be helped. Both the Department of Health and NPIS should be leading the way to develop consensus on diagnosis, treatment and management of patients and working with practitioners.

The international context
OP poisoning is a worldwide problem and developing countries look to the North to provide solutions. The World Health Organisation is trying to help poisons centres throughout the world develop a better understanding and response to pesticide poisoning. The guidelines on poisons control were published by the World Health Organisation in 1997: Dr Murray helped to write them. Victims worldwide desperately need properly functioning and resourced poisons centres. 
    We look to the Department of Health and NPIS to rise to these challenges in the UK. After 50 years of intensive pesticide use and 13 years after the Body Report those whose health has been affected by pesticides deserve no less – both here and in developing countries.

References
1. The Effects of Pesticides on Human Health, House of Commons Agriculture Committee, Vols I-III. HMSO, London, 1987.
2. Hansard, Vol 354 28, July 2000, col 945W.
3. NPIS website: http://www.npis.org, London centre website: http://www.medtox.org.uk.
4. 1997 Annual Report of the UK NPIS, DoH, undated.
5. Chief Medical Officer Welcomes Report on Organophosphate Sheep Dip, DoH, Press Circular 0508, 11 November 1998.
6. Response to the Committee on Toxicity’s Recommendations on Organophosphates, (Editorial) S. Myhill, Jo. Nutritional and Env. Sci, Vol 10:1 March 2000 11-12.
7. Letter Dr Volans to Dr Myhill 17 Oct 2000. 
8. Organophosphates, Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment, DoH, London 1999, DoH website: http://www.doh.gov.uk/cot.htm.
9. Monitoring by Government Departments of the Ill-Health Effects of Pesticide Exposure: A Review of Existing Arrangements, HSE, London 1998.
10. GP-Based Scheme for Monitoring Pesticide Related Ill-Health, Letter from Mrs S. Senior (HSE Health Directorate B) to PAN-UK and others. 31 October 2000.

*The NHS Direct number is 0845 46 47.

[This article first appeared in Pesticides News No.50, December 2000, p3-4]