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Poisoning Cases Reported to 
Poison Information Centre, 
Ahmedabad, India: A Three Year 
Observational Study 
 
Avinash Pagdhune1, Kundan Kunal1, 
Kanubhai Amrutlal Patel1, Aswin 
Bhailalbhai Patel1, SukhDev Mishra2, 
Rajendra Palkhade3, Jaseer 
Muhamed1,4,* 
 
1Poison Information Centre, ICMR-National 
Institute of Occupational Health, Ahmedabad, 
Gujarat, India; 
2Biostatistics and Data Management, ICMR-
National Institute of Occupational Health, 
Ahmedabad, Gujarat, India; 
3Animal Facility, ICMR-National Institute of 
Occupational Health, Ahmedabad, Gujarat, 
India; 
4Biochemistry, ICMR Regional Occupational 
Health Centre (Southern), Karnataka, India 
 
*Corresponding author email: 
jaseermuhamed@gmail.com 

 
Vol. 9, No. 1 (2020)   |   ISSN 2166-7403 (online)  
DOI 10.5195/cajgh.2020.471  |   http://cajgh.pitt.edu 



 
 
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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 
 

Central Asian Journal of Global Health 
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Abstract 

Introduction: Morbidity and mortality associated with pesticide poisoning is a major public health issue, especially in lower and 
middle income countries, including India. Timely understanding of poisoning trends is required for improved prevention. The 
objective of the present study was to analyze the trend of poisoning cases in Ahmedabad, India in the period of 2015-2017. 
Methods: Detailed history, including demographic data, risk factors, poisoning history, agents involved, and occupational 
influence were collected for poisoning cases reported to the Poison Information Centre in Ahmedabad. Cholinesterase activity and 
HPTLC method for detection of sanguinarine in urine were used to investigate the agents of poisoning. Non-parametric tests,  such 
as Chi-square test and Mann-Whitney U Test were applied to test statistical significance between the groups. All statistical analysis 
was carried out using IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. 
Results: A total 1373 poisoning cases were investigated. The incidence and fatality rate was found to be higher in males compared 
to females (M/F ratio 1.89:1). About 91.62% of the poisoning were through the oral route. Erythrocyte cholinesterase activity assay 
results indicated that 41.29% of the cases were due to organophosphorus/carbamate poisoning. Insecticides were found to be the 
agent of poisoning in 26.29% cases, and 11.07% of all the cases were agricultural workers. Poisoning with medications, household 
pesticides and chemicals were also reported. Few cases of food poisoning with sanguinarine were detected.  
Conclusion: The data presented here suggest that pesticides used for agriculture are the major source of poisonings. Implementation 
of usage guidelines, educating farmers and vulnerable population, and finding novel alternatives for highly toxic chemicals may be 
helpful in decreasing the number of poisoning cases.  

Keywords: Trend of poisoning; Pesticide poisoning; Organophosphorous; Suicide  
 
 
Poisoning Cases Reported to Poison 
Information Centre, Ahmedabad, India: 
A Three Year Observational Study 
 
Avinash Pagdhune1, Kundan Kunal1, Kanubhai 
Amrutlal Patel1, Aswin Bhailalbhai Patel1, 
SukhDev Mishra2, Rajendra Palkhade3, Jaseer 
Muhamed1,4,* 
 
1Poison Information Centre, ICMR-National 
Institute of Occupational Health, Ahmedabad, 
Gujarat, India; 
2Biostatistics and Data Management, ICMR-
National Institute of Occupational Health, 
Ahmedabad, Gujarat, India; 
3Animal Facility, ICMR-National Institute of 
Occupational Health, Ahmedabad, Gujarat, India; 
4Biochemistry, ICMR Regional Occupational 
Health Centre (Southern), Karnataka, India 
 
*Corresponding author email: 
jaseermuhamed@gmail.com 

Research 

Morbidity and mortality due to pesticide 
poisoning is a major public health issue, especially in 
lower and middle income countries.1 According to the 
National Crime Records Bureau of India, the official 
estimate of suicides resulted from insecticide poisoning 
was 10.4% of the total suicide cases in 2014.2 This 
estimate is more likely to be lower than the actual number 
because of under-reporting of suicide cases and exclusion 
of poisoning cases associated with rodenticides, 
fungicides and herbicides.1 An estimate of 11.3% of total 
suicide cases due to insecticide poisoning was also 
reported in lower and middle income countries of the 
South-East Asia region.1 In 2010, there was reports of 
incidence of 38.8% of suicide by pesticide ingestion in 
India.3 Among the Indian states, Gujarat state accounts 
for 5.4% of the suicide cases, and this is above the 
national average of the country.4  



 
 

CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 
 

 

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To date, considerable efforts have been taken by 
the World Health Organization (WHO) and different 
countries to reduce the incidence of poisoning cases.  One 
such initiative is an IPCS INTOX program by WHO in 
1988, which promoted chemical safety by establishing 
poison information centers, which is a global endeavor to 
promote chemical safety by the introduction and support 
of poison information centers. The program aimed to 
harmonize the collection of poisoning data, training and 
sharing of information related to poisoning within 
member countries.5 In accordance with this program, 
India currently has six poison information centers. The 
Central Insecticides Board & Registration Committee, 
under the Department of Agriculture and Co-operation, 
Government of India, is engaged with registration of 
pesticides used in agriculture in the country. Its activities 
involve banning the  pesticides and chemicals that are 
hazardous to health and the environment, establishing 
guidelines for registration of new pesticides, establishing 
minimum infrastructure requirements for pesticide 
manufacturing, and setting guidelines for the export and 
import of pesticides.6 Still, morbidity and mortality from 
poisoning continue to be a major public health concern in 
the country. 

The incidence of poisoning depends on several 
factors including socioeconomic status, culture and 
religion, educational status, agricultural practices and 
knowledge of pesticides and other poisonous substances, 
extent of industrialization, and geographical conditions.7 
Consequently, the epidemiology of poisoning cases may 
vary depending on geographic location, while 
understanding of the pattern and trend of poisoning in a 
particular area is necessary for efficient design and 
implementation of sustainable prevention and control 
strategies. Previous study conducted in Delhi, India, 
identified that household chemicals followed by drugs, 
agricultural pesticides, and industrial chemicals were the 
major agents of poisoning.8 The objective of this study 
was to understand the trend of the poisoning cases arising 
from human exposure to different poisons, including 
pesticides, during 2015-2017 to inform preventive 

measures that may help to reduce future incidence of 
poisoning cases. The article describes the trend of 
poisoning cases reported to a poison information center 
at Ahmedabad, Gujarat between 2015 and 2017. 

 

Methods 

Fatality rate due to poisoning 

In order to understand the annual mortality trend 
due to poisoning, the rate of fatality due to poisoning was 
obtained. It was calculated from the number of fatalities 
due to poisoning and the total number of poisoning cases 
reported.  

Collection of epidemiological data 

A detailed history of poisoning cases was taken 
for each of the poisoning cases reported to the poison 
information center from January 1, 2015 to December 31, 
2017. The ethical committee approval was obtained from 
institutional ethics committee at the National Institute of 
Occupational Health, Ahmedabad, Gujarat, India. 
Informed oral consent was obtained from each patient 
and/or their guardians for the use of their data in this 
research. The proforma for patient history included 
patients’ personal data such as age, sex, marital status, 
education and geographical area of residence. 
Occupation of the patient was noted to identify any 
occupational exposures. The poison severity score (none, 
minor, moderate or severe) as per Persson et al., 19989 
was documented at the time of admission to the hospital 
and was obtained for this study. Efforts were taken to 
document information on the chemical involved in the 
poison. Other information like chronicity of poisoning, 
route of poisoning, such as oral, inhalation, dermal 
exposure, etc. were obtained from the attending 
physician. Information such as the consciousness of the 
patient at the time of admission, as well as requirement 
of ventilator support, were also documented for each 
patient. 

 



 
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Estimation of cholinesterase activity 

Cholinesterase activity was used as the 
diagnostic tool for acute organophosphorus poisoning. 
Plasma and/or RBC cholinesterase activity was measured 
using modified Ellman’s spectrophotometric method.10 
Briefly, plasma was added and mixed with 5,5’-dithiobis-
(2-nitrobenzoic acid) reagent (Sigma) and acetyl 
thiocholine substrate (Sigma) was added to the mixture. 
The yellow color developed was measured at 410nm 
using a spectrophotometer (Cary 100 Bio, Varian), and 
cholinesterase activity was expressed in units per liter of 
plasma. The value of cholinesterase activity was then 
compared with biological reference range generated in-
house.  

Detection of sanguinarine 

Sanguinarine in urine samples of poisoning 
cases were detected by HPTLC method according to 
methodology published by Shenolikar et al.11 Briefly, 
sanguinarine in urine samples was extracted with 1% 
acetic acid in chloroform and spotted onto TLC plates 
(Sigma) along with standard and developed with butanol-
acetic acid-water in the ratio 63:10:27 by volume. The 
plates were then observed under ultraviolet light and the 
golden-yellow fluorescent band in line with standard 

sanguinarine spot was identified and evaluated as 
sanguinarine in the sample.  

Statistical analysis 

Non-parametric tests such as Chi-square test 
and Mann-Whitney U Test were applied to test statistical 
significance between the groups. All statistical tests were 
carried out at 5% level of significance. All statistical 
analyses were carried out using IBM SPSS Statistics for 
Windows, Version 26.0. Armonk, NY: IBM Corp. 

 

Results 

A total of 1373 poisoning cases was reported to 
the poison information center, with the highest number in 
the year 2016 (480 cases). Although the fatality rate due 
to poisoning in Ahmedabad showed an increasing trend 
annually (Table 1), it was not statistically significant. The 
male to female ratio was 1.4, 1.8 and 2.7 in the years 
2015, 2016 and 2017, respectively, indicating the 
increasing trend of incidence of poisoning in males. Also, 
the fatality rate was significantly high in males compared 
to females. The distribution of poisoning cases with 
respect to the age of patients12 represented as young  (age 
≤35 years), middle age (36-55 years) and older (age ≥56) 
are shown in Figure 1A. 
 

 2015 2016 2017 Total 
Number of cases 447 480 446 1373 
     Males 262 310 326 898 
     Females 185 169 120 474 
     Third gender 0 1 0 1 
Male to female ratio 1.42 1.83 2.72 1.89 
Number of fatalities 27 42 43 112 
     Number of fatalities (male) 19 30 36 85* 
     Number of fatalities (female)  8 12 6 26 
Percentage of fatal rate 6.04% 8.75% 9.64% 8.15% 
*significant at p-value 0.10  

Table 1. Data on poisoning cases reported to poison information center



 
 
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The highest level of incidence was observed in the 
younger age group. Figure 1B shows the education status 
of the patients. The educational status of 136 patients was 
not known. The trend was similar in all the three years of 
the study.  

The poison severity score at the time of 
admission to the hospitals revealed that 338 cases were 
severe (24.61%), while 51.42% cases were of moderate 
severity. Figure 2A shows the three-year trend of severity 
at admission, indicating similar trends in these three 
years. During the course of treatment, 289 (21.04%) 
poisoning cases required ventilator support. A total of 47 
patients suffered from limb paralysis due to poisoning 
during this time period. The route of exposure was oral 
in the majority of the cases with 89.5%, 91.6% and 93.7% 
cases reported in the years 2015, 2016 and 2017, 
respectively. A total of 23 poisoning cases were reported 
due to poisoning through inhalation of toxic agent. Four 
cases of poisoning through dermal exposure were also 
documented. Figure 2B illustrates the trend of various 
chemical agents used for poisoning. The trend was 
similar in all three years, except the occurrence of seven 
edema cases due to contaminated edible oil in the year 
2015, followed by one case in 2016. There were no 
edema cases reported in the year 2017. The chemical 
nature of the poison was not known to the investigators 
in 52.5% of the cases. Agricultural insecticides were 
found in 26.29% cases, followed by household chemicals 
like phenyl, rodenticides, mosquito repellents and 
bleaching powder, together comprising about 12.31% of 
the poisoning cases.   

The trend in relation to circumstances of 
poisoning cases reported is shown in Figure 3A. Most of 
the cases were suicidal in nature (73.4%, 75.2% and 
88.8% in the years 2015, 2016 and 2017, respectively) 
with intentional oral intake of poison at home. 
Agricultural chemicals stored in home were found to be 
the poisoning agent in 28.18% of the suicide cases. 

 

 

Figure 1. The pie chart shows the number of poisoning 
incidences in young, middle and older aged subjects (A) 
and educational status of the patients (B) between 2015 
and 2017. 

 

 

  



 
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Figure 2. The annual trend of poisoning cases in relation 
to the severity of cases at the time of admission to 
hospital (A) and the agents involved in poisoning (B) 
between 2015 and 2017. 

 

 

Chemical agents included acephate, phorate, 
adrin, carbofuran, celphos, chlorophos, chorpyriphos, 
cypermethrin, DDT, gamexin, dimethoate, 
imidochloprid, malathion and monocrotophos. The list 
also includes some insecticides with local trade names 
whose chemical composition was not clear. Analysis of 
cholinesterase activity in these patients revealed 571 
(52.57%) cases with reduced plasma cholinesterase 
activity and 428 (39.41%) cases with reduced RBC 
cholinesterase activity, indicating the widespread use of 
organophosphorus chemicals for intentional poisoning. 
Plasma/serum cholinesterase activity and RBC 
cholinesterase activity reduced in 49.67% and 41.29% of 
all the cases. The cholinesterase values of poisoning 
cases due to agricultural pesticides were significantly 
lower than that of poisoning due to causes other than 
agricultural pesticides (p value <0.05) as shown in Figure 
3B.  

Thirteen cases were homicidal in nature (1, 10 
and 2 cases in the year 2015, 2016 and 2017, 
respectively). Six of them had reduced RBC 
cholinesterase activity with normal level of plasma 
cholinesterase activity, and another 2 cases had very low 
level of plasma cholinesterase activity.  

About 55 cases of food poisoning and 35 cases 
of accidental poisoning were recorded in the study 
period. The number of food poisoning cases showed a 
decreasing trend with 38, 16 and 1 cases in the year 2015, 
2016 and 2017, respectively. Paralysis of both limbs of 
the patients were present in 18 food poisoning cases 
reported in 2015. Among these, eight were suspected 
cases of argemonium oil consumption, and HPTLC 
analysis of urine sample of the patients revealed the 
presence of sanguinarine in three cases. About 38.18% of 
the food poisoning cases showed reduction in the plasma 
cholinesterase activity, and 65.45% showed reduced 
RBC cholinesterase activity. 



 
 
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Figure 3. The trend of poisoning 2015-2017 in relation to the circumstances of poisoning (A), the box plot showing 
plasma cholinesterase activity in victims of poisoning due to agricultural pesticides in comparison to other known 
causes (B), and the occupation of patients (C). 



 
 
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Fourteen cases were associated with the abuse 
of toxic substances. Four of them were with Bhang, a 
locally available cannabinoid substance, and one case 
with locally made alcohol. Three of these patients 
showed reduced plasma/RBC cholinesterase activity 
indicating the possibility of organophosphorus 
poisoning.  

Twenty-eight cases were reported with 
poisoning related to occupational exposures. All of these 
were acute poisoning cases, out of which 16 cases were 
from inhalation of toxicant, and 11 cases were oral 
poisoning cases. At least 21 of them had reduced plasma 
cholinesterase activity, and 15 cases had reduced RBC 
cholinesterase activity, indicative of organophosphorus 
poisoning in occupational settings. Figure 3C shows the 
trend of poisoning with respect to the occupation of 
patients. In all three years, housemakers constituted the 
highest number of poisoning cases (21.2%), followed by 
laborers (11.2%), agricultural workers (11.0%) and 
industrial workers (7.7%). The number of industrial 
workers exposed to poison at workplace was 19, 29 and 
56 in the years 2015, 2016 and 2017, respectively.  

 
Discussion 

This study presents the trend of poisoning cases 
reported to poison information center, Ahmedabad from 
2015 through 2017. The fatality rate due to poisoning was 
found to be similar from 2015 to 2017, underlining the 
importance of poisoning as a public health concern. This 
rate may be an underestimate because of under-reporting 
of deaths due to poisoning. The incidence and fatality due 
to poisoning was higher in males. A similar study 
conducted in a tertiary hospital in Karnataka state, India 
also reported higher incidence (75.4%) of poisoning 
among males compared to females.13 However, there are 
studies that reported higher incidence in females14 , as 
well as comparable incidence in males and females.15 
This might be attributed to the difference in the cultural, 

lifestyle, occupational and socioeconomic nature of the 
population studied.  

In the present study, 11.07% of the population 
comprised of agricultural workers, and in 26.29% of the 
reported cases, the poisoning was associated with 
insecticides used in the agriculture sector. This is a matter 
of concern, especially in the context of recent reports of 
fatal occupational poisoning of 45 agricultural workers in 
the Bt-cotton plantations of Maharashtra state.16 A 
similar method of cotton cultivation is being practiced in 
Gujarat too.17 Though Bt-cotton plants are supposed to 
be resistant to insect cotton ballworms, new reports are 
suggestive of development of resistance in ballworms.18 
This leads to heavy insecticide use in Bt-cotton 
plantations and results in occupational poisoning in 
agricultural workers, as well as higher incidence of 
suicide. A notable study among 127 acute poisoning 
cases in Maharashtra reported 48.8% cases in agriculture 
workers.19 The cause of higher incidence of poisoning 
cases among farmers of Vidarbha region of Maharashtra 
was identified as a complex interplay of social, political 
and environmental factors. Relief packages, as well as 
implementation of mental health programs at the regional 
level to offer support and counselling to vulnerable 
population, may prevent the incidence of poisoning cases 
in future.20 Similarly, the use of personal protective 
equipment and safety guidelines in the use of pesticides 
may also aid in reducing the occupational poisoning, 
especially in workers who spray the insecticide solution. 
Proper training in integrated pest management has been 
proven as an effective strategy in reducing the number of 
poisoning cases in farm workers of South India.21  

Organophosphorus pesticides are the most 
common cause of poisoning in agricultural workers and 
other unskilled workers.22 Currently, cholinesterase 
activity in serum/plasma/RBC is used as most reliable 
tests for organophosphorus poisoning.23 This study 
revealed reduced cholinesterase activity in plasma of 
victims exposed to agricultural pesticides compared to 
cases due to other means of poisoning, emphasizing the 



 
 

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prevalence of poisoning with pesticides such as 
organophosphorus chemicals/carbamates in the 
community. This observation warrants the need for 
replacing highly poisonous organophosphorus chemicals 
with less toxic chemicals. We would also like to 
emphasize the need to regulate the supply of toxic 
chemicals, implementation of usage guidelines, and 
banning of highly toxic pesticides. 

Poisoning with alcohol is relatively low in 
Gujarat.24 In this study, we came across 11 alcohol 
poisoning cases, which comprised only 0.80% of total 
poisoning cases reported. This could be the result of 
Bombay prohibition bill passed in 1949 and subsequent 
amendments by the state government, according to which 
liquor is prohibited by law in Gujarat state.25 However, 
previous studies on the drunkenness at Ahmedabad civil 
hospital have reported some episodes of alcohol 
poisoning, and the alcohol prohibition by law did not 
necessarily change the behavior of people towards the 
usage of alcohol.24  

Eight cases of poisoning through contaminated 
edible oil was reported. Out of this, the presence of 
sanguinarine, a toxic alkaloid present in Argemone 
mexicana seeds was detected in the urine of three 
patients, suggestive of edema (epidemic dropsy), in the 
year 2015. Edema  usually occurs in the form of an 
epidemic affecting a population that consume edible oil 
adulterated with Argemone mexicana oil.26 In the year 
2012, thirteen cases of edema were reported from 
Panchmahal district of Gujarat.27 Hence, even though a 
small incidence of the disease was reported to the poison 
information center in the year 2015, the data points 
towards the need of active toxicovigilance and anti-food 
adulteration activities. Moreover, the toxicology 
laboratories have to be strengthened for timely detection 
and diagnosis of edema in future.  

Household chemicals like insecticides, 
rodenticides, phenyl, bleaching powder and mosquito 
repellents constituted 12.31% of the poisoning cases. 
Previous studies also reported a higher incidence (44%) 

of poisoning due to such household chemicals.8 This 
difference in the trend of poisoning might be attributed to 
the differences in the culture, education status and 
availability of other toxicants for suicide purpose. The 
probability of poisoning is inversely proportional to the 
education level.28 The education status of patients in this 
study also showed that the poisoning incidence is high 
among the uneducated or less educated population 
(Figure 1B). Therefore, increasing the awareness on 
poisonous substances may be effective in reducing the 
number of poisoning cases in future.  

According to WHO, pesticide poisoning 
accounts for the most of the global suicides, and the 
majority of them occur in lower and middle income 
countries.29 The present study also shows that agriculture 
pesticides are the major means of poisoning and related 
fatality. A multifaceted approach with legislation to ban 
highly toxic pesticides, improvements in medical 
management of poisoning cases, awareness and storage 
guidelines may help to reduce the incidence of poisoning, 
as found effective in Srilanka.30 More effective 
toxicovigilance by the regulatory agencies also can 
contribute to bring down the poisoning cases to minimum 
level.31 

The limitation of this study is that it is possible 
that not all poisoning cases have been reported to the 
center. The availability and nature of particular antidotes 
were also not documented in this study. These are very 
important for assessment of health resources required to 
deal with poisoning cases in a particular region. 
Therefore, strengthening the reporting procedures of 
poisoning cases to the poison information center and 
special attention to availability of antidotes is an 
important aspect of future work in this important area.  

Poisonings with toxic chemicals continue to be 
a major health concern in Gujarat, and poison 
information centers play a crucial role in reducing the rate 
of poisoning. The data presented in this paper suggest 
that pesticides used in agriculture were a major source of 
poisoning between 2015 and 2017. Highly toxic 



 
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chemicals used in agriculture should be either banned or 
given to farmers with strict usage guidelines and 
documentation explaining the risks involved. Most of the 
poisoning cases reported here were suicidal in nature, 
indicating the need for effective measures to prevent the 
suicidal tendency and improve psychological health in 
the community. The epidemiological trend of poisoning 
cases presented in this paper may be helpful in reducing 
the incidence of poisoning cases in future.  

 

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