5 TOXICOVIGILANCE AND PREVENTION
5.6 PROGRAMMES FOR POISONING PREVENTION
Activities for preventing poisoning are the counterpart to toxicovigilance. As for toxicovigilance, the responsibility for poisoning prevention is shared by organizations such as health bodies, poison centres, government agencies, industry and civil society (21).
Poisoning prevention programmes require good information about the local situation, including details of acute and chronic poisoning cases, environmental contamination, substance abuse patterns and the circumstances that give rise to a high risk of exposure. Through toxicovigilance, poison centres are well placed to identify priorities for poisoning prevention. Box 5 describes the role of poison centres in the prevention of children’s exposure to liquid laundry detergent capsules.
Box 5. Role of poison centres in reducing paediatric exposure to liquid laundry detergent capsules (15)
An example of effective prevention due to poison centre activities is the identification by numerous centres of the toxicological hazards of liquid laundry detergent capsules, which led to improvements in their packaging and labelling. These capsules were introduced in France, Ireland and the United Kingdom in 2001 as a convenient pre-measured dose of detergent. Poison centres soon began to receive reports of cases of eye and throat injuries in children. Nevertheless, the capsules were introduced onto the Italian market in 2010 without child-protective packaging. Shortly afterwards, the National Poison Control Centre in Milan identified an increase in enquiries about paediatric exposure, including reports of respiratory and ocular effects associated with the new product. After alerting the manufacturers and public health authorities, the National Poison Control Centre collaborated with the National Centre for Epidemiology, Surveillance and Health Promotion in the National Institute of Health to further monitor the potential problem and conducted a study to compare the severity of poisoning by traditional laundry detergents and by liquid laundry detergent capsules in children under 5 years between 2010 and 2015. The study demonstrated that the capsules were more likely to be associated with multiple-route exposure, the development of symptoms, more severe symptoms and a greater likelihood of hospitalization. By publishing these trends, the Poison Centre provided evidence to encourage manufacturers to adopt voluntary preventive measures, including more visible warnings on packaging, opaque packaging, child-resistant closure and a public information campaign. Use of these measures (particularly opaque packaging) resulted in a steep decrease in the number of enquiries to the Poison Centre about the capsules, and the protective measures became mandatory in Italy. Shortly afterwards, similar measures became mandatory in the European Union, with additional requirements for use of aversive agents, slower dissolution of the capsule in water and increased mechanical resistance. Engagement in toxicovigilance and active surveillance made the Poison Centre central in identifying a novel pathway of exposure to poisons, proposing measures to address the issue and demonstrating the effectiveness of risk management measures.
The principal types of preventive action that can be initiated by poison centres are:
• monitoring: investigating trends in toxic exposure to both well-known agents and emerging threats to public health by collecting data from enquiries and from other sources, such as attendance at hospital emergency departments to identify local risks;
• analysing and interpreting data generated by monitoring;
• reporting to and collaborating with other organizations and institutions on the development of safer products, safety measures in packaging, design, labelling, transport and handling of hazardous products and withdrawing or limiting the availability of selected toxic substances;
• education of particular groups at risk as well as the general public and professional health care workers, including dissemination of leaflets, social media messaging, articles in the mass media, education sessions and targeted outreach as well as organization of regular poisons prevention campaigns (21); and
• evaluation of effectiveness, which should be planned for any preventive activity, with poison centre data, market share data and other data to demonstrate the effectiveness of prevention and harm reduction measures (15, 21).
Box 6 illustrates the use of poison centre data to provide evidence for strengthening regulation of nicotine refill products for electronic nicotine delivery systems.
Box 6. Poison centre data and regulation of electronic nicotine delivery systems in the USA
Nicotine, a pharmacologically active compound in tobacco products, is toxic, particularly for young children, and high concentrations can result in death (22). Children’s exposure to nicotine has usually been a result of ingesting conventional cigarettes and other tobacco products, such as chewing tobacco and snuff. Since its development and release, however, nicotine replacement therapy such as nicotine chewing-gum has also resulted in poisoning in infants. In 2010–2011, electronic nicotine delivery systems (ENDS) such as e-cigarettes and vape pens and solutions of nicotine in cartridges or as refills entered the market in the USA, with no regulation requiring child-resistant closures on refill products or standardized concentrations. As ENDS became more widely used, poison centres started to receive calls about young children ingesting nicotine solutions. An analysis of cases documented in the National Poison Data System between January 2012 and April 2015 showed that the number of children under 5 years of age who were exposed to nicotine cartridges and refill products had increased by approximately 1500% during the study period (23). Children who were exposed to these products were 2.6 times more likely than children who were exposed to traditional tobacco products to have severe symptoms and 5.2 times more likely to be admitted to a health care facility (22). Researchers noted that the packaging, colours and flavours of these products might have increased their appeal to children (23). The American Association of Poison Control Centers used the data collected in the National Poison Data System to advocate for stronger regulation of these products (6). Amendments to the Federal Food, Drug, and Cosmetic Act in 2016 gave the Food and Drug Administration authority to regulate ENDS and associated products, which has resulted in the introduction of industry requirements for marketing, packaging and sales (24, 25).
Examples of educational and campaign activities for prevention include:
• general campaigns on poisoning prevention, perhaps at fixed dates during the year (such as a regular
“poisoning prevention week”) or at high-risk periods, for example, warning against eating wild mushrooms during the autumn;
• posters demonstrating the dangers of poisoning by household products;
• booklets identifying poisonous fungus, plant and animal species; and
• booklets identifying specific groups at risk (such as pregnant women, or rural workers who use pesticides).
The methods used for preventing and generating awareness of poisoning should be adapted to the national situation and circumstances. Media and communications experts can ensure that the messages used are clearly understandable and attractive. Establishment of a multidisciplinary group of professionals to review data on poisonings and to prioritize and plan poisoning prevention activities can be valuable. See Annex 4 for a description of the Canadian community of practice for toxicovigilance and prevention.