ABSTRACT:

Background:

Pesticide poisoning causes high morbidity and mortality. Surveillance is required for post-marketing monitoring of these products.

Aim:

To assess poisonings and associated factors with lethality by pesticides.

Method:

This is a case-control study based on the cases of pesticide poisoning assisted in 2017 by Brazilian Poison Control Centers. Patients who died were the cases and the survivors, the control. The odds ratio (OR) of death and 95% confidence interval (CI) were calculated. From the regression model, a predictive model of death was developed, stratified by age, gender and occupational context to investigate the risk of agricultural workers poisoned by extremely hazardous agents.

Results:

3,826 patients poisoned by pesticides were identified, of which 146 died. Older people (OR = 4.94; 95%CI 2.49 - 9.80), males (OR = 1.68; 95%CI 1.15 - 2.46), agricultural workers (OR = 2.20; 95%CI 1.15 - 4.24), suicide attempts (OR = 13.27; 95%CI 6.48 - 27.19) and exposure to extremely hazardous products (OR = 2.77; 95%CI 1.84 - 4.16) odds of death from pesticide poisoning.

Conclusion:

Out of 100 pesticides poisoning, four died. Elderly, males, working in the agricultural sector, suicide attempts and extremely hazardous products had a higher risk of death.

Keywords:
Pesticides; Agrochemicals; Poisoning; Mortality; Poison control centers; Case-control studies

INTRODUCTION

Pesticide poisoning is an important cause of morbidity and mortality that goes beyond occupational and environmental contexts. These agents are estimated to be involved in 10 to 20% of suicides worldwide, with a high burden of disease on mental health¹1. Mew EJ, Padmanathan P, Konradsen F, Eddleston M, Chang SS, Phillips MR, et al. The global burden of fatal self-poisoning with pesticides 2006-15: Systematic review. J Affect Disord 2017; 219: 93-104. https://doi.org/10.1016/j.jad.2017.05.002
https://doi.org/https://doi.org/10.1016/... . Restricting access to highly hazardous products through regulatory enforcement reduces poisonings, suicide attempts and related mortality²2. Gunnell D, Knipe D, Chang SS, Pearson M, Konradsen F, Lee WJ, et al. Prevention of suicide with regulations aimed at restricting access to highly hazardous pesticides: a systematic review of the international evidence. Lancet Glob Health 2017; 5(10): e1026-e37. https://doi.org/10.1016/S2214-109X(17)30299-1
https://doi.org/https://doi.org/10.1016/... ^,33. Cha ES, Chang SS, Choi Y, Lee WJ. Trends in pesticide suicide in South Korea, 1983-2014. Epidemiol Psychiatr Sci 2020; 29: 1-9. https://doi.org/10.1017/S2045796019000118
https://doi.org/https://doi.org/10.1017/... .

Surveillance of the use of pesticides is necessary to monitor the activities involving these compounds, from production, transportation, storage, marketing to their use. The report of poisonings assisted by poison control centers (centros de informação e assistência toxicológica - CIATox) is a significant source for monitoring in the post-marketing phase of products and is routinely employed in developed countries⁴4. Wang A, Law R, Lyons R, Choudhary E, Wolkin A, Schier J. Assessing the public health impact of using poison center data for public health surveillance. Clin Toxicol (Phila) 2018; 56(7): 646-52. https://doi.org/10.1080/15563650.2017.1413194
https://doi.org/https://doi.org/10.1080/... ^,55. Brett J, Wylie CE, Raubenheimer J, Isbister GK, Buckley NA. The relative lethal toxicity of pharmaceutical and illicit substances: A 16-year study of the Greater Newcastle Hunter Area, Australia. Br J Clin Pharmacol 2019; 85(9): 2098-107. https://doi.org/10.1111/bcp.14019
https://doi.org/https://doi.org/10.1111/... .

Despite the high consumption of pesticides⁶6. Brasil. Ministério do Meio Ambiente. IBAMA. Relatórios de comercialização de agrotóxicos. Brasília: IBAMA; 2019., Brazil lacks analyses to support public policies that mitigate the damage caused by these products. National research on pesticide poisoning is restricted to one location or is of an ecological nature, with less causal power⁷7. Pignati WA, Lima F, Lara SS, Correa MLM, Barbosa JR, Leão L, et al. Spatial distribution of pesticide use in Brazil: a strategy for Health Surveillance. Ciênc Saúde Coletiva 2017; 22(10): 3281-93. https://doi.org/10.1590/1413-812320172210.17742017
https://doi.org/https://doi.org/10.1590/... ^,88. Queiroz PR, Lima KC, Oliveira TC, Santos MMD, Jacob JF, Oliveira A. Notifiable Diseases Information System and human poisoning by pesticides in Brazil. Rev Bras Epidemiol 2019; 22: e190033. https://doi.org/10.1590/1980-549720190033
https://doi.org/https://doi.org/10.1590/... . Investigations with individual and nationwide data have the potential to contribute with better quality evidence on the topic.

This research aimed to analyze pesticide poisoning attended by Brazilian CIATox in 2017 and the factors associated with death from these products.

METHOD

STUDY DESIGN

This is a case-control study carried out based on pesticide poisoning assisted by CIATox that were registered in the Brazilian Poison Data System (Datatox) in 2017.

SETTING

CIATox are units of the Unified Health System (Sistema Único de Saúde - SUS), members of the Trauma Care Line, of the SUS Urgency and Emergency Care Network⁹9. Brasil. Ministério da Saúde. Portaria nº 1.678, de 2 de outubro de 2015. Institui os Centros de Informação e Assistência Toxicológica (CIATox) como estabelecimento de saúde integrantes da Linha de Cuidado ao Trauma, da Rede de Atenção as Urgências e Emergências no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União 2015: 55-6.. They work 24 hours a day, seven days a week, to guide the management of poisonings, and follow up until the case is resolved, in person or remotely.

For real-time recording of cases attended to, the Brazilian Association of Toxicological Information Centers developed Datatox, through a research project in partnership with the Telemedicine Laboratory of the Federal University of Santa Catarina¹⁰10. Alves JM, Albino DBL, Resener MC, Zannin M, Savaris A, Wangenheim CG, et al., editores. Quality Evaluation of Poison Control Information Systems: A Case Study of the DATATOX System. In: IEEE 29th International Symposium on Computer-Based Medical Systems (CBMS); 2016. 2016.^,1111. ABRACIT. DATATOX. Sistema Brasileiro de Dados de Intoxicações [Internet]. 2018 [acessado em 4 fev. 2020]. Disponível em: Disponível em: http://datatox.abracit.org.br
http://datatox.abracit.org.br... . The system was structured as a database of agents down to the substance level (active agent principle), which enables the correct classification of the products involved and avoids standardization problems previously mentioned in the literature¹²12. Galvao TF, Pereira MG. [ Standardization of toxicological information in Brazil]. Ciênc Saúde Coletiva 2011; 16(8): 3633-4. http://dx.doi.org/10.1590/S1413-81232011000900030
https://doi.org/http://dx.doi.org/10.159... . The registration of images, symptoms, details of exposures, guidance given to the applicant and clinical evolution is privileged in the system.

PARTICIPANTS

All patients assisted by Brazilian CIATox due to poisoning by pesticides in 2017 and registered with Datatox were included. The group of cases was made up by patients who evolved to death, and the control group, by those who survived poisoning, since they were originally from the same population. There were no exclusion criteria, and incomplete data were treated separately as “not informed”.

VARIABLES

The following independent variables were included: age group (0-19; 20-39; 40-59, ≥ 60 years of age), sex (male, female), occupational context (agricultural sector/other), suicide attempt (yes, no), toxicity of the pesticide (highly; highly/moderately/slightly toxic), signs/symptoms and oral route (yes, no). The occupational context was grouped into workers in the agricultural area (multipurpose family farmer, agronomist, agropecuarista, agricultural applicator, insecticide applicator, agricultural assistant, rancher, orange picker, pest control, agriculture day laborer, farmer, vegetable horticulturist, plowman, agricultural machine operator, agricultural pilot, rural producer, rural worker and agricultural tractor) and other workers/those who do not work.

The toxicity of the pesticide was classified as recommended by the National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária - Anvisa) at the time of care¹³13. Agência Nacional de Vigilância Sanitária. Regulariação de Produtos. Agrotóxicos [Internet]. Brasil: ANVISA; 2019 [acessado em 27 jul. 2019]. Disponível em: Disponível em: http://portal.anvisa.gov.br/registros-e-autorizacoes/agrotoxicos/produtos/monografia-de-agrotoxicos
http://portal.anvisa.gov.br/registros-e-... : class I (extremely hazardous), class II (highly hazardous), class III (moderately hazardous), and class IV (slightly hazardous). Pesticides were also classified according to the most relevant chemical and/or action group (cholinesterase inhibitors, herbicides, pyrethroids, other insecticides, etc.), according to the frequency of the group.

STATISTICAL METHODS

The cases and controls were described in terms of age, sex, occupational context, motivation, toxicity, route of exposure, pesticides, and symptoms. To investigate the factors associated with death, the odds ratio (OR) was used as a measure of association, with a 95% confidence interval (CI). A direct acyclic graph was built to guide statistical analysis. The unadjusted OR of deaths were calculated by the following independent variables, obtained by logistic regression: age group, sex, agricultural sector, suicide attempt, and toxicity of the pesticide.

In each regression, the Akaike information criterion (AIC) and the Schwarz Bayesian information criterion (BIC) were also obtained, both based on the likelihood ratio test¹⁴14. Long JS, Freese J. Regression Models for Categorical Dependent Variables Using Stata. 3ª ed. College Station: Stata Press; 2014.. Multicollinearity was attributed if the variables had values of variance inflation factors (VIF) greater than 10¹⁵15. Belsley DA, Kuh E, Welsch RE. Regression diagnostics: identifying influential data and sources of collinearity. Nova Jersey: Wiley; 1980.. The variables without multicollinearity were included in a logistic regression model (adjusted analysis), in which the previously obtained AIC and BIC values were compared.

Through the regression model, a predictive model of death was developed, stratified by age group, sex and suicide attempt, to investigate the risk of workers in the agricultural sector and the toxicity of the pesticide. All analyses were performed using the Stata 14.2 program (Stata Corporation, College Station, TX, United States).

ETHICAL ASPECTS

The research project was approved by the Research Ethics Committee of the State University of Campinas (Opinion No. 3.395.121, of June 17, 2019; Certificate of Presentation for Ethical Appreciation - CAAE 12896719.2.0000.5404).

RESULTS

3,826 patients poisoned by pesticides were included, of whom 146 (3.8%; 95%CI 3.2 - 4.4%) died (case group). Most of the poisonings occurred in adults (20-59 years), men, in an occupational context unrelated to the agricultural sector, and due to suicide attempt (Table 1). In comparison to the control group, the group of cases had a higher proportion of men and individuals aged 40 years old or older.

Pesticides from the cholinesterase inhibitor group were involved in 37.3% of the poisonings (95%CI 35.8 - 38.8%), followed by herbicides (22.7%, 95%CI 21.4 - 24.0%) and pyrethroid insecticides (18.6%, 95%CI 17.5 - 19.8%) (Table 2). Chumbinho [anti-cholinesterase agent illegally used as rodenticide in Brazil] (24.8%, 95%CI 23.5 - 26.1%); glyphosate (12.5%, 95%CI 11.6 - 13.6%) and deltamethrin (6.1%, 95%CI 5.4 - 6.9%) were the most frequent agents. Paraquat had the highest lethality (28.8%, 95%CI 21.8 - 37.0%). Among the cases of death, compared to the control, the extremely hazardous agents, chumbinho , paraquat, glyphosate, and 2,4-D presented the highest frequency.

Gastrointestinal disorders (vomiting, nausea, diarrhea, and epigastric pain) were the most common symptoms of poisoning (24.2%, 95%CI 23.3 - 25.2%). More severe symptoms, such as changes in the level of consciousness, hypotension, coma, respiratory failure and cardiorespiratory arrest, occurred in 5.3% (95%CI 4.9 - 5.8%) of poisonings (Table 3). The following signs and symptoms were observed only in deaths: rhabdomyolysis (n = 4), acute respiratory distress syndrome (n = 3), bacterial sepsis (n = 2), muscle concussion (n = 1), aphasia (n = 1), areflexia (n = 1), disseminated intravenous coagulation (n = 1), hydroelectrolytic disorder (n = 1), subcutaneous emphysema (n = 1), ventricular fibrillation (n = 1), and compartment syndrome (n = 1 ).

The elderly, male, workers in the agricultural sector, suicide attempts and extremely hazardous agents increased the odds of death after adjustments (Table 4). Multicollinearity was negligible in the variables included in the adjusted analysis (VIF <10). The values of AIC (997.0) and BIC (1,056.6) were lower in the adjusted analysis in all variables compared to the unadjusted analyzes (AIC = 1,077.9 - 1,244.0; BIC = 1,092.8 - 1,259, 0), which suggests consistency in the model adopted. A higher probability of death was observed among men working in the agricultural sector attempting suicide (Figure 1).

DISCUSSION

Pesticides caused death in four out of every 100 people treated by CIATox in 2017 due to poisoning, with a greater odds of death in men, the elderly, workers in the agricultural sector, who attempted suicide, and used extremely hazardous toxic products.

The present analysis is based on cases assisted and recorded by CIATox mainly in an emergency context, in which the priority is to guide the management of the case or to treat the poisoning itself. Failure to record calls can occur and represent information bias. It is possible that the poisonings referred to CIATox are the most severe ones, coming from health services, which indicates selection bias. Under-representation of chronic and occupational poisoning by pesticides, whose clinical association is generally neglected, may have occurred in the present sample¹⁶16. Faria NMX, Fassa AG, Facchini LA. Intoxicação por agrotóxicos no Brasil: os sistemas oficiais de informação e desafios para realização de estudos epidemiológicos. Ciênc Saúde Coletiva 2007; 12(1): 25-38. http://dx.doi.org/10.1590/S1413-81232007000100008
https://doi.org/http://dx.doi.org/10.159... ^,1717. Oliveira-Silva JJ, Meyer A. O sistema de notificação das intoxicações: o fluxograma da joeira. In: Peres F, Moreira JC, editores. É veneno ou é remédio. Rio de Janeiro: Fiocruz; 2003. p. 317-26.. In spite of this, the assessment of data from these services is a health surveillance tool widely used in different contexts¹⁸18. Bentur Y, Lurie Y, Cahana A, Bloom-Krasik A, Kovler N, Neuman G, et al. Poisoning in Israel: Annual Report of the Israel Poison Information Center, 2017. Isr Med Assoc J 2019; 21(3): 175-82.^,1919. Gummin DD, Mowry JB, Spyker DA, Brooks DE, Osterthaler KM, Banner W. 2017 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 35th Annual Report. Clin Toxicol (Phila) 2018: 56(12): 1213-415. https://doi.org/10.1080/15563650.2018.1533727
https://doi.org/https://doi.org/10.1080/... ^,2020. Perry L, Adams RD, Bennett AR, Lupton DJ, Jackson G, Good AM, et al. National toxicovigilance for pesticide exposures resulting in health care contact - An example from the UK’s National Poisons Information Service. Clin Toxicol (Phila) 2014; 52(5): 549-55. https://doi.org/10.3109/15563650.2014.908203
https://doi.org/https://doi.org/10.3109/... . The present research is the first effort to analyze national data with the clinical details that the CIATox services allow.

Poisonings treated in health services are mandatory to be reported in the Notifiable Diseases Information System (SINAN), according to the Ordinance of the Minister’s ­Office/­Ministry of Health (GM/MS) No. 204/2016. This notification system has an open field for the substance, and there may be variations or typing errors that make it impossible for the agent to mine data. Through SINAN reports, it is possible to know the national number of poisonings by a given group of agents, without further clinical details or the active principle involved. Datatox’s poisonings come from CIATox that adopted this system to record their attendance and also include cases managed outside of health services. Access to CIATox requires that the person in need of assistance - health professional or not - knows the service and contacts it voluntarily. Although CIATox are free and work around the clock, the cases handled by these centers are likely to have limited representativeness.

The toxicity of pesticides was based on the Anvisa classification in force at the time of the poisonings¹³13. Agência Nacional de Vigilância Sanitária. Regulariação de Produtos. Agrotóxicos [Internet]. Brasil: ANVISA; 2019 [acessado em 27 jul. 2019]. Disponível em: Disponível em: http://portal.anvisa.gov.br/registros-e-autorizacoes/agrotoxicos/produtos/monografia-de-agrotoxicos
http://portal.anvisa.gov.br/registros-e-... . The modification of criteria by the agency carried out in 2019 considers in the top hazardous class products that lead to death in acute exposure and removes those that cause eye damage, such as blindness, as well as skin irritations, allergies, asthma, and breathing difficulties²¹21. Agência Nacional de Vigilância Sanitária. RDC nº 294, de 29 de julho de 2019 - Dispõe sobre os critérios para avaliação e classificação toxicológica, priorização da análise e comparação da ação toxicológica de agrotóxicos, componentes, afins e preservativos de madeira, e dá outras providências. Brasil: Agência Nacional de Vigilância Sanitária; 2019.. This modification reduces the number of products considered extremely hazardous and the respective control and evaluation mechanisms, in addition to artificially indicate higher safety of the products²²22. Moraes RF. Agrotóxicos no Brasil: padrões de uso, política da regulação e prevenção da captura regulatória. 2019. https://doi.org/10.13140/RG.2.2.12874.72645
https://doi.org/https://doi.org/10.13140... . The weakening of regulation and the growing approval of highly hazardous products increase the risks for the Brazilian population, especially for the most vulnerable ones²³23. Brasil. Instituto de Pesquisa Econômica Aplicada. TD 2506 - Agrotóxicos no Brasil: padrões de uso, política da regulação e prevenção da captura regulatória. Brasil: Instituto de Pesquisa Econômica Aplicada; 2019..

There was a high mortality in pesticide poisoning attended by Brazilian CIATox. The severity and difficulty of treating these poisonings reflect greater lethality²⁴24. Eddleston M, Karalliedde L, Buckley N, Fernando R, Hutchinson G, Isbister G, et al. Pesticide poisoning in the developing world--a minimum pesticides list. Lancet 2002; 360(9340): 1163-7. https://doi.org/10.1016/s0140-6736(02)11204-9
https://doi.org/https://doi.org/10.1016/... , especially when caused by extremely hazardous agents.

Higher risk of death was observed among men, similarly to the study conducted in India in 2007²⁵25. Bose A, Sandal Sejbaek C, Suganthy P, Raghava V, Alex R, Muliyil J, et al. Self-harm and self-poisoning in southern India: choice of poisoning agents and treatment. Trop Med Int Health 2009; 14(7): 761-5. https://doi.org/10.1111/j.1365-3156.2009.02293.x
https://doi.org/https://doi.org/10.1111/... . Occupations with greater contact with pesticides are carried out largely by men²⁶26. World Health Organization. World Health Statistics 2019: Monitoring health for the SDGs [Internet]. World Health Organization; 2019 [acessado em 4 fev. 2020]. Disponível em: Disponível em: https://www.who.int/gho/publications/world_health_statistics/2019/en/
https://www.who.int/gho/publications/wor... ^,2727. Hendges C, Schiller ADP, Manfrin J, Macedo EK, Jr., Goncalves AC, Jr., Stangarlin JR. Human intoxication by agrochemicals in the region of South Brazil between 1999 and 2014. J Environ Sci Health B 2019; 54(4): 219-25. https://doi.org/10.1080/03601234.2018.1550300
https://doi.org/https://doi.org/10.1080/... , which may explain the greater exposure among these individuals. The impact of these deaths on this economically active population must also be taken into account. The odds of death - already adjusted for age and other factors - was also higher in the elderly, which is similar to the research that found more cases of suicide in divorced or widowed people, residents of smaller municipalities, and in areas with intensive use of pesticides²⁶26. World Health Organization. World Health Statistics 2019: Monitoring health for the SDGs [Internet]. World Health Organization; 2019 [acessado em 4 fev. 2020]. Disponível em: Disponível em: https://www.who.int/gho/publications/world_health_statistics/2019/en/
https://www.who.int/gho/publications/wor... ^,2727. Hendges C, Schiller ADP, Manfrin J, Macedo EK, Jr., Goncalves AC, Jr., Stangarlin JR. Human intoxication by agrochemicals in the region of South Brazil between 1999 and 2014. J Environ Sci Health B 2019; 54(4): 219-25. https://doi.org/10.1080/03601234.2018.1550300
https://doi.org/https://doi.org/10.1080/... .

Suicide had the highest measure of association in the present analysis and proved to be a strong predictor of death in pesticide poisoning. Ecological analysis with data from the Brazilian Mortality Information System from 1996 to 2010 observed 4.2 times more suicides with pesticides among men than among women²⁸28. Faria NM, Fassa AG, Meucci RD. Association between pesticide exposure and suicide rates in Brazil. Neurotoxicology 2014; 45: 355-62. https://doi.org/10.1016/j.neuro.2014.05.003
https://doi.org/https://doi.org/10.1016/... . In developing countries, the use of pesticides in suicide attempts has a high mortality²⁴24. Eddleston M, Karalliedde L, Buckley N, Fernando R, Hutchinson G, Isbister G, et al. Pesticide poisoning in the developing world--a minimum pesticides list. Lancet 2002; 360(9340): 1163-7. https://doi.org/10.1016/s0140-6736(02)11204-9
https://doi.org/https://doi.org/10.1016/... , representing one third of the total numbers²⁹29. World Health Organization. Safer Access to pesticides for suicide prevention. Experiences from community interventions. Genebra: World Health Organization; 2016., and is more frequent in underdeveloped countries³⁰30. World Health Organization. The public health impact of chemicals: knowns and unknowns. Genebra: World Health Organization ; 2016. and by highly hazardous agents³¹31. Swiderska A, Wisniewski M, Wiergowski M, Krakowiak A, Sein Anand J. Poisonings in Poland reported to the Polish National Health Fund in the years 2009-2011. BMC Pharmacol Toxicol 2018; 19: 62. https://doi.org/10.1186/s40360-018-0254-x
https://doi.org/https://doi.org/10.1186/... ^,3232. Chowdhury FR, Dewan G, Verma VR, Knipe DW, Isha IT, Faiz MA, et al. Bans of WHO Class I Pesticides in Bangladesh-suicide prevention without hampering agricultural output. Int J Epidemiol 2018; 47(1): 175-84. https://doi.org/10.1093/ije/dyx157
https://doi.org/https://doi.org/10.1093/... . In addition to emotional losses, these deaths have an economic impact as they mainly affect the most productive part of society.

Some factors such as failure in productivity, financial problems, emotional problems, domestic arguments, and depression stood out among the triggers for suicide attempts³³33. Eddleston M, Phillips MR. Self poisoning with pesticides. BMJ 2004; 328(7430): 42-4. https://doi.org/10.1136/bmj.328.7430.42
https://doi.org/https://doi.org/10.1136/... . Exposure to pesticides - many of which are proven to be neurotoxic - causes behavioral changes, emotional and affective disorders, and is sufficient cause to increase suicidal ideation³⁴34. Kori RK, Singh MK, Jain AK, Yadav RS. Neurochemical and Behavioral Dysfunctions in Pesticide Exposed Farm Workers: A Clinical Outcome. Indian J Clin Biochem 2018; 33(4): 372-81. https://doi.org/10.1007/s12291-018-0791-5
https://doi.org/https://doi.org/10.1007/... . Easy access to agents is associated with high rates of poisoning and death, and favors suicide attempts²³23. Brasil. Instituto de Pesquisa Econômica Aplicada. TD 2506 - Agrotóxicos no Brasil: padrões de uso, política da regulação e prevenção da captura regulatória. Brasil: Instituto de Pesquisa Econômica Aplicada; 2019.^,2424. Eddleston M, Karalliedde L, Buckley N, Fernando R, Hutchinson G, Isbister G, et al. Pesticide poisoning in the developing world--a minimum pesticides list. Lancet 2002; 360(9340): 1163-7. https://doi.org/10.1016/s0140-6736(02)11204-9
https://doi.org/https://doi.org/10.1016/... . The pesticides bans effectively prevents suicide by these products and also occurrences caused by accidental exposures³3. Cha ES, Chang SS, Choi Y, Lee WJ. Trends in pesticide suicide in South Korea, 1983-2014. Epidemiol Psychiatr Sci 2020; 29: 1-9. https://doi.org/10.1017/S2045796019000118
https://doi.org/https://doi.org/10.1017/... ^,2828. Faria NM, Fassa AG, Meucci RD. Association between pesticide exposure and suicide rates in Brazil. Neurotoxicology 2014; 45: 355-62. https://doi.org/10.1016/j.neuro.2014.05.003
https://doi.org/https://doi.org/10.1016/... . The withdrawal of these products from the market, even in poor countries, reduced deaths due to suicide attempts, without loss of agricultural or economic productivity³²32. Chowdhury FR, Dewan G, Verma VR, Knipe DW, Isha IT, Faiz MA, et al. Bans of WHO Class I Pesticides in Bangladesh-suicide prevention without hampering agricultural output. Int J Epidemiol 2018; 47(1): 175-84. https://doi.org/10.1093/ije/dyx157
https://doi.org/https://doi.org/10.1093/... ^,3535. World Health Organization. Preventing suicide: a resource for pesticide registrars and regulators. Genebra: World Health Organization / Food and Agriculture Organization of the United Nations; 2019.^,3636. Knipe DW, Chang SS, Dawson A, Eddleston M, Konradsen F, Metcalfe C, et al. Suicide prevention through means restriction: Impact of the 2008-2011 pesticide restrictions on suicide in Sri Lanka. PLoS One 2017; 12(3): e0172893. https://doi.org/10.1371/journal.pone.0172893
https://doi.org/https://doi.org/10.1371/... , and is recommended worldwide as a simple, low-cost and effective measure to prevent suicide, especially in the economically active population³⁵35. World Health Organization. Preventing suicide: a resource for pesticide registrars and regulators. Genebra: World Health Organization / Food and Agriculture Organization of the United Nations; 2019.. Such robust evidence must be considered in Brazil to modify the present scenario.

Glyphosate, dichlorophenoxyacetic acid (2,4-D) and paraquat are among the most commercialized and used pesticides in Brazil⁶6. Brasil. Ministério do Meio Ambiente. IBAMA. Relatórios de comercialização de agrotóxicos. Brasília: IBAMA; 2019.^,77. Pignati WA, Lima F, Lara SS, Correa MLM, Barbosa JR, Leão L, et al. Spatial distribution of pesticide use in Brazil: a strategy for Health Surveillance. Ciênc Saúde Coletiva 2017; 22(10): 3281-93. https://doi.org/10.1590/1413-812320172210.17742017
https://doi.org/https://doi.org/10.1590/... and were responsible for a high number of deaths in this investigation, reflecting the extensive use of herbicides in monocultures. Chumbinho - illegal rodenticide based on carbamate and organophosphate anticholinesterase agents - also showed high lethality in this and previous analyzes³⁷37. Cruz CC, Carvalho FN, Costa VÍB, Sarcinelli PN, Silva JJO, Martins TS, et al. Epidemiological profile of Aldicab poisoning registered by the Forensic Medical Institute in the State of Rio de Janeiro from 1998 to 2005. Cad Saúde Coletiva 2013; 21(1): 63-70. http://dx.doi.org/10.1590/S1414-462X2013000100010
https://doi.org/http://dx.doi.org/10.159... ^,3838. Nelson LS, Perrone J, DeRoos F, Stork C, Hoffman RS. Aldicarb poisoning by an illicit rodenticide imported into the United States: Tres Pasitos. J Toxicol Clin Toxicol 2001; 39(5): 447-52. https://doi.org/10.1081/clt-100105414
https://doi.org/https://doi.org/10.1081/... . Despite the prohibition of its commercialization, it is probably of easy access, which requires effective control measures³²32. Chowdhury FR, Dewan G, Verma VR, Knipe DW, Isha IT, Faiz MA, et al. Bans of WHO Class I Pesticides in Bangladesh-suicide prevention without hampering agricultural output. Int J Epidemiol 2018; 47(1): 175-84. https://doi.org/10.1093/ije/dyx157
https://doi.org/https://doi.org/10.1093/... ^,3636. Knipe DW, Chang SS, Dawson A, Eddleston M, Konradsen F, Metcalfe C, et al. Suicide prevention through means restriction: Impact of the 2008-2011 pesticide restrictions on suicide in Sri Lanka. PLoS One 2017; 12(3): e0172893. https://doi.org/10.1371/journal.pone.0172893
https://doi.org/https://doi.org/10.1371/... . The sale of illegal products may explain the lethality found³⁷37. Cruz CC, Carvalho FN, Costa VÍB, Sarcinelli PN, Silva JJO, Martins TS, et al. Epidemiological profile of Aldicab poisoning registered by the Forensic Medical Institute in the State of Rio de Janeiro from 1998 to 2005. Cad Saúde Coletiva 2013; 21(1): 63-70. http://dx.doi.org/10.1590/S1414-462X2013000100010
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https://doi.org/http://dx.doi.org/10.512... . Comprehensive environmental policies, rigorous evaluation of new pesticides and banning products with greater toxicity would reduce poisoning, preventable deaths and costs with treatments and sequelae without affecting food production³²32. Chowdhury FR, Dewan G, Verma VR, Knipe DW, Isha IT, Faiz MA, et al. Bans of WHO Class I Pesticides in Bangladesh-suicide prevention without hampering agricultural output. Int J Epidemiol 2018; 47(1): 175-84. https://doi.org/10.1093/ije/dyx157
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https://doi.org/https://doi.org/10.1371/... .

When analyzing the frequency of the main signs and symptoms, there are more severe signs, such as rhabdomyolysis, acute respiratory distress syndrome, sepsis and ventricular fibrillation, which require greater urgency and emergency care and are associated with the worst outcome⁴⁰40. Moon JM, Chun BJ. Predicting acute complicated glyphosate intoxication in the emergency department. Clin Toxicol (Phila) 2010; 48(7): 718-24. https://doi.org/10.3109/15563650.2010.488640
https://doi.org/https://doi.org/10.3109/... . In the elderly population, these effects represent a worse prognosis, due to kinetic and dynamic changes in their physiological functions⁴¹41. Kim YH, Lee JH, Cho KW, Lee DW, Kang MJ, Lee KY, et al. Prognostic Factors in Emergency Department Patients with Glyphosate Surfactant Intoxication: Point-of-Care Lactate Testing. Basic Clin Pharmacol Toxicol 2016; 119(6): 604-10. https://doi.org/10.1111/bcpt.12624
https://doi.org/https://doi.org/10.1111/... .

CONCLUSION

For every 100 people poisoned by pesticides in 2017, four died. Lethality is higher in suicide attempts, in men, in the agricultural sector, and in extremely toxic hazardous pesticides. Restriction of registration and banning of dangerous pesticides would reduce deaths from these poisonings in the country.

ACKNOWLEDGMENTS

The authors thank the following CIATox for collecting research data: Amazonas, Goiás, Campina Grande/PB, Ceará, Bahia, Pernambuco, Rio Grande do Norte, Espírito Santo, Campinas/SP, Ribeirão Preto/SP, São José do Rio Preto/SP, São Paulo/SP, Curitiba/PR, Londrina/PR, and Santa Catarina.

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