Prevention of poisoning – safe storage of pesticides in developing countries 1 Department of International Health, University of Copenhagen 2 South Asian Clinical Toxicology Research Collaboration 3 Center for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, England. 4 Department of Clinical Medicine, University of Peradeniya, Sri Lanka. 5 School of Population Health, University of Newcastle Australia Flemming Konradsen 1,2, Ravi Pieris 2, Manjula Weerasinghe 2, Wim van der Hoek 1, Michael Eddleston 2,3 and Andrew H. Dawson 2,4,5

Rationale for safe storage The majority of self-poisoning episodes follow impulsive acts of self-harm, where the ready availability of highly toxic pesticides in the farming households will result in a high proportion of deaths from such attempts (Eddleston & Phillips, 2004; Konradsen et al., 2006)

Safe Storage WHO Pesticides and Health Initiative (point 5.5) “Promote safe storage that limits impulsive access to pesticides for self-harm” FAO in the International Code of Conduct on the Distribution and Use of Pesticides “5.1/ Governments should: make provisions for safe storage of pesticides at both warehouse and farm level” Keeping pesticides under lock and key promoted as one of the key strategies to reduce number of impulsive self-poisoning episodes, examples below:

Safe Storage (cont’d.) CropLife, in their guidelines for the safe and effective use of crop protection products “Storage: crop protection products must always be stored securely to ensure that they are kept away from children and unauthorized persons..” and ”.. store crop protection products separately, preferably in a separate building and under lock and key..” Croplife image

Background Previous studies in Sri Lanka have shown high community acceptance of in-house pesticide storage boxes ( Ratnayeke, 2006; Konradsen et al, 2007) Studies in north central Sri Lanka found an increased storage of pesticides in the homes and less in the field following the introduction of in- house storage devices

Background Safe storage devices needs to be developed that will allow the farmers to store pesticides in the field during the cultivation season Pesticide storage boxes developed during the pilot stage was not sufficiently strong to prevent individuals to gain access to the pesticides when attempting self-harm The introduction of storage devices increased safe storage of pesticides in the short term but surveys needs to be made to assess long term use

Baseline – Observations

Objectives To determine how different in-house and in- field pesticide safe storage devices influences community acceptance, use and pesticide storage practices To assess use of in-house storage devices 24 months after the initial distribution To identify ways to improve on the technical design of in-field devices and locking systems

Methods Two study villages in North Central Sri Lanka

In-house safe storage devices Device made of metal Large device made of mango wood Small device made of mango wood

Safe storage devices Pine device Concrete device

Methods Baseline survey Distribution of storage devices and promotion of use 200 households in two villages received in-house safe storage devices and was followed up after seven months and 24 months 195 households in two villages received either an in- house or an in-field safe storage device and was followed up after seven months Focus group discussions and transect walks In-depth interviews with key informants

Definition of exclusively use of pesticide safe storage device: All pesticides stored in the device and device locked No pesticides visible in the home and home garden areas Household members reporting that no pesticides stored in the field

Findings - use Overall storage of pesticides under lock increased from the baseline level of 2-3% to a minimum of 66% after seven months A gradual decline was found among the households that were followed for 24 months where, in some villages, only less than half the households used the locked device after two years

Findings – location of storage The introduction of storage devices, both in-field and in-house, significantly reduced the storage of pesticides hidden in the field. This resulted in pesticides being stored either in or near the house giving rise to concerns that this shift may increase its availability among vulnerable individuals.

Utilization of safe storage devices among 368 households using pesticides at the time of survey Type of device No. of households with device No. of households using pesticides at the time of survey No. of households with locked devices* No. of households with unlocked devices After 7 months After 24 months After 7 months After 24 months After 7 months After 24 months Large device made of mango wood (78%)20 (63%)7 (22%)12 (37%) Small device made of mango wood (83%)42 (57%)14 (17%)31 (43%) Device made of pinewood 5653*38 (72%)*15 (28%)* Device made of metal (82%)27 (48%)10(18%)29 (52%) In-field device made of concrete *68 (66%)*35 (34%)*

Findings – design options The preferred design influenced by occupational and agricultural factors such as land size, distance to fields, crop patterns and types and the quantity of pesticides used and it is clear that one design will not suit all farmers When farmers lease land or have land in different locations not feasible to use in-field devices Material of devices important for households in relation to protection of costly pesticides (theft) and prevention of easy access to pesticides (self-harm/accidents) The in-field design was not sufficiently strong and especially the lock was not adequate to withstand the conditions in the field

Findings – managing the key Some farmers do not consider keeping the device locked to be important as they think self-poisoning would not occur in their household Difficult to find a place within the household to keep key out of sight of other household members Keeping the key away from other family members was a big challenge to farmers: at the 24 month follow-up it was revealed that in 57% (n=42) of the households the children could find key within minutes Padlocks found to be impractical to use when pesticides was applied frequently The keeper of the key is vulnerable to easy access to pesticides

Regular access to the hidden key increased the chances of the hiding place being spotted by other family members Key easily accessible to all Key in the padlock Deliberately hiding the

Acute Poisoning Cases 12 cases of acute pesticide reported  Total population in the two villages - around 1900  Four cases at the seven month follow-up and eight cases at 24 month follow-up Seven families had received a device  [ 2 deaths – key responsible person] [ 1 – unlocked device]  [ 1 – forced and opened] [ 2 – pesticides obtained from outlets]  [ 1 – No clear information] Four failed attempts owing to device

Conclusions Provision of in-house safe storage devices had high community acceptance and utilization, especially in the short-term Provision of only in-house devices appears to encourage farmers to store pesticides at home, which may increase domestic risk of impulsive self-poisoning episodes The ability of other household members, especially children, to find the key easily is worrying

The person in charge of the key is vulnerable to easy access of pesticides Hiding the key from other family members was still a big challenge to farmers Improvement of locking mechanism would be one of the best options to switch non-users to users Device had posed some barrier for self-poisoning episodes Conclusions (cont’d)

Acute Poisoning Cases 14 cases of acute pesticide reported Seven families had received a device  [ 2 deaths – key responsible person] [ 1 – unlocked device]  [ 1 – forced and opened] [ 2 – pesticides obtained from outlets]  [ 1 – No clear information] Four failed attempts owing to device

Poisoning attempts

Conclusions Provision of in-house safe storage devices had high community acceptance and utilization, especially in the short-term The introduction of in-field devices was not sufficient to reduce storage in or close to the homes Storage of pesticides at home, may increase domestic risk of impulsive self-poisoning episodes

Conclusions (cont’d) The ability of other household members, especially children, to find the key easily is worrying The person in charge of the key is vulnerable to easy access of pesticides Device had posed some barrier for self-poisoning episodes

Acknowledgment We acknowledge the financial support provided by both the South Asian Clinical Toxicology Research Collaboration Research grant (Wellcome Trust/NHMRC International Collaboration Research Grant GR071669MA) and the Danish Development Agency, DANIDA (104.Dan.8-902).

Next applications…. UV resistant plastic design Modified concrete design

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