Microsoft word - annual report201

Swedish Poisons Information Centre
Unit in Medical Products Agency
Tasks Connected to the Telephone Service Comments to the Annual Report
2011 IN BRIEF The Swedish Poisons Information Centre (SPIC) received during 2011 in total 79 503 inquiries, an increase of 3% compared to last year. The number of calls from health care professionals continues to increase even more, a trend that has been evident for several years together with a rising number of consultations from ambulance personnel during turnout. The increased call volume during evenings, nights and weekends has made it necessary to impose restrictions on opening hours for inquiries about animal poisoning during these time periods. As a result such calls decreased from 4 700 to 3 700. The current poisoning panorama highlights the worrying trend of new synthetic and herbal drugs of abuse ordered over the Internet. Often it is unclear what is taken and in what dose. The symptoms are sometimes severe and several lethal cases have occurred. This year only 16 inquiries related to methanol poisoning were registered, which probably reflects the decreased availability of methanol containing consumer products. A slight increase was seen again regarding paracetamol poisoning, but it is not possible to establish a causal relationship with the increased availability of analgesics in stores others than pharmacies. Nine scientific studies carried out by SPIC were presented at the International European Congress of Clinical Toxicology (EAPCCT) in Dubrovnik. SPIC has published an information leaflet on poisonous mushrooms in 23 different languages, available on www.giftinformation.se. This was undertaken since tourists and immigrants are clearly overrepresented among cases of mushroom poisoning. Co-workers from SPIC have had an influential role in EAPCCT's task force dealing with the new European Chemicals Regulation (CLP), which seeks to harmonize information from chemical companies sent to Poisons Information Centres. The international cooperation with other Poisons Centres was extensive and is now conducted by well-established channels. As an example, SPIC was visited by the authorities of Saudi Arabia who are seeking guidance in the process of starting up and developing a national PC. Stockholm in April 2012 Mark Personne Director The Swedish Poisons Information Centre started in 1960 and is located at the Karolinska University Hospital. Since November 1st 2009 the centre is a part of the Medical Product Agency. The budget for the year 2011 was 3.6 million Euro. The centre is staffed by 34 full-time employees: 6 physicians, 24 pharmacists, 3 administrative personnel and 1 computer technician. The main responsibility of the pharmacists is the telephone service. An internal education and training period of three to six months is required before new pharmacists are allowed to answer tele-phone calls on their own. The physicians, specialized in anaesthesiology, intensive care and clinical toxicology have the medical responsibility. They also have the possibility to practice in the ICU on a regular basis.
The main responsibility of the centre is to inform about risks, symptoms and treat-
ment in cases of acute poisoning. The service is on a twenty-four hour basis and
connected to the national alarm number 112. Inquiries are received from hospitals
and physicians as well as from the general public. The centre is the only unit of this
kind in Sweden and serves a population of 9.4 million inhabitants.
TELEPHONE INQUIRIES

During 2011 the centre received 79,503 calls. The development in number of calls
from 1961 to 2011 could be seen in Figure 1.

Figure 1. Total number of calls 1961-2011

The average of calls per twenty-four hours was 218 and most of the calls were made
between 4 and 7 o'clock p.m. Figure 2 shows the variation in number of calls received
per twenty-four hours.
Figure 2. Number of calls received per twenty-four hours

During the summer months both children and adults can be exposed to berries,
mushrooms, wasps and snakes. The average of calls per twenty-four hours from May
to September was 236. In Figure 3 you can see that the number of calls to the centre
increases markedly during this period.
Figure 3. Monthly variation of calls
During 2011 the centre received 79,503 calls. 69,042 involved humans and 3,655
animals. 6,806 were requests for general information not connected to a certain case.
See Figure 4.
Figure 4. Calls (n=79,503)

HUMAN POISONINGS

A majority of the 69,042 calls came from the general public and a little bit more than
one quarter from medical/health professionals (Figure 5).
45% of the questions were related to children <10 years old, 47% concerned adults
and 7% adolescents (10-19 years old). As the pattern of poisoning differs
considerably in these groups they are reported separately.
Figure 5. Inquirer (n=69,042)

Overdose with certain non-prescription painkillers - adults and
adolescents >10 years

Over the years the Swedish Poisons Information Centre has followed the
development of the number of overdose cases with non-prescription painkillers. Since
November 1st 2009 some of them are sold in other places than pharmacies, e.g.
supermarkets. There is a concern that increased accessibility would lead to a sharp
increase in the number of overdose cases. The first year after the accessibility change
there was no marked increase, but 2011 the number of inquiries concerning
paracetamol rose with 19% compared to 2010, while the number of inquiries
concerning ibuprofen is almost the same. These are the two non-prescription
painkillers that most inquiries relate to (Figure 6). The Swedish Poisons Information
Centre continues to follow the development closely.
Figure 6. Number of inquiries about paracetamol and ibuprofen in the years
2000-2011 - adults and adolescents >10 years

Childhood poisoning - children <10 years

In 2011 the centre received 31,260 calls concerning children <10 years. Close to
80% involved children 1-4 years old and involved boys more often than girls (Figure
7). Most of the poisoning accidents occurred at home. Ingestion was the main route
of exposure (90% of the cases).
Figure 7. Age/sex, children <10 years (n=31,260)

The most common questions concerned children who had tasted chemical products,
mostly domestic products or products for personal care. Nearly half of the questions
were related to such products, 29% involved pharmaceuticals and 13% plants.
Other questions were related to tobacco, mushrooms, insects and snakes
(Figure 8).
Figure 8. Poisoning agent, children <10 years (n=31,260)
Chemical products most frequently involved in poisoning incidents among
children <10 years (% of total number of questions about chemical products in
parentheses)
Cleaning products: dishwasher detergents, washing detergents, wc-cleaning etc.
(40%)
Cosmetics/personal care products: shampoo, soap, lotion nail products etc. (15%)
Disinfectants (4%)
Pesticides (4%)
Paint (4%)
Of 15,020 paediatric poisoning incidents involving chemical products the estimated
risk was minor in 90% of the cases and could be dealt with at the accident site.
The remaining 10% were recommended to seek medical attention or advice was
given to health care personnel. Half of these inquiries involved products containing
petroleum distillates that can cause chemical pneumonitis if aspirated or corrosive
products. The most common chemical products where the incidents were assessed to
be hazardous are listed in Figure 9.
Figure 9. Most common chemical products amongst children <10 years, who
were advised to go to hospital or were treated in hospital (n=1,477)

Pharmaceuticals most frequently involved in poisoning incidents among
children <10 years (% of total number of questions about pharmaceuticals in
brackets)
Analgesics, including anti-inflammatory and antirheumatic pharmaceuticals (24%)
Cough preparations (10%)
Health foods, natural remedies (6%)
Antihistamines for systemic use (5%)
Vitamins (4%)
The risk of poisoning was considered minor in 88% of the 9,140 cases related to
pharmaceuticals. 12% of the cases were recommended to seek medical attention or
advice to health care personnel was given. The most common pharmaceuticals in
these cases are listed in Figure 10.

Figure 10. Most common pharmaceuticals amongst children <10 years, who
were advised to got to hospital or were treated in hospital (n=1,112)


Childhood poisoning with plants

3,082 inquiries involved children who had tasted plants. The majority of these
incidents were considered innocuous and only 4% required medical attention.
Poisoning in adolescents 10-19 years old

The total number of questions to the poisons centre in 2011 concerning adolescents
10-19 years was 5,069. Just over a third of these inquiries related to attempted suicide
or self-harming, in most cases with pharmaceuticals. In addition 15% were
intentional, but with unclear purpose. Close to a fourth of the incidents were due to
accidents and 6% to abuse. Figure 11 shows the different types of poisoning.
Figure 11. Cause, adolescents 10-19 years old (n=5,069)


In the adolescent group, poisoning with pharmaceuticals was most common and
amounted to 64% of the questions. Chemical products accounted for just over a fifth
of the calls (Figure 12).
Figure 12. Poisoning agent, adolescents 10-19 years old (n=5,069)
Pharmaceuticals, including drugs of abuse, most frequently involved in poison-
ing incidents among adolescents 10-19 years old (% of total number of inquiries
about pharmaceuticals in brackets)
Analgesics, including anti-inflammatory and antirheumatic pharmaceuticals (27%)
Psychoanaleptics, including antidepressants (22%)
Neuroleptics, sedatives, hypnotics (15%)
Antihistamines for systemic use (6%)
Antiepileptics (5%)
Drugs of abuse (5%)
Of the 3,402 cases in this group 65% were recommended to seek medical attention or
advice was given to health care personnel.

Chemical products most frequently involved in poisoning incidents among
adolescents 10-19 years old (% of total number of inquiries about chemical products
in brackets)
Cleaning products (19%)
Cosmetics/personal care products (13%)
Gases (10%)
Fuel (9%)
The risk of poisoning was considered minor in 66% of the 1,088 cases. 34% of the
cases were recommended to seek medical attention or advice was given to health care
personnel. The most common chemical products that lead to medical attendance were
strongly irritating/corrosive cleaning agents, gases and products containing petroleum
distillates which can cause pneumonia if aspirated.
Most of the incidents were caused by mistakenly swallowed chemical products, eye
contact or inhalation. In a little less than 8% of the cases the chemical products were
ingested in a self-harming purpose.


Poisoning in adults
A little bit more than one third of a total of 32,713 inquiries in the adult group were
related to accidents, including occupational accidents and "do it yourself" activities at
home (Figure 13). However, the most serious poisonings were the intentional ones,
including suicide attempts and abuse, mostly with pharmaceuticals and drugs of
abuse. These constituted over a third of all poisonings in the adult group.
20% of the inquiries concerned therapeutic errors. In this group unintentional double
dosing of pharmaceuticals at home dominated, which seldom leads to poisoning.
Figure 13. Type of exposure, adults (n=32,713)

Over half of all adult poisoning cases were related to pharmaceuticals and one third
to chemical products, while inquiries about drugs of abuse, plants, insects, snakes and
mushrooms were a minor part (Figure 14).
Figure 14. Poisoning agent, adults (n=32,713)

Pharmaceuticals, including drugs of abuse, most frequently involved in
poisoning incidents among adults (% of total number of questions about
pharmaceuticals in brackets)
Neuroleptics, sedatives, hypnotics (22%)
Analgesics, including anti-inflammatory and antirheumatic pharmaceuticals (19%)
Psychoanaleptics, including antidepressants (12%)
Antiepileptics (6%)
Drugs of abuse (6%)
In the adult group 59% of 18,419 cases required treatment in hospital. In this group
there were many serious cases of overdoses. For the remaining 41% the risk of
poisoning was considered relatively low. Many of the harmless incidents were related
to persons who accidentally had taken a double dose of a pharmaceutical.

Chemical products most frequently involved in poisoning incidents among
adults (% of total number of questions about chemical products in brackets)
Cleaning products (27%)
Gases (11%)
Fuel (8%)
Cosmetics/personal care products (7%)
Car products (7%)
Disinfectants (7%)
The risk of poisoning was considered relatively low in 63% of the 10,631 adult cases
with exposure to chemicals. For the remaining 37% the caller was recommended to
seek medical attention or advice was given to health care personnel. The products
that most frequently required medical care were corrosive cleaning products, gases
and industrial chemicals. Fuel or anti-freezing agents, mistakenly ingested as a
substitute for alcohol, led to serious poisonings.
The most common route of exposure for chemical products was inhalation or eye
contact. This applied to a bit more than half of the cases. Ingestion of a chemical
product by mistake was also relatively common.
POISONING IN ANIMALS

The Poisons Information Centre also gives advice in poisoning cases concerning
animals, if possible regarding time and information (human cases are always given
priority). In 2011 84% of the 3,655 calls were related to dogs, 14% to cats and 2% to
other animal species.
A scarce majority of the questions involved chemical products (mainly domestic
products) and one third pharmaceuticals. 13% of the questions concerned plants and
the remaining questions were related to other poisoning agents (Figure 15). The risk
of poisoning was considered relatively low in 65% of the cases. The remaining 35%
were recommended veterinary contact or advice was given directly to a veterinary.
16% of these animals had ingested pesticides (particularly rodenticides). 10% were
dogs that had eaten chocolate and 8% were dogs or cats that had ingested anti-
inflammatory or antirheumatic drugs, which they are sensitive to.
Figure 15. Poisoning agent, animals (n=3,655)


Toxicological and medical data is collected from different sources and processed to
be used in the telephone service. The means and ways of poisoning are continuously
changing which makes it very important to update the information. Medical articles
published in the world literature are processed and new information integrated into
the database.
Case records
An important source of information is discharge summaries collected from hospitals.
This information is especially essential in unusual cases of poisoning or when a drug
or chemical is new on the market. The centre receives approximately 4,000 copies
from Swedish hospitals annually.
Product information
Incidents with chemical products are relatively common. In order to make as accurate
an assessment as possible in each case and give appropriate advice, the poisons centre
needs detailed information about the contents of various chemical products. This
information, sent to the center by manufacturers and importers on a voluntary basis,
is kept strictly confidential. On the same conditions the Swedish Chemicals Agency
as well as the industry provide the centre with information on pesticides.
Substance monographs
The ambition is to have updated monographs on those pharmaceuticals, chemical
substances and natural toxins which frequently occur in poisoning. These documents
are elaborated by the poisons centre staff and focus on symptoms and treatment.
Tasks Connected to the Telephone Service
Antidote programme
The poisons centre gives advice on the selection and amount of antidotes to be stored
in hospitals all over the country. The centre keeps an updated register of stocks of
antidotes in collaboration with hospitals and pharmacies in Sweden. An updated list
on the use of antidotes with treatment instructions is also issued by the centre.
Education
The centre participates in several different education programmes e.g. postgraduate
courses for physicians and other medical personnel. Among the many teaching
activities, a national course for doctors during their specializing period with 75
participants can be mentioned.
Major chemical accidents
In the field of major chemical accidents the centre is the expert body of the National
Board of Health and Welfare and is also together with the National Board of Health
and Welfare responsible for the antidote programme in case of major accidents.
Research
Studies of certain poisonings, often in close collaboration with hospitals, e.g. to
elucidate the severity of poisoning, epidemiological data, circumstances of poisoning
incidents or to evaluate new treatment recommendations, are continually ongoing
activities.
Swedish National ICE Centre
The poisons centre is the Swedish National ICE (International Chemical Environ-
ment) Centre, the Swedish part of a European network of emergency response centres
for chemical accidents, initiated and financed by the chemical industry. This means
that the centre, along with health hazards information and first aid advice, provides
information regarding environmental hazards from safety data sheets concerning
chemical products from the participating companies.
Toxicovigilance and prevention
An important task is to alert authorities and manufacturers on trends and risks of
poisoning with e.g. new pharmaceuticals or chemical products. Information materials
for different purposes, e.g. books, posters and brochures on the prevention of
poisoning and first aid measures are regularly produced.

Information on poisonous mushrooms translated into 23 different languages.
Every year a number of non-Swedes are poisoned by mushrooms. In some cases
severe symptoms develop, and even deaths have occurred. Often the reason is that
poisonous mushrooms are mistaken for edible ones that foreigners normally pick in
their home countries. Language difficulties can be another reason. To prevent
mushroom poisonings among immigrants and tourist a special brochure has been
elaborated.
The pictures and descriptions cover the most poisonous mushrooms in Sweden. The
brochure can be downloaded from our web site www.giftinformation.se.

Collaborative project with the Swedish Chemicals Agency
In order to strengthen clinical toxicology and the newly established poisons centre in
Macedonia, the Swedish Poisons Information Centre participated in a collaboration
project with the Swedish Chemicals Agency. Two representatives from the Swedish
centre visited Skopje and after that the centre received visits from their university
clinic. Further activities took place in 2010 – doctors from Macedonia participated in
the International Congress of the European Association of Poisons Centres and
Clinical Toxicologists (EAPCCT) in Bordeaux and the Annual Nordic Meeting for
poisons information centres. Another visit was made in Macedonia to check the
progress of their poisons centre. The project included both educational activities with
medical and toxicological orientation and organizational support. In 2011, six of our
treatment documents were translated from Swedish to English. The documents dealt
with common and important intoxications occurring in Macedonia.
Leonardo da Vinci
To create opportunities for education and information exchange with other Poisons
Information Centres in Europe, SPIC previously conducted two collaborative projects
within EU, known as Leonardo da Vinci projects.
In 2011 additional funds were granted for exchanges with centres in Prague (Czech
Republic), Ljubljana (Slovenia), Dublin (Ireland), Newcastle (England) and Bergamo
(Italy). The current series of study visits are due to start in February 2012.
The project aim is to open up opportunities for participants to gain new knowledge
from other Poison Control Centres and medical departments of Clinical Toxicology,
some with a specialized unique profile. The selected organizations have varying
focus and the intention is to get a thorough understanding of their activities.

Collaborative project regarding Toxicity Investigation and Risk Assessment of
Internet drugs based on clinical analyses (STRIDA)
A relatively new and growing phenomenon is that many synthetic preparations or
plant products with psychoactive effects are offered for sale openly on various
websites (Internet drugs) as legal alternatives to illegal drugs. The range of drugs is
changing rapidly, however, while the information on their injurious effects is
extremely limited. The number of contacts to the Swedish Poisons Information
Centre concerning Internet drugs has increased dramatically in recent years. The
Swedish centre has, therefore, in cooperation with the department of Clinical
Pharmacology, Karolinska University Laboratory taken the initiative to STRIDA,
aiming to gain access to current information on the prevalence of Internet drugs,
content of active ingredients and their acute toxicity. This can be achieved by linking
together information from anonymous copies of patient logs from hospitals with
analyses of biological samples from users of these drugs, who apply for help at
Swedish hospitals. Drugs that turn out to be hazardous may later be classified as
narcotics. In 2011, the project has progressed, and an article was published in the
Swedish physician’s medical journal as an e-publication; while the printed version
was published in November. Until the end of August 2011, 200 cases have been
reported through the project.
Exhibition "wonderful children ".
Sweden's largest trade show for children "wonderful children" took place at
Stockholm International Älvsjö Exhibition Center October 14 to 16 (14 300 visitors
over 3 days). SPIC participated and received a very positive response from all visitors
at the booth. Many of them expressed great appreciation for the posters and
information material that was distributed. Approximately 100 journalists reported
from the exhibition.
Case record project 2010.
The project aims to identify the general poisoning panorama in Sweden 2010. All
incoming discharge summaries from 2010 were saved and the severity of the
poisonings was assessed according to the EAPCCT Poisoning Severity Score (PSS).
The results will then be compared with the corresponding panorama from 10 and 20
years ago. The material will also be a basis to highlight certain types of poisoning in
more detail.
Recently registered drugs – overdose characteristics
Cases of poisoning with drugs registered during the last five years are subject to
special surveillance according to EU directives. Discharge summaries are assessed
and those particularly interesting are summarized. From this material, pharmaceutical
companies have the possibility receive information on case reports that are relevant to
their own preparations.
Antidote database
Development and production of a new antidote database (Antidote registry). An
updated on-line database showing the stocks of antidotes available in all Swedish
hospitals

National

The centre collaborates with a number of national organizations like the Swedish
National Institute of Public Health, the Swedish Chemicals Agency and the National
Board of Health and Welfare.
International

∗ General Secretary of the European Association of Poisons Centres and Clinical
∗ Chairman of the Nordic Association of Poisons Centres (NAPC) ∗ CPNP working group (Cosmetics Notification Portal) ∗ Member in CEFIC. ICE Integration Group ∗ “Expert workshop” for Life Long Learning Programme, Leonardo da Vinci ∗ EAPCCT - Workshop on the Harmonisation of Information to be submitted to ∗ Appointed by EAPCCT and AACT, together with Professor William Troutman, New Mexico, to write an update to the "Position Statement on Ipecac"
EAPCCT 2011. XXXI International Congress of the European Asso-
ciation of Poisons Centres and Clinical Toxicologists. Dubrovnik,
Kroatien

∗ Arvidsson S, Höjer J. A European survey on the availability of antidotes. Poster.
∗ Backman E, Luhr KM, Sjöberg G. Acute quetiapine overdose in adults - experience in Sweden. Poster. Clin Toxicol 2011;49:267-8 ∗ Bäckberg M, Hägerkvist R, Rafstedt K, Helander A, Beck O. A Swedish early- warning system on novel and emerging recreational drugs: The STRIDA-project. Oral presentation. Clin Toxicol 2011;49:200 ∗ Enghag EM, Hultén P, Höjer J. Carbon monoxide poisoning caused by waterpipe smoking. Poster. Clin Toxicol 2011;49:210-1 ∗ Hultén P. Hallucinogens – disturbances of perception, mood and thought. Oral ∗ Nilsson U, Personne M, Svanhagen AC, Arvidsson S. Oral ricin exposure – less poisonous than expected. Poster. Clin Toxicol 2011;49:231 ∗ Personne M, Sjöberg G. Metformin toxicity – poison centre experience versus Cochrane reports. Oral presentation. Clin Toxicol 2011;49:249-50 ∗ Tellerup M, Persson H. Swedish pharmacy deregulation – any impact on Poisons centre consultations? Poster. Clin Toxicol 2011;49:235 ∗ Westerbergh J, Hultén P. Novel synthetic cannabinoids, CRA13, JWH-015, JWH- 081 and JWH-210 – detected in a case series. Oral presentation. Clin Toxicol 2011;49:222 NAPC 2011. XXXIII Nordic Association of Poisons Centres. Annual
Meeting. Vejle, Danmark

∗ Didner C. A large intake of Megacollybia platyphylla
∗ Luhr K. Recreational overdoses with Argyreia nervosa (Hawaiian Baby
∗ Olsson E. Serious poisoning in children ∗ Personne M. Treatment of intralipids ∗ Personne M. Pre-hospital treatment. Use of ipecacuanha, early administration of activated charcoal and supply of antidotes ∗ Personne M. The Swedish Poisons Information Centre 2010-2011 ∗ Petersson E. The Nordic glycol ether project ∗ Rafstedt K. Drugs of abuse in Sweden – current trends and new legislative ∗ Westberg U. Gas welding in pipes for district heating ∗ Westberg U, Karlson-Stiber C. Information on poisonous mushrooms intended for Two publications are written by the centre on regular basis; a chapter on drug over-dose, updated every year, as well as a list of antidotes with treatment instructions, updated every second year. The former is a chapter in the catalogue on Pharma-ceutical specialities in Sweden, FASS. The list of antidotes is published in a book called Läkemedelsboken, LB. These books are distributed to all physicians and pharmacies in the country. The centre also publishes articles in medical journals, books etc. Andersson Ulf, Arvidsson S. Behandlingsanvisningar vid händelse med kemiska ämnen. Fastställd av RKMK 2006-05-10. Reviderad 2007-11-06 och 2011-01-15 Enghag EM, Höjer J. Vattenpiprökning kan leda till allvarlig kolmonoxidförgiftning. Läkartidningen 2011;108:1359-60 Fodor E, Hellerud C, Hulting J, Karlson-Stiber C, Abrahamsson L, Nyström T, Andersson D, Sjöholm Å. Glycerol kinase deficiency in adult hypoglycemic acidemia. N Eng J Med 2011;364(18):1781-2 Helander A, Beck O, Hägerkvist R, Hultén P. STRIDA i kampen mot (o)lagliga internetdroger. Läkartidningen 2011;108:2-5 Höjer J, Enghag M. Carbon monoxide poisoning caused by waterpipe smoking. Clin Toxicol 2011; 49:702-3 Personne M, Arvidsson S. Antidotlista. I: Förgiftningar – behandlingsanvisningar och antidotlista. Särtryck ur Läkemedelsboken 2011-2012, Läkemedelsverket, sid 26-36 Luhr K, Petersson E, ”Åtgärder vid förgiftningsfall” Bokkapitel i Socialstyrelsens bok ”Bekämpningsmedel och skadedjur” SWEDISH POISONS INFORMATION CENTRE

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