Caustic soda poisoning in Ghana an

alarming increase
Emma Weldon
1
, Pamela M. Martey
2
1
North Tyneside General Hospital, Tyne & Wear, UK, and
2
Okomfo Anokye Teaching Hospital, Kumasi, Ghana
Background: In 2010, there was a sudden increase in the number of children admitted to Okomfo Anokye
Teaching Hospital, Kumasi with caustic soda poisoning.
Aim: To quantify the increase and identify possible causes.
Methods: Detailed review of case-notes of all children admitted with poisoning from January 2009 to June
2010 was undertaken using a standardised proforma.
Results: From January to June 2010, there was a six-fold increase in the number of children admitted with
caustic soda poisoning compared with January to June 2009 (13 vs 2). Owing to the increase in caustic
soda ingestion, there were almost twice the number of cases of chemically-induced poisoning in January
June 2010 (34) as in JanuaryJune 2009 (19 cases). In the entire period (January 2009 to June 2010), the
majority of admissions for chemical poisoning were children (3 years of age and 50 of the 72 (69.4%)
cases were boys. In six of the 13 cases in the JanuaryJune 2010 period, caustic soda was drunk directly
from a plastic water bottle. All children with caustic soda poisoning had been given palm oil to drink by their
guardians.
Conclusion: It is suggested that the recent introduction of bottled water is an important element in the
increase of caustic soda poisoning. Previously, water was sold in plastic bags. The plastic water bottles are
re-used to store caustic soda which children then drink, mistaking it for water.
Keywords: Caustic soda, Ingestion, Public health, Paediatrics
Introduction
It was suspected that there was an increase in the
number of paediatric admissions to Okomfo Anokye
Teaching Hospital, Kumasi with caustic soda inges-
tion and possibly also with kerosene and parazone
ingestion. The morbidity and mortality associated
with caustic soda ingestion is preventable
1
and palm
oil used by guardians to induce emesis puts children
at further risk of aspiration. In December 2009,
WHO published a report highlighting the dangers of
caustic soda ingestion whilst acknowledging that in
low-income countries information about measures to
prevent these accidents is scarce.
2
For this reason it
was decided to undertake a retrospective review of
admissions for poisoning from January 2009 to June
2010.
Methods
Using the admissions books, all cases of chemical
poisoning by ingestion of caustic soda, kerosene and
parazone (hair bleach) between 1 January and 30 June
2010 were identied. Cases recorded as chemical
pneumonitis were also included. This period was
compared with the previous 6 months. In order to
reject the hypothesis that the observed increase was
related to seasonal variation, the period was also
compared with 1 January to 30 June 2009. De-
mographic data recorded included date of admission,
age and gender. Where chemical pneumonitis was
recorded, medical notes were obtained and the
substance causing the pneumonitis was identied.
Having conrmed an increasing incidence of
caustic soda ingestion, all medical notes for caustic
soda ingestion between January and June 2010 were
reviewed. Data were gathered on home town, em-
ployment of major income provider, National Health
Insurance Scheme (NHIS) status, method of inges-
tion, rst aid and complications. The case-notes were
reviewed by one person using a standardised pro-
forma.
Results
Between January 2009 and June 2010 there were 72
cases of chemical ingestion. There was a six-fold
increase in caustic soda ingestion during January
June 2010 compared with JanuaryJune 2009 (13 vs 2
cases). There was no signicant increase in parazone
Correspondence to: E Weldon, North Tyneside General Hospital, Rake
Lane, North Sheilds, Tyne & Wear, NE29 8HN, UK. Email: e.c.weldon@
doctors.org.uk
158
W. S. Maney & Son Ltd 2012
DOI 10.1179/2046905512Y.0000000007 Paediatrics and International Child Health 2012 VOL. 32 NO. 3
or kerosene ingestion (Table 1) and no seasonal
variation (Fig. 1).
The majority of children affected were (3 years
(82%) (Table 2). Patients came from a wide geogra-
phical area, some having an 8-hour journey to reach
the hospital. The most common method of inges-
tion was by drinking from a plastic water bottle
(6/13, 46%). All had been given palm oil by their
guardians as rst-aid before reaching the healthcare
facility.
There was a high burden of morbidity including
complications from oesophageal ulceration (10/13,
77%), malnutrition at discharge (9/13, 70%), aspira-
tion pneumonia (8/13, 62%) and death (1/13, 8%).
Discussion
The majority (95%) of deaths worldwide caused by
accidental poisoning occur in low- and middle-
income countries.
3
In high-income countries, deaths
from poisoning are declining,
2
but, in low-income
countries, a lack of comprehensive surveillance makes
it hard to establish how the incidence of ingestion of
corrosive substances is changing.
It is known that caustic soda ingestion occurs
frequently in Africa where it is commonly used as a
household cleaning agent. Despite a comprehensive
literature search using Medline and Embase, no
reliable data for the incidence in Ghana were identied.
However, a large study from Senegal reported that 38
of 381 accidents in children requiring hospital admis-
sion were owing to caustic soda ingestion.
4
Caustic
soda ingestion is associated with high morbidity and
mortality.
5,6
It is established that public health
measures can reduce accidental injury in Africa.
7
Statistics are not available for many medical condi-
tions in low-income settings and therefore surveillance
of non-notiable diseases is usually carried out on an ad
hoc basis. It has been established that retrospective
analysis of medical records in Africa is useful for
surveillance.
8
The knowledge gained from this type of
evaluation can help clinicians respond appropriately
and with early, targeted public health interventions.
Possible explanations for this alarming trend in
caustic soda ingestion in Ghana include (i) increased
use of plastic water bottles, (ii) introduction of the
NHIS, and (iii) increased use of caustic soda.
The favoured hypothesis to explain the alarming
trend is the increased use of plastic drinking bottles.
Over the last few years, drinking water has increas-
ingly been sold in plastic bottles rather than pla-
stic bags. Water used to be drunk directly from the
plastic bags, but now is often drunk directly from the
plastic bottles. It is not uncommon to see a toddler in
the streets of Kumasi carrying a plastic water bottle.
The bottles are re-used and caustic uid is sold in
them unlabelled. Caustic soda is also sold as dry
powder which is made into cleaning uid at home.
Mothers of children admitted to the Department of
Paediatrics with caustic soda ingestion explained how
their children had drunk directly out of these bottles,
not recognising the danger. Safety mechanisms to
regulate the sale and storage of harmful chemicals are
not employed in Ghana as they are in industrialised
countries such as the UK.
9
The new NHIS was set up in Ghana in 2003 and
provides free health care to registered children. The
increasing number of children registered each year
has led to the suggestion that the observed increase in
the incidence of caustic soda poisoning is actually the
Table 1 Type of chemical poisoning and period of presentation
JanJun 2009 JulyDec 2009 JanJun 2010
Total no. of cases of chemical 19 19 34
poisoning
Kerosene 10 8 13
Parazone 7 8 8
Caustic soda 2 3 13
Figure 1 Chemical poisoning according to sub-type in the
three study periods (%caustic soda, kerosene, parazone)
Table 2 Gender, age and period of chemical poisoning
All ingestions Caustic soda
Jan 2009Jun 2010 JanJune 2010
Gender
F 20 2
M 52 11
Age, y
,3 59 9
35 10 2
510 3 2
.10 0 0
Weldon and Martey Caustic soda poisoning in Ghana
Paediatrics and International Child Health 2012 VOL. 32 NO. 3 159
result of increased reporting. However, there are a
number of reasons to refute this suggestion: (i) the study
was undertaken at a central government hospital so the
cost of treatment was less of a barrier to treatment than
the cost of transport and the necessary time off work
(some patients travelled up to 150 miles); (ii) only 50%
of patients were registered on the NHIS so it is unlikely
to account for the total increase in presentations; and
(iii) there is no similarly increasing trend in kerosene or
parazone ingeston. We are unaware of any increase in
the domestic use of caustic soda.
A public health campaign is needed to raise
awareness of the dangers of caustic soda ingestion
and the use of palm oil to cause emesis. Legislation is
required to regulate the sale and labelling of corrosive
substances. A large prospective study is required to
establish that caustic soda poisoning is increasing in
Ghana, and the reasons for it.
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160 Paediatrics and International Child Health 2012 VOL. 32 NO. 3
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