Human & Experimental Toxicology (2007) 26: 73 81
http:het.sagepub.com
Profile of poisoning admissions in Malaysia
*,1 2 3
R Rajasuriar , R Awang , SBH Hashim and HRBH Rahmat
1
Department of Pharmacy, Faculty of Medicine, University of Malaya, Malaysia;
2
National Poison Centre, Universiti Sains Malaysia, Malaysia;
3
Disease Control Division, Ministry of Health, Malaysia
We retrospectively reviewed poisoning admissions to all
government health facilities from 1999 to 2001, in an effort to
expand our current knowledge on poisoning in Malaysia to a level
that better reflects a nationwide burden. There were 21 714
admissions reported with 779 deaths. The case-fatality rate was
35.88/1000 admis-sions. The majority of admissions (89.7%) and
deaths (98.9%) occurred in adults. Some 55.1% of all admissions
were female, mostly involving pharmaceutical agents. Male
poisoning admissions were more often due to chemical
substances. The prevalence of poisoning and death was highest
among Indians compared to all other races in Malaysia. Overall,
the majority of poison-ing admissions were due to pharmaceutical
agents, with agents classified as non-opioid analgesics, anti-
pyretics and anti-rheumatics the most common. Pesti-cides
Introduction
Poisoning is defined as an exposure to any sub-stance,
either natural or synthetic, which results in structural
1 complete and comprehensive sur-veillance systems, in
damage or functional disturbance to the body. In 2000,
WHO reported that there were 315 000 fatalities due to
poisoning worldwide. However, this number accounted for
2 policies be de-signed to help reduce the burden of
B2% of the total reported cases of poisoning globally.
Most of the economic burden of poisoning derives from the
implications of treatment costs and the potential years of
3 country dedicated to performing the function of
life lost in non-fatal cases of poisoning. As the occurrence
of poisoning is sometimes inevitable, especially those
arising from accidental exposures, learning from each
circumstance would probably be the most important
preventive measure one can take to avert future events.
Similarly, at a national level, the relevant authorities should
regularly assess the reported incidences of poisoning to
detect danger-ous trends occurring in the community, a
function known as toxicovigilance. Reliable poisoning
statis-
*Correspondence: Reena Rajasuriar, Department of Pharmacy,
Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur,
Malaysia
E-mail: reena@um.edu.my
Received 4 October 2005; revised 10 May 2006; accepted 1 June 2006
– 2007 SAGE Publications
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3
accounted for the largest number of fatalities. It was also the
commonest substance reported in cases of intentional self-harm.
Most cases of poisoning admissions occurred due to accidental
exposure (47%), followed by cases of intentional self-harm
(20.7%). Overall, this study has managed to contribute substantial
additional information regarding the epidemiology of poisoning in
Malaysia, highlighting important issues, such as the rampant
poisonings involving pesticides and analgesics, as well as the high
prevalence of poisoning among Indians in Malaysia. Human &
Experimental Toxicology (2007) 26, 73 81
Key words: epidemiology; hospital admission; Malaysia; pesti-cides;
poisoning
tics forms the basis of all toxicovigilant studies, and it is of
paramount importance that this information is derived from
order to clearly define the extent of the problem. Only then
can effective and workable preventive measures and
poisoning.
In Malaysia, there is no single organisation in the
toxicovigilance. As such, the surveillance informa-tion on
poisoning in the country remains very scattered. There are
laws in place that require occupational-related poisonings
4
to be reported to the relevant authorities, however, the
onus of reporting is left to the treating physician and
factory managers. Without regular enforcement, this report-
ing scheme has become more voluntary in nature, and the
data on poisoning derived from it under-estimates the true
5
burden of the problem. Further-more, this reporting
scheme only involves cases of poisoning that are sustained
occupationally. Malay-sia’s National Poison Center was
established in 1994. Its function, among others, is to
answer poison-related inquiries from the general public and
healthcare practitioners. Similar to most poison centers
worldwide, all inquiries to the center are
10.1177/0960327107071857
 Profile of poisoning admissions in malaysia
R Rajasuriar et al.
74
documented. However, not all cases of poisoning are
reported to the center and, therefore, poisoning data
derived from analysis of poisoning inquiries also fall short
of representing the actual occurrence of poisoning in the
6 injury precluding its use to estimate the prevalence of
country. Most published data on poisoning in Malaysia
have thus far either focused on occupational-related
5
incidences, or reviewed poisoning admissions at single
7,8
health facilities. This paucity of information regarding
the epide-miology of poisoning in Malaysia, on which firm
decisions regarding poisoning preventive measures can be
based, prompted us to look for alternative sources of
information. It has been reported in the literature that a
5,9 11
substantial portion (range: 59.6 85.3%), of patients
seeking medical treatment at the emergency department for
poisoning have been admitted as a result. As such, we felt a
review of all hospital admission records for poisoning
would provide important additional information regarding
poisoning in this country. More impor-tantly, government
hospital admission records are not subject to voluntary
reporting, and all admissions are recorded following a
standard for-mat. Therefore, the results of this review
would provide a more representative pattern of poisoning
in Malaysia than previously described.
We retrospectively reviewed all government hos-pital
admission records from 1999 to 2001, to achieve the
following objectives: to estimate the caseload and case
fatality of poisoning admissions nationwide; to describe the
demographic and geo-graphic distribution of poisoning
admissions as well as the circumstances of their
occurrence; and to identify the category of substances
implicated in these cases of poisoning.
Methods
Database description
All hospital admissions to government health facili-ties in
Malaysia are documented using a standard Hospital
Management Information System format. Patient
demographics and certain admission infor-mation are
reported at discharge (or death) by trained records office
personnel at each hospital using a standard form. The
diagnosis at discharge (or death) is recorded using codes
specified by the International Statistical Classification of
Disease and Related Health Problems, 10th revision (ICD-
10). The Information and Documentation System (IDS)
Unit under the Ministry of Health is respon-sible for
maintaining this database, as well as processing and
disseminating important informa-tion regarding healthcare
delivery nationwide, which include statistics on health
performance
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indicators set by the Ministry of Health, Malaysia. Hospital
admissions due to drug and chemical poisoning are not
reported separately as a health performance indicator, but
are collectively reported with other cases of accidental
poisoning.
Data extraction
The present investigation was a cross-sectional study that
reviewed all admissions due to drug and chemical
poisoning to all government health facilities in Malaysia
from 1999 to 2001, as these were the most recent years
with completely com-piled data available at the time of the
review. The IDS Unit database, which is formatted in
Microsoft Access, was used, and data relevant to poisoning
was extracted using the relevant ICD-10 primary cause
codes for poisoning by drugs and chemicals. The primary
cause codes identified the category of substance involved
in each poisoning event. Every case with a primary cause
code also had a corre-sponding external cause code
reported which iden-tified the circumstances of poisoning.
Due to the vast number of poisoning cases reported, a web-
based data extraction program was specifically created to
report the exact number of cases accord-ing to each
variable specified in the program command. The program
was created such that it allowed the number of cases to be
identified either based on a single variable of interest (eg,
ages 0 5 years) or when multiple variables were specified
(eg, ages 0 5 years and male). Following the identifica-tion
of the total number of poisoning cases for each category of
substance involved, the program was used to further break
down the number of cases according to the variables
studied, which were age, gender, race, circumstances of
poisoning and hospi-tal location.
Inclusion and exclusion criteria
Poisoning admissions for all drugs and chemicals with an
identifying ICD-10 code were included. Poisoning
admissions as a result of spoilt food or food contaminated
by infectious organisms and poisoning by venomous
animals were excluded in this study.
Data analysis
As the initial case extraction was carried out based on the
relevant ICD-10 codes for poisoning and, subsequently,
stratified for demographic and geo-graphic distribution,
these numbers were pooled to derive nationwide profiles.
Where totals did not add up exactly, the difference was
cited as missing information. The data extraction method
used

only reported total numbers for each category of substances
and, therefore, cases of readmissions and transfer between
government hospitals could not be excluded. Variables of
age were reported as child (0 12 years) or adult (13 99
years), gender as male or female, and race as Malays,
Chinese, Indians or ‘others’. The race category of ‘others’
constituted the indigenous tribes found in some parts of
Peninsular Malaysia and extensively in East Malaysia.
Geo-graphic distribution was described by the territorial
state, whereby the admitting hospital was governed. There
are 13 states in Malaysia and two federal territories.
However, for health administrative pur-poses, the Federal
Territory of Labuan comes under the jurisdiction of the
state of Sabah. Therefore, the data for poisoning in Sabah
and Labuan are com-bined in this study. The poisoning
substances involved were analysed according to the ICD-
10 classification of substances. The circumstances of
poisoning were identified from the external cause codes
which classified circumstances as either accidental (X40
X49), intentional (X60 X69), as-sault (X85 X90) or
undetermined intent (Y10 Y19).
Population denominators used for the calculation of rates
were estimated from national census data obtained from the
National Department of Statistics. Population data for the
year 2000 was considered to represent the mean population
for the study dura-tion and was used to compute period
prevalence for the 3 years studied.
Microsoft Excel 2000 was used to perform de-scriptive
statistics, while EpiInfo (Version 3.3.2) was used to map
the geographic distribution of poison-ing prevalence and
case-fatality rates for the 3 years studied.
Results
Rates of poisoning and fatality
There were a total of 21 714 admissions due to poisoning
recorded in the IDS Unit database from 1999 to 2001. This
accounted for 0.43% of
Table 1 Distribution of pharmaceutical and chemical poisoning admissions and fatalities by age and gender
No. of admissions
Pharmaceutical Chemical
substance (row%) substance (row%)
Age
Adult 11 054 (56.7) 8433 (43.3)
Child 632 (35.3) 1156 (64.7)
Age not assigned 230 (52.4) 209 (47.6)
Gender
Male 4378 (44.9) 5372 (55.1)
Female 7538 (63.0) 4426 (37.0)
11 916 (54.9) 9798 (45.1)
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Profile of poisoning admissions in malaysia
R Rajasuriar et al.
75
all admissions to government health facilities in Malaysia.
The rates of admission for poisoning for the years 1999,
2000 and 2001, were 29.13, 31.77 and 31.79/100 000
populations, respectively. There were a total of 779 deaths
due to poisoning for all 3 years studied, and this translated
to a case-fatality rate of 35.88/1000 admissions.
Demographic characteristics
The majority of the poisoning admissions involved adults
(89.7%), while 1788 admissions occurred in children.
There were 439 (2.1%) cases with no age assigned. Of the
779 deaths reported, only two (0.3%) occurred in children,
98.9% in adults and 0.8% with ages undetermined. The
hospitalisation involving females exceeded that of males
(55.1 versus 44.9%). However, fatalities occurred more
commonly among male poisoned patients (68.7%)
compared to fe-males. Table 1 describes the distribution of
poisoning admissions and fatalities by age and gender
accord-ing to the type of substance involved.
The distribution of admissions by race was di-vided
according to the three main ethnic origins found in
Malaysia, while patients of the remaining smaller ethnic
descents were collectively cate-gorised as ‘others’. We
failed to obtain the specific break down of population
numbers for the smaller ethnic groups categorised as
‘others’ from the most recent census data available, and,
therefore, the distribution of poisoning admissions by race
is reported in percentages, as described in Table 2. Malays
accounted for the majority of the admission cases, with
37.1% of cases involving this ethnic group. Indians
accounted for the second largest distribution, 25%,
followed by Chinese (19.8%) and ‘others’ (18.1%). Death
due to poisoning was highest among the Indians, with more
than one-third of deaths occurring in this community. Case-
fatality rates were also highest among the Indians,
indicating a significant problem of poisoning among
Indians compared to all the other races in Malaysia.
Although the percentage of admissions was highest
No. of fatalities
Total (col%) Pharmaceutical Chemical Total
substance (row%) substance (row%) (col%)
19 487 (89.7) 100 (13.0) 671 (87.0) 771 (98.9)
1788 (8.2) 0 (0) 2 (100.0) 2 (0.3)
439 (2.1) 1 (16.7) 5 (83.3) 6 (0.8)
9750 (44.9) 63 (11.8) 472 (88.2) 535 (68.7)
11 964 (55.1) 38 (15.6) 206 (84.4) 244 (31.3)
21 714 (100) 101 (13.0) 678 (87.0) 779 (100.0)
 Profile of poisoning admissions in malaysia
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76
Table 2 Distribution of admissions and fatalities by race and circumstance of poisoning

No. of admissions (col%) No. of fatalities (col%) Fatality rate/1000 admissions

Race
Malay 8065 (37.1) 97 (12.5) 12.03
Chinese 4306 (19.8) 202 (25.9) 46.91
Indian 5419 (25.0) 294 (37.7) 54.25
Others 3924 (18.1) 186 (23.9) 47.40
Circumstances
Accidental 10 220 (47.0) 218 (27.9) 21.3
Intentional self-harm 4485 (20.7) 362 (46.5) 80.7
Assault 57 (0.3) 1 (0.1) 17.5
Undetermined intent 4038 (18.6) 157 (20.2) 38.9
Missing data 2914 (13.4) 41 (5.3) 13.9

among the Malays, they accounted for the least number of
deaths and the lowest fatality-rate.
Geographical distribution
The distribution of poisoning prevalence and case-fatalities
by states in Malaysia are shown in Figures 1 and 2,
respectively. The majority of the northern states in
Malaysia reported a higher pre-valence of poisoning
admissions compared to the other states, with 100/100 000
of the affected state population being admitted for
poisoning. Kuala Lumpur and Sarawak were the other two
states not in the northern region also reporting a similarly
high prevalence (Figure 1). The distribution of case-fatality
rates, however, showed a very different pattern with the
highest fatalities occurring in the central regions of
Peninsular Malaysia and the entire East Malaysia. (Figure
2). These states reported fatality rates of 40 59.9/1000
admissions.
Poisoning substances involved
The substances involved in poisoning admissions could be
broadly classified into two categories; pharmaceutical
(ICD-10 codes T36 T50) and che-mical (ICD-10 codes T51
T60 and T65) substances. The majority of the poisoning
admissions occurred due to pharmaceutical agents (54.9%)
(Table 1). However, when differentiated by age, poisoning
admissions among children was more often due to
chemical substances. The distribution of substances
involved between genders was also significantly different.
Some 55.1% of the poisoning cases among males involved
chemical substances, while majority of poisoning
admissions among females (63%) involved pharmaceutical
agents. The number of poisoning admissions involving the
specific ICD-10 pharmaceutical and chemical categories
and their respective fatality rates are shown in Table 3. The
majority of the poisoning admissions was caused by
pharmaceutical agents with the ICD-10 code of T39-non-
opioid analgesics, anti-pyretics and anti-rheumatics
(17.21%), followed by the code T50-diuretics and other
unspecified drugs, medicaments and biological substances
(17.17%), and the chemi-cal substance category of T60-
pesticides (16.01%). Chemical substance exposures had a
higher fatality rate compared to exposures to
pharmaceutical agents, with 87% of all fatalities occurring
due to chemical substances. More than 75% of the total
fatalities were caused by the single ICD-10 category, T60-
pesticide, indicating the severe extent and nature of
pesticide poisoning in this country.
Circumstances of poisoning
The circumstances of poisoning in 2914 (13.4%)
admissions could not be determined, as these cases

Figure 1 Geographical distribution of poisoning prevalence in Malaysia, 1999 2001.

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 Profile of poisoning admissions in malaysia
R Rajasuriar et al.

77

Figure 2 Distribution of poisoning case-fatalities in Malaysia, 1999 2001.

did not have an external cause code assigned. Of the
remaining cases (n 18 800), 10 220 was due to accidental
exposure, 4485 due to intentional self-harm, 57 cases of
assault, and 4038 were events of undetermined intent
(Table 2). A further analysis of the six most common
substances involved in acci-dental exposure revealed the
involvement of the following agents in order of frequency;
T52-organic solvent (20.2%), T60-pesticides (16.4%), T50-
diure-tics and other unspecified substances (14.9%), T39-
non-opioid analgesics, anti-pyretics and anti-rheu-matics
(13.9%), T49-topical agents (8.5%) and T54-corrosive
substances (5.5%). These six substances were implicated in
79.4% of all accidental poison-ing admissions (n 10 220).
In poisoning admis-
sions of intentional self-harm, T60-pesticides was found to
be the most common substance taken, contributing to more
than a quarter of poisoning admissions by this intent. The
five other most commonly implicated substances in order
of fre-quency were: T39-non-opioid analgesics, anti-pyre-
tics and anti-rheumatics (22.3%), T-50 diuretics and other
unspecified agents (13.2%), T49-topical agents (9.1%),
T54-corrosive substances (6.9%) and T42-antiepileptics
(4.2%). All these substances were involved in 84.6% of all
poisoning admissions due to intentional self-harm (n 4485).
Majority of deaths (46.5%) occurred in cases of intentional
self-harm, 27.9% in patients with accidental expo-sure,
20.2% in patients with undetermined intent,

Table 3 Poisoning admissions and fatalities by substances based on the ICD-10 categories

Poisoning substance categorised based on ICD-10 codes Admissions Fatality

No . Col% No . Fatality rate/
1000 admissions
T36: Systemic antibiotics 281 1.29 4 14.23
T37: Other systemic anti-infectives and anti-parasitics 44 0.20 0 0
T38: Hormones and their synthetic substitutes and antagonists, not elsewhere classified 102 0.47 2 19.61
T39: Non-opioid analgesics, anti-pyretics and anti-rheumatics 3738 17.21 26 6.96
T40: Narcotics and psychodysleptics (hallucinogens) 69 0.32 1 14.49
T41: Anaesthetics and therapeutic gases 77 0.35 0 0
T42: Antiepileptic, sedative-hypnotic and anti-Parkinsonism drugs 688 3.17 5 7.27
T43: Psychotropic drugs, not elsewhere classified 432 1.99 6 13.89
T44: Drugs primarily affecting the autonomic nervous system 150 0.69 0 0
T45: Primarily systemic and haematological agents, not elsewhere classified 550 2.53 1 1.82
T46: Agents primarily affecting the cardiovascular system 118 0.54 2 16.95
T47: Agents primarily affecting the gastrointestinal system 90 0.41 2 22.22
T48: Agents primarily acting on smooth and skeletal muscles and the respiratory system 176 0.81 2 11.36
T49: Topical agents primarily affecting skin and mucous membrane and by 1672 7.70 20 11.96
ophthamological, otorhinolaryngological and dental drugs
T50: Diuretics and other and unspecified drugs, medicaments and biological substances 3729 17.17 30 8.05
T51: Alcohol 167 0.77 5 29.94
T52: Organic solvent 2521 11.61 5 1.98
T53: Halogen derivatives of aliphatic and aromatic hydrocarbons 62 0.29 0 0
T54: Corrosive substance 1236 5.69 19 15.37
T55: Soaps and detergents 277 1.28 0 0
T56: Metals 61 0.28 0 0
T57: Other inorganic substances 27 0.12 2 74.07
T58: Carbon monoxide 102 0.47 1 9.80
T59: Other gases, fumes and vapours 369 1.70 3 8.13
T60: Pesticides 3672 16.91 605 164.76
T65: Other and unspecified substances 1304 6.01 38 29.14
Total of all poisonings 21 714 100 779 35.88

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 Profile of poisoning admissions in malaysia
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78
1400
and only one (0.1%) death reported as a result of assault. 1200
Figures 3 and 4 depict the distribution of the six most
common substances involved in accidental and intentional

NO OF ADMISSIONS
1000
self-harm poisonings, respectively.
800

Discussion 600

Malaysia’s healthcare services are heavily subsi-dised by 400

the government, as the country’s National Health Insurance

200
Scheme is yet to be launched. Health facilities run by the
government constitute large general hospitals and 0
specialised medical institutes. These facilities are well
networked with smaller district and health centers in the T60-Pesticides T39-Analgesics T50-Diuretics & T49-Topical T54-Corrosive T42-
other agents agents substances Antiepileptics
rural areas, so communities in these areas are not AGENTS
marginalised from access to the best healthcare services in
the country. There are also mobile clinics responsible for Figure 4 Six most commonly implicated substances in inten-tional self-
harm poisoning admissions.
providing healthcare services to the most remote areas in
the country. In 2000, health facilities funded by the
government made up almost 80% of the total 47 066 countries varied from as low as 16 to as high as 40.5/100
12 14
hospital beds available in the country. Government health 000 population. This variation is prob-ably largely
facilities received 1.5 million admissions in that year.
12 influenced by the difference in report-ing schemes used to
generate these data rather than a genuine difference in the
Therefore, although the IDS Unit database reviewed in this
incidence of poisoning. The case-fatality rate for poisoning
study only represented hospital admissions at government in this study was also much higher than previously reported
health facilities, it still represents the majority of hospital in a local
admissions in the country, and the poison-ing data derived 7
individual hospital study, and within the range of those
from it is substantially larger and more representative than 10,13,15 17
reported elsewhere, 0.04 9%.
any study previously reported.
The majority of poisoning admissions occurred in adults,
while B10% occurred in children B12 years of age. This
finding differed from other reports. The US Toxic Exposure
Surveillance Sys-tem (TESS) reported that children within
The 3-year period studied reported 21 714 admis-sions the same age bracket accounted for 59.7% of all
due to poisoning, representing 0.43% of admissions to all 15
government health facilities in the country. Prior individual poisoning, while another study conducted locally also
hospital-based studies conducted locally reported much reported that almost 60% of poisonings occurring in
7
7,8
lower admission rates. The annual admission rates due to hospital involved children below the age of 10. The reason
poison-ing ranged from 29.13 to 31.79/100 000 population. for this discrepancy is not entirely clear, but it could be due
The reported prevalence of poisoning in other to the fact that although children are known to be more
prone to poisoning exposures due to their inquisitive
nature, they are generally less affected,
2500
13
ADMISSIONS

2000
presenting with milder symptoms, and having favorable
18,19
outcomes. This might have resulted
1500 in the majority of these children being discharged from the
emergency department without requiring hospital
admission and, therefore, not captured in this study. There
NOOF

1000
were also only two fatalities reported among children. This
number, however,
500 could not be compared with most other large
10,13,15,16
studies, which reported higher fatalities,
0 because the classification of age used in this study was
tailored to derive data for local interests, and the pediatric
patient population in Malaysia is still classified as 12 years
T52-Organic T60-Pesticides T50-Diuretics T39-Analgesics T49-Topical T54-

solvents
Corrosive
and other agents agents substance
and below, and not 18, as recommended by the WHO.
AGENTS Therefore, the adoles-cent age group which accounted for
most of the fatalities due to suicidal reasons in those
Figure 3 Six most commonly implicated substances in acciden-tal
poisoning admissions. studies

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were excluded from our calculations for the category of
children, but instead included in the adult
category. Two small studies reviewing poisoning in
18,19
children with the same age classification, re-
ported no fatalities.
Our findings on the distribution of gender in the
cases of poisoning were consistent with most other
10,11,13,15 17
studies, which also reported most ad-
missions occurring among females, but mortality more
prevalent among males. This finding might be partly
explained by the difference in the type of substance
commonly involved in the poisoning in each group.
Chemical agents were found to be implicated more often in
poisoning among males compared to their female
counterparts, who were mostly admitted due to poisoning
by pharmaceuti-cal agents. The more toxic nature of
chemical substances compared to pharmaceuticals, which
are generally manufactured with some margin of
therapeutic safety, would explain the higher inci-dence of
death among the males, as well as in the majority of the
cases when chemical agents were involved in poisoning.
The Malays make up the largest proportion of the
population in Malaysia, approximately 55% fol-lowed, by
the Chinese (26%), Indians (8%), and ‘others’ (11%).
Although Indians make up only a small proportion of the
population, they accounted for almost a quarter of the
poisoning admissions and reported the highest fatalities.
8 locally also reported analgesics as the most preva-lent
Fathelrahman et al., conducted a hospital-based study on
poisoning admissions in a largely Chinese populated state
in Malaysia, and also found that Indians accounted for the
highest rates of admissions due to poisoning. The Indians
in Malaysia have a higher involvement in the plantation
sector compared to all other races, where exposure to agro-
chemicals, especially pesti-cides, is widespread. The
20
majority of these work-ers have also been reported not to
have received proper training and information with regard
to the use of proper protective gear while spraying pesti-
cides.
21
Studies investigating completed suicides in
Malaysia have also reported that the rates of suicides are
22,23
highest among Indians. The higher suicidal tendencies
among Indians, together with their greater access to agro-
chemicals, as well as their unprotected handling of these
substances, might explain our findings of the high
prevalence of poisoning admissions and death among the
Indians in this country.
The geographical distribution of poisoning found in this
study is difficult to explain, as it shows no consistent trend
with factors that are generally known to influence the
pattern of poisoning. The trend does not seem to be
influenced by the major
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Profile of poisoning admissions in malaysia
R Rajasuriar et al.
79
economic involvement of the states, as states with
predominantly agricultural or industrial emphasis have
both reported high rates of admission. Addi-tionally,
urbanisation does not seem to be an influencing factor, as
the states in East Malaysia which are not considered
urbanised, have reported a high prevalence of poisoning
and fatalities. Access to healthcare facility is also an
unlikely explanation, as the states in the central region of
Peninsular Malaysia which reported the highest fatalities
are serviced by the most densely networked hospi-tals,
comprising of referral and trauma centers. The explanation
for the distribution is probably multi-factorial, and
ascertaining the likely reasons is beyond the scope of this
study. Highlighting the geographical distribution will,
however, assist in directing future research in the most
affected states.
Overall, both chemical and pharmaceutical agents were
equally important substances in causing poi-soning
admissions, although exposure to chemical agents more
often resulted in a fatal outcome. Non-opioid analgesics,
anti-pyretics and anti-rheumatics were found to be the
commonest identifiable agents involved in poisoning.
Benzodiazepines and other psychotropics were only
involved in a small number
of poisoning cases, unlike the findings from else-
10,11,15,16,24
where. Other smaller studies carried out
7,8
agent involved in poisoning admissions. The difference
in the type of agents involved can probably be attributed to
varying prescribing pat-terns among different countries and
the availability of these agents. Benzodiazepines are
classified as psychotropics, and the sale and use of this
drug is governed by the Poisons (Psychotropic Substance)
25
Regulations 1989. Prescribing benzodiazepines requires
adherence to stringent regulations of doc-umentation and
accountability, which might dis-courage its extensive use.
However, no formal studies on how legal issues have
affected the consumption of benzodiazepines have been
con-ducted to confirm this. The majority of the agents
classified under the group T39-non-opioid analge-sics,
26
anti-pyretics and anti-rheumatics, may be obtained as
over-the-counter medications in Malay-sia without a
prescription. Paracetamol-containing products can even be
obtained from convenience stores, and, unlike many
countries in Europe and Australia, there is no restriction in
Malaysia on the number of tablets that may be sold at any
one time. This ready availability might also explain why
these agents were found to be the commonest pharmaceu-
tical agent ingested in cases of intentional self-harm.
 Profile of poisoning admissions in malaysia
R Rajasuriar et al.
80
Exposure to chemical agents accounted for the majority
of deaths due to poisoning. Pesticides alone accounted for
three-quarters of the total deaths reported. The problem of
pesticide poisoning has long been acknowledged as an
important health problem, especially among agricultural
20 21
workers in Malaysia. A study by Jeyaratnam et al., in
the mid 1980s assessed the extent of pesticide poisoning
among these workers in the region and found that the rate
of pesticide poisoning was high, and attributed this to the
inadequate knowledge among workers with regards to the
potential health hazards of pesticides. They also
highlighted that a substan-tial number of pesticide
poisoning cases was due to suicidal ingestions. Our
findings indicate that the problem still persists, and
pesticides are still highly popular in cases of intentional
self-harm. In an initiative to reduce the mortality due to
pesticides, the Malaysian authorities have banned all
products containing paraquat, a highly lethal herbicide. The
ban took effect in August 2002 and the affected products
are currently in the process of being phased out. It would
be interesting to assess how this ban has affected the
prevalence of pesticide poisoning, and it should be the
subject of future research.
While this study has managed to highlight im-portant
trends of poisoning admissions, and sub-stantially
contributed to the database of poisons information
currently available in this country, there were a few
important limitations. This study only reviewed cases of
poisoning admissions and, there-fore, probably only
represents cases of poisoning that are of moderate-to-
severe in nature. However, for prevention purposes, this
allows a focus on the more severe end of the spectrum.
Another important limitation to the study was the reliance
on the ICD-10 codes for reporting of the substance
involved in
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