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MAGAM II: Prospective observational multicentre poisons centre study on eye exposures caused by cleaning products
Abstract
Objective: Local effects on the eye following cleaning product exposures are frequently reported. According to EU chemicals legislation many cleaning products are labelled with Hazard Phrase 318 indicating risk of irreversible eye damage. The objectives of this study were to identify cleaning products with potential for irreversible eye damage by collecting human exposure data from poisons centres (PC), and to clarify to what degree exact product identification is possible during a PC telephone call.
Methods: MAGAM II was a multicentre binational prospective observational PC study. All human eye exposures to detergents or maintenance products reported to nine PCs taking calls from the public and medical professionals during an 18-month period were included. The severity of eye effects was rated according to the WHO Poisoning Severity Score.
Results: Five hundred and eighty-six cases were included. Product identification by name leading to formula information was successful in 533 cases (91%). Follow-up was successful in 528 exposures. Irrigation was performed in 94% of cases. Duration of symptoms was ≥24 hours in 73 patients (25%). 33 (6%) patients developed moderate eye injury. Healing was reported in all cases. The percentage of moderate cases was highest in the group of drain cleaners (25%), toilet cleaners (18%) and oven cleaners (15%). Products intended for professional use caused relatively more moderate eye injuries than products also intended for consumer use.
Conclusion: MAGAM II has shown that PCs are able to identify formulas in sufficiently high quality as needed for product-directed toxicovigilance. The results underline the potential of PC exposure case data for product safety monitoring. The results indicate that irreversible eye damage is very rare after cleaning product exposure.
... The underlying human dataset for the current assessment was obtained from a prospective multicentre poison centre (PC) study, that reported eye effects caused by accidental exposures to detergents, cleaning and maintenance products. This study, MAGAM 1 II DISC (Denmark, Italy, Slovakia and the Czech Republic) (Färber and Desel, 2015;, was conducted between 2013 and 2015, in parallel with a second study branch MAGAM II DEAT (Germany and Austria) (Hermanns-Clausen et al., 2019). The PCs participating in both MAGAM II studies covered approximately one-third of the EU population. ...
The use of lower cut-off values/concentration limits for the calculation of mixture classification in UN GHS/EU CLP versus the previous regulatory scheme (EU Dangerous Preparations Directive, DPD), has resulted in an increased number of classifications in the highest eye hazard category. Herein, a semi-quantitative categorisation of severity of eye effects, following accidental human exposures to detergents, was compared to the classification category of the products. Three schemes were evaluated: EU DPD; EU CLP (based on all available data and information, including weight of evidence); and EU CLP (based entirely on the calculation method). As reported by four EU Poison Centres, the vast majority of exposures had caused minor or no symptoms. Classification was a poor predictor of effects in man subjected to accidental exposure. Note however that this is also because effects are not only driven by the intrinsic hazard (as reflected in the classification), but also by the exposure conditions and mitigation (i.e. rinsing). EU CLP classification using all available data and information was more predictive of medically relevant symptoms than the EU CLP calculation method. The latter led to a poorer differentiation between irritating products versus products potentially causing serious eye damage.
Most poisons centers were established in Germany in the 1960s and originally linked to clinical units treating cases of poisoning and staffed by clinicians. A national network was substantially strengthened following the reunification of Germany and instituted in all states (Länder) by Federal law in 1990. Over time these centers have amalgamated and there are currently 8 centers, providing 24-h services daily to clinicians and the public. The centers have played an active role in the development of legal processes around poisoning and its prevention and have been academically active since their institution. The present roles and profiles of German poison centers are discussed.
Fallberichte über gesundheitsschädliche Einwirkungen von chemischen Stoffen und Gemischen (Vergiftungen im weiteren Sinne) haben große Bedeutung für die Verbesserung der Patientenversorgung, die Stoff- und Produktsicherheit sowie für die medizinische Aus- und Weiterbildung. Sie sind die Basis der Toxikovigilanz, d. h. der vom klinischen Fall ausgehenden Erkennung und Bewertung von Vergiftungsrisiken in der Gesellschaft. Die Vergiftungsdokumentation erfolgt v. a. durch Ärztinnen und Ärzte sowie Fachkräfte in der Pflege, toxikologischen Laboratorien und Giftinformationszentren (GIZ) der Bundesländer.
Objective: Exposure to ethylene glycol (EG), a common component of antifreeze, is associated with very poor prognosis in cats. Exposure causes renal failure which is reversible with haemodialysis support, both impractical and uncommon in veterinary practice. The objective was to analyse the prevalence and risk factors associated with clinical signs in suspected EG exposure. Methods: Retrospective analysis of suspected EG exposure in cats (with outcome) reported to the VPIS between December 1996 to February 2014. Results: There were 240 cases; 6 cats (2.6%) remained asymptomatic and 234 developed signs (97.5%) including 163 (69.7%) which were euthanised, 42 that died (17.9%), 24 made that recovered (10.3%) and 5 with on-going signs at the time of follow-up (2.1%). Most enquiries were made between October and March (153/240, 64%) peaking in December (32/240, 13%). Enquiries were greatest in male cats (95/150 63.3%) compared to 55/150 (36.7%) females; 90/240 (37.5%) had unspecified sex and in cats aged 1-3 years 97/205 (47.3%) peaking in 2-3 year olds 40/205 (19.5%) – 35/240 (14.6%) had unspecified age. The most common signs were ataxia (83/234, 35.5%), lethargy (78/234, 33.3%), vomiting (73/234, 31.2%) and collapse (73/234, 31.2%). The commonest biochemical abnormalities reported included azotaemia (113/234, 48.3%), hypocalcaemia (82/234, 35%) and hyperglycaemia (47/234, 20.1%). Oxaluria was identified in 32 cases although it was unclear if urinalysis was assessed in every case. Intravenous fluid therapy was administered in most cases (188/240, 78.3%) and ethanol in 66/240 (27.5%). Of those that received the ethanol antidote 49 died and 17 survived. Of those that survived with time to treatment reported ethanol was started within an average of 5.75 hours (median 1.5 hours, n=10) compared to those that died or were euthanized receiving ethanol therapy (21.4 hours average, 24 hours median, n=17). Reasons for euthanasia included poor prognosis (53/163, 32.5%) no response to treatment (26/163, 16%), worsening azotaemia (13/163, 8%), development of anuria (4/163, 2.5%) ,uncontrolled seizures (3/163. 1.8%) and not specified (64/163, 39.3%). Seizures occurred in 18/42 (42.9%) in those that died versus 2/24 (8.3%) that recovered. Conclusion: EG exposure is commonest in younger cats and in male cats. Caution should be taken in winter months especially in animals presenting with ataxia, lethargy, vomiting and collapse. Biochemical abnormalities such as hypocalcaemia, azotaemia and hyperglycaemia can aid diagnosis, however, prognosis is very poor particularly in cats with convulsions. Antidotal therapy is only useful if started in the first few hours after exposure.
Ocular chemical burns are common and serious ocular emergencies that require immediate and intensive evaluation and care. The victims of such incidents are usually young, and therefore loss of vision and disfigurement could dramatically affect their lives. The clinical course can be divided into immediate, acute, early, and late reparative phases. The degree of limbal, corneal, and conjunctival involvement at the time of injury is critically associated with prognosis. The treatment starts with simple but vision saving steps and is continued with complicated surgical procedures later in the course of the disease. The goal of treatment is to restore the normal ocular surface anatomy and function. Limbal stem cell transplantation, amniotic membrane transplantation, and ultimately keratoprosthesis may be indicated depending on the patients' needs.
To ascertain the reported toxicity of current United Kingdom (UK) household products following the launch of new products, such as liquid detergent capsules, and the manufacture of more concentrated formulations.
Between 1 March 2008 and 30 April 2009 the UK National Poisons Information Service (NPIS) collected prospectively 5939 telephone enquiries relating to household products, approximately 10% of all telephone enquiries received over this period.
The majority of enquiries (n = 3893; 65.5%) concerned children 5 years of age or less and were received predominantly from hospitals (n = 1905; 32.1%), general practitioners (n = 1768; 29.8%) and NHS Direct/NHS 24 (n = 1694; 28.5%). The majority of exposures occurred at home (n = 5795; 97.6%); most exposures were accidental (n = 5561; 93.6%). Liquid detergent capsules were most commonly involved (n = 647), followed by bleaches (n = 481), air fresheners (n = 429), multipurpose cleaners (n = 408), dishwasher products (n = 399) and descalers (n = 397). Exposure to household products occurred mainly as a result of ingestion (n = 4616; 75.8%), with eye contact (n = 513; 8.4%), inhalation (n = 420; 6.9%) and skin contact (n = 187; 3.1%) being less common; 5.1% (n = 313) of enquiries involved multiple routes of exposure. The most commonly reported features were vomiting (ingestion), pain (eye contact), dyspnoea (inhalation) and burns (skin contact). In 5840 of 5939 enquiries the Poisoning Severity Score (PSS) was known. The majority of patients (n = 4117; 70.5%) were asymptomatic (PSS 0), 28.0% (n = 1638) developed minor features (PSS 1), 1.3% (75 patients) developed moderate features (PSS 2) and 0.15% (nine patients) developed serious features (PSS 3). Four of these nine patients made a complete recovery, two died from exposure to drain cleaner and PVC solvent cleaner; the outcome in three was unknown.
In the UK, advice from the NPIS is sought commonly regarding household products, but such exposures only rarely result in clinically serious features. As 65.5% of exposures were in children less than 5 years of age, parents clearly have an important role to play in ensuring that household products are stored safely at all times.
The goal was to examine comprehensively the patterns and trends of household cleaning product-related injuries among children treated in US emergency departments.
Through use of the National Electronic Injury Surveillance System database, cases of unintentional, nonfatal, household cleaning product-related injuries were selected by using product codes for drain cleaners, ammonia, metal polishes/tarnish removers, turpentine, dishwasher detergents, acids, swimming pool chemicals, oven cleaners, pine oil cleaners/disinfectants, laundry soaps/detergents, toilet bowl products, abrasive cleaners, general-purpose household cleaners, noncosmetic bleaches, windshield wiper fluids, caustic agents, lye, wallpaper cleaners, room deodorizers/fresheners, spot removers, and dishwashing liquids. Products were categorized according to major toxic ingredients, mode of action, and exposure.
An estimated 267 269 children<or=5 years of age were treated in US emergency departments for household cleaning product-related injuries. The number of injuries attributable to household cleaning product exposure decreased 46.0% from 22 141 in 1990 to 11 964 in 2006. The product most-commonly associated with injury was bleach (37.1%). Children 1 to 3 years of age accounted for 72.0% of cases. The primary mechanism of injury was ingestion (62.7%). The most common source or container was spray-bottles (40.1%). Although rates of household cleaner-related injuries from regular bottles or original containers and kitchenware decreased during the study period, spray-bottle injury rates showed no decrease.
Although national rates of household cleaning product-related injuries in children decreased significantly over time, the number of injuries remains high.
Context:
Chemical eye injuries are ophthalmological emergencies with a high risk of secondary complications and severe visual loss. Only limited epidemiological data for such injuries are available for many countries.
Patients and methods:
We performed two independent studies. The cause of chemical eye injuries was assessed with a prospective questionnaire study. Questionnaires were sent to all ophthalmologists in Switzerland. A total of 163 patients (205 eyes) were included, between December 2012 and October 2014. Independent of the questionnaire study, the incidence of chemical eye injuries was assessed with a retrospective cohort study design using the database of the mandatory accident insurance.
Results:
Ophthalmological questionnaires revealed that plaster/cement (20.5%), alkaline (12.2%) and acid (10.2%) solutions caused the highest number of chemical injuries. Only 2% of all injuries were classified as grade III and none as grade IV (Roper-Hall classification). The official toxicological information phone-hotline was contacted in 4.3% of cases. Using data from the accident insurance, an incidence of chemical eye injuries of about 50/100 000/year was found in the working population.
Conclusion:
Here, we present data on the involved agents of chemical eye injuries in Switzerland, and also the incidence of such injuries in the working population. This may also help to assess the need for further education programs and to improve and direct preventive measures.
For the 14 months 1 January 1985 to 28 February 1986 all cases of chemical eye injury presenting to the Croydon Eye Unit were analysed. Of the 180 cases 19 were caused by assaults and 14 were admitted for treatment. The wide range of injurious substances is emphasised, and the circumstances of injury are listed. A discussion of the management of chemical eye injury is included.
A standardized and generally applicable scheme for grading the severity of poisoning allows a qualitative evaluation of morbidity and facilitates comparability of data. Working from a simple grading scale proposed by the European Association of Poisons Centres and Clinical Toxicologists, a Poisoning Severity Score has been developed jointly with the International Programme on Chemical Safety and the European Commission.
The Poisoning Severity Score has been elaborated, tested, and gradually revised during a project running 1991-1994. Fourteen poisons centers from various countries have participated. Each center independently graded 371 cases of acute poisoning by ten different toxic agents. The data were then analyzed and compared.
The concordance in grading the severity increased during the study period, and in the last phase there was an acceptable concordance among centers in 80% or more of the cases. Given the condition and quality of the original case records, this result was considered satisfactory and agreement was reached on the scoring scheme presented here. The Poisoning Severity Score grades severity as (0) none, (1) minor, (2) moderate, (3) severe, and (4) fatal poisoning. It is intended to be an overall evaluation of the case, taking into account the most severe clinical features. Use of the Poisoning Severity Score normally requires a follow-up of all cases, but may be used on admission or other times during the course of poisoning if this is clearly stated when data are presented.
A Poisoning Severity Score has been developed and found applicable for grading the severity of poisoning. It is foreseen that the Poisoning Severity Score will meet the expectations and be used in practice, but its future use and evaluation may result in some further revision and refinement.
Various ocular alkali burn classification schemes have been published and used to grade human chemical eye injuries for the purpose of identifying treatments and forecasting outcomes. The ILSI chemical eye injury classification scheme was developed for the additional purpose of collecting detailed human eye injury data to provide information on the mechanisms associated with chemical eye injuries. This information will have clinical application, as well as use in the development and validation of new methods to assess ocular toxicity.
A panel of ophthalmic researchers proposed the new classification scheme based upon current knowledge of the mechanisms of eye injury, and their collective clinical and research experience. Additional ophthalmologists and researchers were surveyed to critique the scheme. The draft scheme was revised, and the proposed scheme represents the best consensus from at least 23 physicians and scientists.
The new scheme classifies chemical eye injury into five categories based on clinical signs, symptoms, and expected outcomes. Diagnostic classification is based primarily on two clinical endpoints: (1) the extent (area) of injury at the limbus, and (2) the degree of injury (area and depth) to the cornea.
The new classification scheme provides a uniform system for scoring eye injury across chemical classes, and provides enough detail for the clinician to collect data that will be relevant to identifying the mechanisms of ocular injury.