Day R, Eddleston M, Thomas SHL, Thompson JP, Vale JA. Exposures to traditional automatic dishwashing tablets and a comparison with exposures to soluble film tablets reported to the United Kingdom National Poisons
semanticscholar(2016)
摘要
Introduction: Traditional automatic dishwashing tablets are contained within an external wrapper that requires removal prior to use. Objective: To determine the toxicity of traditional tablets and to compare this with our previously reported experience of soluble film dishwashing tablets. Methods: Telephone enquiries regarding traditional tablets were analysed retrospectively for the period January 2008 to December 2015. Results: Traditional tablets. There were 503 enquiries relating to 492 patients who had been exposed to a traditional tablet. Most involved children aged 5 years or less (87.4%). The majority (78.6%) of patients did not develop symptoms after exposure; 21.1% developed minor (PSS 1) symptoms while one patient developed moderate features. Exposure occurred predominantly as a result of ingestion (n=476, 96.7%); the most common feature in symptomatic patients (n=99, 20.8%) was vomiting (70 [14.7%] cases). Significantly (p<0.0001) more adults (44.9% of 49 adults; 95% CI = 31.9-58.7) were reported with features than children (18.2% of 434; 95% CI = 14.9-22.1). There were five cases of eye contact which resulted in eye pain in two patients and eye irritation in another. Only one of 11 patients exposed dermally developed features (a rash around the mouth). Comparison with soluble film exposures: The percentage of patients that were reported with clinical symptoms following ingestion of a soluble film dishwashing tablet (31.7% of 473 patients; 95% CI = 27.7-36.0) was significantly greater (p<0.0001) than that for traditional tablet (20.9% of 483 patients; 95% CI = 17.5-24.8). Vomiting was the most commonly reported feature and occurred significantly (p<0.0001) more frequently amongst patients who had ingested a soluble film tablet (25.5%; 95% CI = 21.8-29.6) than a traditional tablet (14.7%; 95% CI = 11.8-18.1). Conclusions: Exposure to both traditional and soluble film tablets only rarely produced clinically significant symptoms (PSS ≥ 2). However, ingestion of a soluble film tablet was significantly more likely to result in clinical features than ingestion of a traditional tablet. Introduction Traditional tablets* for automatic dishwashing machines are contained within an external wrapper that requires removal prior to loading the enclosed tablet into the machine. These tablets are still used commonly worldwide. There have been few reports on the toxicity of traditional automatic dishwashing detergents; [1,2,3,4] the most recent report was published 20 years ago and the composition of these older products was different from the current tablets. Some 10 years ago automatic dishwashing tablets* contained within a soluble film became available in the United Kingdom (UK) and are now marketed in many European countries and in North America. We have previously published data on 488 exposures involving soluble film automatic dishwashing tablets. [5] Soluble films used in this way are claimed to have two main advantages. Firstly, the exact amount of chemicals recommended for the product’s intended purpose is delivered once the film dissolves completely in water. Secondly, as there is avoidance of direct contact with the chemicals, products were promoted to improve safety. That being said, the integrity of the soluble film can be compromised and the contents of the tablet can be released prematurely when in contact with moist hands or saliva. [5] The traditional (wrapper covered) type of tablet consists entirely of a compressed powder, whereas soluble film tablets can also contain liquid and/or gel components. That said, the chemical composition of traditional and soluble film dishwashing tablets is similar. Both types of tablet contain a source of hydrogen peroxide (often as sodium percarbonate ≤ 20%) and non-ionic surfactants ≤ 5%. Other constituents in some formulations include sodium carbonate ≤ 30%, sodium tripolyphosphate ≤ 50%, and sodium silicate ≤ 10%, which reduce water hardness. The tablets have a resulting alkaline pH (generally between 9 and 11 when dissolved in water). *Tablet is a generic name for the products which, up to a few years ago, largely comprised of compressed powder using the tableting technique. It in fact is a pars pro toto employed by Industry for these products which now include soluble film products. As the chemical composition of present day traditional tablets is similar to those enclosed in a soluble film, it would not be anticipated that the toxicity of traditional tablets as reported to the United Kingdom (UK) National Poisons Information Service (NPIS) over the period 2008-2015 would be different from that which we have reported for soluble film automatic dishwashing tablets over the same period. [5] Nonetheless, as the toxicity of present day automatic dishwashing tablets has not been ascertained previously, we have investigated the reported toxicity of these tablets and ascertained whether or not they are more likely to result in clinically important features than those enclosed in a soluble film. In addition, we have compared the toxicity reported in children and adults with both types of tablet. Methods The UK NPIS (www.npis.org) provides information and evidence-based management advice about individual substances through its online database TOXBASE® and its 24-hour telephone advice service, staffed by information scientists and supported by a rota of consultant clinical toxicologists. The UK NPIS takes telephone enquiries from NHS healthcare professionals. A retrospective analysis of telephone enquiries to the UK NPIS from across the UK regarding automatic dishwashing tablets was undertaken for the period 1 January 2008 to 31 December 2015. The NPIS UKPID (United Kingdom Poisons Information Database) central database was searched for enquiries involving all types of automatic dishwashing products and each exposure to a tablet was categorized as being of the traditional or soluble film type. The data relating to the traditional type of tablets were analyzed and their toxicity then compared to that of soluble film tablets. [5] Confidence intervals were calculated and a two-sample Chisquared test was performed using GraphPad Prism Version 7.01 to determine whether there were significant differences between exposures to traditional and soluble film tablets and between children and adults. Enquiries received from outside the UK were excluded from this study. Data (both from the text narrative as well as discrete data fields) extracted from the enquiries included: age of patient; route(s) of exposure; source of enquiry; location where exposure occurred; circumstances of exposure; product information; features reported at the time of enquiry and the assigned World Health Organisation /International Programme on Chemical Safety /European Commission /European Association of Poison Centres and Clinical Toxicologists (WHO/IPCS/EC/EAPCCT) Poisoning Severity Score (PSS). [6] Data on composition were obtained from the NPIS Product Data Centre which contains safety datasheets (SDS) on products marketed in the UK. This study did not require approval by a UK Research Ethics Committee as the UK Health Research Authority has declared that ethical approval is not needed for research studies that use information collected routinely in any UK administration (England, Wales, Scotland, Northern Ireland) as part of usual clinical care, provided this information is passed to the researchers in a fully anonymised format. Results There were 1290 enquiries (1266 exposures) involving automatic dishwashing tablets over the period of 2008 to 2015. There were 503 enquiries (492 exposures) about the traditional type, 498 enquiries (488 exposures) about the soluble film type and 289 enquiries (286 exposures) regarding an automatic dishwashing tablet which could not be identified due to incomplete information relating to the product being available to the enquirer. Traditional tablets Over half of 503 enquiries (n=266, 52.9%) were received from NHS (National Health Service) Direct and NHS 24 [Scotland]. NHS Direct closed on March 31 2014 in England (though not in Wales) and was replaced by NHS 111. These services provide the public with advice on health issues. Enquiries from general practices, including out-of-hours services (n=146; 29.0%), hospitals (n=65; 12.9%), ambulance services (n=24, 4.8%) and walk-in centres (n=2, 0.4%) accounted for the remainder of the enquiries. The majority (n=440, 89.4%) of the 492 exposures involved children (<18 years); most were aged 5 years or less (n=430, 87.4%) but there were also two cases where the age of the child was not known. Of the remaining 52 adult cases, the adult age group most frequently reported to have been exposed to traditional dishwashing tablets were those aged 70 years or greater (n=19, 36.5%). In two adult exposures cases, the exact patient age was not known. Exposure occurred at home in the majority of cases (n=483, 98.2%). The other nine cases (1.8%) occurred in a nursing/care home. Ingestion alone accounted for most exposures (n=476, 96.7%). There were 11 other cases of ingestion which also involved other exposure routes, most commonly skin contact (n=10, 2.0%); the eye was also involved in one case (0.2%). The remaining 5 cases comprised eye contact alone (n=4, 0.8%) and skin contact alone (n=1, 0.2%). Information was available to permit product identification and, therefore, determination of the composition in 411 of the 492 cases (83.5%) (Table 1). A Poisoning Severity Score (PSS) was calculated at the time of the telephone enquiry in 487 (99.0%) of the 492 exposures (Table 2); insufficient details were given in the remaining 5 cases to determine the PSS. Most patients (n=383; 78.6%) had not developed any symptoms (PSS 0) at the time the enquiry was made. One hundred and three patients (21.1%) developed minor symptoms (PSS 1), and the remaining case was graded as moderate (PSS 2) toxicity due to prolonged vomiting for over 24 hours. There
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