Guía de actuación y abordaje frente a intoxicación por dióxido de cloro/clorito de sodio, a partir de la experiencia de los CIAT de América Latina / Guidelines for action and approach to chlorine dioxide/sodium chlorite poisoning based on the experience of the CIATs in Latin America

Resumen El 11 de marzo de 2020, la Organización Mundial de la Salud, declaró la pandemia a nivel mundial por la COVID-19. Ante este escenario, los centros de información y asesoramiento toxicológico (CIAT) de América Latina comenzaron a recibir consultas por exposición/intoxicación a dióxido de cloro/clorito de sodio y sus compuestos relacionados, por desvío de uso, destinado a la prevención y/o tratamiento de la COVID-19 sin aval científico alguno ni contar con registro sanitario para ese fin. A través de la Red de Toxicología de América Latina y el Caribe (RETOXLAC), se comprobó que no eran hechos aislados, sino que se estaba produ ciendo el mismo fenómeno en toda la región y que existían antecedentes de intoxicaciones con dichos productos y alertas desde hace más de una década, con indicaciones no aprobadas, para el tratamiento de distintas patologías como SIDA, cáncer, esclerosis lateral amiotrófica ELA, malaria, autismo, entre otras, sin evidencia. Ante esta realidad, los CIAT presentan una revisión de los signos y síntomas observados según la vía de ingreso, basados en la comunicación de riesgo en salud; proponiéndose pruebas de apoyo al diagnóstico, algoritmo de tratamiento para las intoxicaciones y modelo de ficha clínica para la vigilancia epidemiológica de los casos atendidos. Recomendamos a las autoridades y organismos responsables, reforzar las acciones tendientes a la vigilancia, control y prevención de este tipo de intoxicaciones, producto del mal uso de un desinfectante no autorizado para fines terapéuticos/médicos.

Abstract On March 11th, 2020, the World Health Organization declared a global pandemic due to COVID-19. Faced with this sce- nario, the Poison Control Centers (CIATs for its initials in spanish) in Latin America began to receive consultations for exposure/poi- soning to chlorine dioxide/sodium chlorite and its related compounds for their use aimed to prevent or treat COVID-19 without any scientific endorsement or having a sanitary registry for that purpose. It was found through the Toxicology Network of Latin America and the Caribbean (RETOXLAC) that they were not isolated events but rather that the same phenomenon was occurring throughout the region and that there has been a history of poisoning and alerts with these products for more than a decade with unapproved indications for the treatment of different pathologies such as AIDS, cancer, amyotrophic lateral sclerosis (ALS), malaria, autism, among others, without evidence. In the light of this situation, the CIATs present a review of the signs and symptoms observed ac- cording to the route of exposure based on health risk communication; proposing tests to support the diagnosis, an algorithm for poisoning treatment, and a model of a clinical record for the epidemiological surveillance of the assisted cases. We recommend to the authorities and responsible organisms reinforce the actions aimed at surveillance, control, and prevention of this type of poisoning due to the misuse of an unauthorized disinfectant for therapeutic or medical purposes.

Caracterización epidemiológica de las exposiciones a dióxido de cloro/clorito de sodio en el contexto de la pandemia COVID-19: Reporte de los centros toxicológicos de América Latina / Epidemiological characterization of exposures to chlorine dioxide/ sodium chlorite in the context of the COVID-19 pandemic: Report of Poison Control Centers in Latin America

Resumen Los centros de información y asesoramiento toxicológico CIATs de América Latina, en el contexto de la pandemia de COVID-19, recibieron una serie de llamadas para consultas y asesoramientos relacionados con el uso de dióxido de cloro/clorito de sodio, que se estaban empleando en el tratamiento o prevención de dicha enfermedad. Dentro de la legislación vigente en los países de América Latina, no se contemplan productos farmacéuticos registrados para uso en humanos, ni se tiene evidencia de registros sanitarios en Europa, Canadá o Estados Unidos para tal fin, que contengan dióxido de cloro o clorito de sodio. Esta publicación, compila la información registrada como parte de la estadística del trabajo de ocho CIATs correspondientes a igual número de países de América Latina. Se identificó sexo, edad, sintomatología, circunstancia y grado de severidad de los 56 casos de pacientes intoxicados con dióxido de cloro/clorito de sodio registrados en el período del 15 de marzo al 30 de septiembre de 2020 en estos ocho países. Los resultados obtenidos confirman que la causa más común fue por mal uso, y el lugar de ocurrencia fue el hogar o sus alrededores, siendo el mayor porcentaje adultos jóvenes comprendidos entre 30 y 49 años. Los síntomas de intoxicación más frecuentemente encontrados fueron gastrointestinales, seguidos de cardiovasculares y respiratorios. La vía de ingreso al organismo en la mayoría de los casos fue por vía oral, reportándose algunos casos por vía inhalatoria, y en el 50% de los casos se constituyeron casos de severidad moderada, severa o fatal (3 fallecimientos). Este estudio contribuye a generar información relevante para las diferentes autoridades sanitarias, los ministerios de salud, las entidades encargadas de inspección, vigilancia y control de los países en los que se comercializan estos productos de manera ilegal por medio de redes sociales y promoviéndolos para uso en humanos para prevenir o curar COVID-19.

Abstract The Poison Control Centers in Latin America, in the context of COVID-19 pandemic, received a series of calls for consultations and recommendations related to the use of chlorine dioxide/sodium chlorite, in the treatment or prevention of CO-VID-19. Under current legislation in Latin America, no pharmaceutical products are registered for use in humans that contain chlorine dioxide or sodium chlorite, nor is there evidence of sanitary registries in Europe, Canada, or the United States for this purpose. This publication compiles the information registered by eight Poison Control Centers that correspond to the same number of Latin American countries. Sex, age, symptoms, circumstance, and degree of severity of the 56 cases of patients poisoned with chlorine dioxide/ sodium chlorite registered in the period from March 15th to September 30th, 2020 were identified. The results obtained confirm that the most common cause of poisoning was unintentional misuse, all of which occurred at home or its surroundings, with the highest percentage of registered cases being young adults between 30 and 49 years old. The most frequent symptoms of intoxication were gastrointestinal, followed by cardiovascular and respiratory. The route of exposure in most cases was oral, with some cases reported by inhalation; 48.2% of the cases were of moderate, severe, or fatal (3 deaths). This study contributes to the generation of relevant information for different health authorities, ministries of health, entities in charge of inspection, surveillance, and control in countries where these products are illegally marketed through social networks and promoted for use in humans to prevent or cure COVID-19.

Determination of Chlorite,Chlorate and Bromate in Drinking Water by Ion Chromatography / 环境与健康杂志

Objective To develop an ion chromatography (IC) for simultaneous determination of chlorite,chlorate and bromate in drinking water. Methods The IC separation was carried out with the IonPAC AS23 column by using 4.5 mmol/L Na2CO3-0.8 mmol/L NaHCO3 at the flow rate of 1.0 ml/min. The injection volume was 250 ?l,the temperature of conductivity detector cell and column were 30 ℃ and 35 ℃,respectively. The pressure upon the bottle of mobile phase was 40 kPa. The current of auto-regenerating suppressor was 25 mA. Results The results showed that in the range of 0 to 1 000 mg/L, the calibration equation for chlorite was y=0.009 6+1.600 0 x (r=0.999 3),for bromate was y=0.003 2+3.184 7 x (r=0.999 9),for chlorate was y= 0.001 8+1.788 9 x(r=0.999 9).The detection limit of chlorite,chlorate and bromate were all 5 ?g/ L,the recovery rates were 89.0% -108.0% and the relative standard deviations (RSD) were 0.21%-2.70%. Conclusion The method is simple,fast,accurate, sensitive,little interference and is applicable to the simultaneous determination of chlorite,chlorate and bromate in drinking water.

Methods for Components in Chlorine Dioxide Disinfectant / 环境与健康杂志

Objective In order to evaluate the quality and performance of chlorine dioxide disinfectant,it is necessary to develop a set of methods to determine the components in chlorine dioxide disinfectant.Methods Iodometry,malonic acid iodometry,improved malonic acid iodometry and five-step iodometry were employed to determine the components including ClO_2, Cl_2,ClO_2~-,and ClO_3~-in chlorine dioxide disinfectant,the advantages and disadvantages of the test methods were compared.Results Using iodometry,the liquid stabilized chlorine dioxide products activated by hydrochloric acid,the content of ClO_2 was 20.23 mg/ml that was accord with the content which was marked in the product label.Using malonic acid iodometriy,the liquid stabilized chlorine dioxide contents of ClO_2 was 19.99 mg/ml,Cl_2 was 0.35 mg/ml,in which a little chlorine was detected.Using improved malonate iodometry and five-step iodometry,the activation rates of the liquid stabilized chlorine dioxide products were 88.0% and 75.6% respectively,ClO_2 and ClO_2~-in the liquid stabilized chlorine dioxide products could be distinguished.Conclusion Active chlorine dioxide and residual ClO_2~-can be detected by using iodometriy and improved malonic acid iodometry,but iodometriy and malonic acid iodometry can not.

Priliminary Study on Chlorite Pollution of Drinking Water Disinfected by Chlorine Dioxide / 环境与健康杂志

[Objective] To explore the status of chlorite pollution in drinking water due to chlorine dioxide , aswell as its causes and counter measures. [Methods]A water plant collecting surface water as raw water slightly pol-luted by organic compounds and B water plant collecting ground water without organic compounds pollution wereselected as observed objectives. Chlorine dioxide generators were used in both of A and B water plants, their rawmaterials was chlorite for A plant and chlorate for B plant. The levels of chlorite in treated water from these twowater plants were determined by amperometric titration. [Results]The levels of chlorite in treated water of A waterplant ranged 0.530～0.760 mg/L, 2.6～3.8 times of the standard value, with a over standard rate of 100％, thelevels of B water plant range 0.257～0.733 mg/L, 1.3～3.7 times of the standard value, with a over standard rateof 83.3％. [Conclusion] The treated water of A and B water plants presented higher pollution by chlorite, the by-product of chlorine dioxide disinfection.