(text extracted from IUTOX Newsletter 11/2005, http://www.iutox.org/newsletter_11_05Full.asp)
Updated version, latest update 2007-02-21
Herbert Desel and Georg Friedrich Kahl
Clinical Toxicology Laboratory and GIZ-Nord Poisons Centre
Department of Pharmacology and Toxicology
University Medicine Göttingen, Georg-August-University
D-37099 Göttingen, Germany
The exact number of patients suffering from poisonings per year in Germany is unknown. Similar to most other countries, the vast majority of xenobiotics-related deaths are caused by chronic exposures, mainly to tobacco smoke (more than 100.000 deaths per year) and diesel fuel emissions (more than 9.000 deaths per year).
Institutions and professionals working in Clinical Toxicology preferentially deal with acute poisonings. Exposures to overdoses of ethanol (unknown number of cases), drugs of abuse (about 1500 deaths per year), fire smoke (about 500 deaths per year), and overdoses of medical drugs (10,000–20,000 cases per year, about 100 deaths) show the highest frequencies.
Treatment of Poisoned Patients
Family doctors usually take care of the mildly poisoned patients. Severe intoxications are primarily treated by doctors trained in emergency medicine at the patient’s home or at the workplace before they are transported to a hospital. Almost all emergency units and the majority of intensive care units (ICU) treat intoxications. There are 3 ICUs in Germany (in Berlin, Mainz, and Munich) with primary focus on toxicological cases.
Education of Specialists
There is no educational degree in clinical toxicology for medical doctors in Germany. Therefore, doctors treating poisoned patients are not formally educated in clinical toxicology, but in emergency medicine or internal medicine. Pediatricians usually treat poisoned children. Professional advice on cases of high risk or rare poisonings is frequently provided by specially trained medical doctors in German poisons information centers.
Poisons Information and Surveillance System
The Chemicals Act (Chemikaliengesetz) provides the legal basis for the establishment and maintenance of poisons information centers (PICs, Giftinformationszentren) by all federal states (Länder) of Germany. The Federal Institute for Risk Assessment (BfR) and the Federal Office of Consumer Protection and Food Safety (BVL) collect and distribute data on hazardous products and poisoning risks.
Poisons Information Centers (Giftinformationszentren) in Germany
The basic functions of the PICs as described (and ordered) by law are collecting data on frequencies and causes of intoxications in Germany and reporting these data to the BfR, and giving advice in all cases of poisoning to the public and to medical professionals.
In addition, PICs work in prevention of poisoning. They teach clinical toxicology to medical professionals and to the public and prepare toxicological expert’s reports. Most PICs are involved in scientific projects by documenting important intoxications in medical literature. All 16 federal states of Germany have officially notified PICs. Some states have one PIC (or even 2 PICs) providing service only for one state while most other Länder have recently founded PICs serving two to four states. In total ten German PICs are on duty, twenty-four hours per day (further information: www.giftinformationszentrum.de).
Medical doctors, primarily educated and experienced in different medical disciplines, provide advice by telephone, email, fax, or traditional mail. Typical consultations include all aspects of poisonings, e.g. identification of product and its ingredients, risk assessment, and recommendations for diagnostic and therapeutic procedures. Cases with rare poisons or new products are documented carefully by follow up calls. All consultations are integrated in a database and analysed for frequencies and poisoning trends. Most German PICs regularly produce annual reports; a national report for 2005 is in preparation.
German PICs report to the BfR, regularly by providing annual reports and additionally by case series requested on purpose.
Federal Institute for Risk Assessment (Bundesinstitut für Risikobewertung, BfR, www.bfr.bund.de)
The Federal Institute for Risk Assessment (BfR) has – among many other tasks - important legal functions in the handling of poisoning risk: it collects data on consumer products on the German market, especially those that have to be labelled as caustic (or toxic) as notified by companies. This data is distributed monthly to all PICs.
Furthermore, all medical doctors who treat patients poisoned with chemicals (and many other poisonous products except contaminated food or medical drugs) have to report clinical data of these cases to the BfR. However, annual reports of this data collection show that only a small fraction of all cases is reported.
Until 2002, the preceding institute of the BfR hosted the Committee on Detection and Treatment of Acute Poisonings (“Giftkommission”), a group of experts from poisons information centers, toxicology and clinical departments with broad experience in clinical toxicology. This committee has developed 800 monographs on diagnosis and treatment of specific poisonings and on antidotes in the German language that have been distributed to the PICs. Unfortunately, this work has been discontinued.
Federal Office of Consumer Protection and Food Safety (Bundesamt für Verbraucherschutz und Lebensmittelsicherheit, BVL, www.bvl.bund.de)
The Federal Office for Consumer Protection and Food Safety (BVL) also has functions in the management of acute poisonings. By law, it has to collect data on all cosmetic products on the German market as notified by companies. This data is another important tool for consultations in the PICs. In addition, information on poisoning risks from food, exchanged between European authorities via the Rapid Alert System for Food and Feed (RASFF), is delivered to all German PICs daily.
Toxicological Documentation and Information Network (Toxikologischer Dokumentations- und Informationsverbund, TDI, www.tdi-network.org)
TDI Research Project
The Toxicological Documentation and Information Network (TDI) was initiated and is sponsored as a research and development project since 1999 by the German Federal Ministry for the Environment, Natural Conservation, and Nuclear Safety. Within this project, a computer network system has been developed for automatic transfer of data between industrial companies and PICs on consumer products using a European standard format (EAPCCT) (in the beginning mainly on household cleaning product and biocides). Tools developed in the project include a detailed description of a protocol for data distribution between multiple senders and several independent receivers (allowing transfer of document add-ons and corrections), a product data exchange format RML (Rosetta Markup Language), a data acquisition program for companies and database software for PICs.
The TDI networking system has been in place since 2003. Data of more than 2000 products have been distributed between all German PICs that use the TDI database daily for data retrieval.
Society of Clinical Toxicology (Gesellschaft für Klinische Toxikologie, GfKT, www.klinitox.de)
The Society for Clinical Toxicology, GfKT, is an association of professionals in clinical toxicology from Austria, Germany, and Switzerland. The GfKT organizes annual meetings on quality control and quality assurance in (German speaking) PICs (visited also by doctors from poisoning treatment facilities).
GfKT committees are working on development of poison information monographs on medical drugs, on quality control in PIC work, on cooperation with non-medical experts on mushrooms, and on detection of frequent causes of lethal intoxications.
Laboratories with Toxicology Services
Many hospital laboratories provide analytical service for poisonings. Besides determination of ethanol in blood, immunochemical assays on drugs of abuse are available in almost every hospital lab. Assays for determination of medical drugs with low therapeutic index, e.g. digitoxin, carbamazepin, or valproate, in blood plasma are available in larger hospitals.
Other important toxicological tests, i.e. assay on amanitins (toxins from Amanita phalloides and related mushrooms), on paracetamol, methanol, ethylene glycol or glycol ethers, are only available in about 10 –20 laboratories in the whole country. Moreover, only a few laboratories are able to detect rare poisons using chromatographic methods or providing systematic toxicological analyses, i.e., screening for primarily unknown substances in body fluids preferentially using mass selective detection after chromatographic separation of compounds.
Society of Toxicological and Forensic Chemistry (Gesellschaft für Toxikologische und Forensische Chemie, GTFCh, www.gtfch.org)
The Society on Toxicological and Forensic Chemistry (GTFCh) is the association for German speaking experts for chemical analyses in cases of poisoning or drug abuse. The GTFCh organizes biannual meetings and contributes regularly to conferences organized by other organizations, e.g. the biannual Analytica in Munich. Several guidelines on analytical procedures have been developed and are available from the GTFCh Web site (partly in English translation).
The Committee on Clinical Toxicology of the GTFCh was established by about 30 professionals involved in emergency analyses to support diagnosis and treatment of acute poisonings in five countries in Europe. Beside other activities the committee is developing a database on availability of toxicological laboratories and analyses and a database containing information on pharmacokinetic/toxicokinetic data. Recent topics are validation of methods for emergency analyses for rare poisons and toxicological analyses for patients with suspected brain death.
Many professionals in clinical toxicology from Germany are personal members of the European Association for Poisons Centres and Clinical Toxicology (EAPCCT, www.eapcct.org) and contribute regularly to the annual scientific EAPCCT congresses.