Introduction
Organophosphate (OP) poisoning remains a significant public health concern worldwide, particularly in rural communities, especially in developing countries where agriculture is a primary economic activity. Studies have consistently reported high rates of OP poisoning among agricultural workers, particularly those involved in pesticide application, mixing, and storage [1, 2]. South and Southeast Asia have recorded some of the highest rates of OP poisoning, with India and Bangladesh experiencing significant burdens [3]. Sub-Saharan Africa has also seen a considerable number of cases, particularly in agriculture-dependent countries [4]. While data may be limited in some regions, Latin American countries have also reported instances of OP poisoning in rural communities [5].
Younger individuals, particularly those under 18, and men working in agricultural settings are at a heightened risk of OP poisoning [6]. These groups often have higher levels of exposure due to direct contact with pesticides during spraying or planting activities, and in many cases, there are limited protective measures in place [7]. Lower education levels are also associated with higher rates of poisoning, as individuals may have limited knowledge about pesticide safety [8]. Poverty and lack of access to healthcare further contribute to higher poisoning rates due to limited preventive measures and delayed medical care [9].
Recent statistics indicate that OP poisoning remains a significant public health concern, with an estimated 3 million cases of pesticide poisoning reported annually globally. In rural agricultural areas, the mortality rate due to OP poisoning is particularly high, with a recent study showing an increase in pesticide-related fatalities over the past decade [2]. Rural communities often face limited access to healthcare facilities, specialized medical expertise, and timely treatment for OP poisoning, and organophosphorus toxins continue to be a leading cause of poisoning worldwide, especially in agricultural communities [2, 4]. Despite advances in medical treatment, gaps remain in the availability of effective antidotes and long-term management strategies, particularly in rural areas where healthcare access is limited. Preventive measures, such as promoting the safe use, storage, and disposal of pesticides, as well as using personal protective equipment (PPE), are crucial in reducing the incidence of OP poisoning [5]. Educational campaigns to raise awareness about pesticide risks, proper handling techniques, and the importance of medical checkups for those in high-risk occupations can further mitigate exposure.
The development of evidence-based guidelines for the management of OP poisoning in rural communities is crucial to improve outcomes and reduce the burden of this health problem. Ongoing research is exploring new treatment options and strategies for OP poisoning. Moreover, OP poisoning can have significant social and economic consequences for individuals, families, and communities. While treatment is crucial, preventive measures are equally important in reducing the burden of OP poisoning. By synthesizing the existing literature, this systematic review will provide a comprehensive overview of the current state of knowledge regarding the management of OP poisoning, particularly in rural communities. The findings may inform the development of guidelines, recommendations, and future research directions.

Method
The PRISMA guidelines were followed in the selection, inclusion, and analysis of studies for this review. This ensured a rigorous and transparent review process, focusing on high-quality studies that met the inclusion criteria.

Search strategy
The search strategy utilized Boolean operators (AND, OR) to combine keywords. For example, ‘OP poisoning’ AND ‘agriculture workers’ OR ‘pesticide exposure’ was used to narrow the search results to the most relevant studies. To identify relevant studies, a comprehensive search was conducted using the following databases: PubMed, Scopus, Web of Science, and Google Scholar. The search terms used included “organophosphate poisoning”, “organophosphate treatment”, “organophosphate management”, “organophosphate prevention”, and “organophosphate outcomes”. Additional relevant keywords were also considered, such as “pesticide poisoning,” “agricultural communities,” and “healthcare access”.

Inclusion and exclusion criteria
All studies in which OP poisoning was reported between 2014 and 2024 were included. The selection of studies from 2014 to 2024 was made to ensure the review reflects the most current research on OP poisoning, including advances in treatment options, new findings on exposure risks, and the evolving epidemiology of pesticide poisoning. The included original articles reported on some or all of the following: studies on humans (including randomized controlled trials, observational studies, case-control studies, and cohort studies). Studies that provided quantitative data on outcomes related to the treatment, management, or prevention of OP poisoning were also included. Studies using the Newcastle-Ottawa scale (NOS) for observational studies with a score of 7 or higher were included. Conference abstracts and duplicate publications were identified through a combination of manual checking and using reference management EndNote software, version X9. Any duplicate studies were excluded from the final analysis to ensure the accuracy and integrity of the review process.

Data extraction and synthesis
Data were extracted independently by two reviewers using a standardized data extraction form. Discrepancies were resolved through discussion and consensus. The following information was extracted from each study: Study title, the name of authors, year of publication, study design, and findings. The extracted data were synthesized using a narrative approach. Findings were categorized based on the subtopics addressed in the studies, such as treatment, prevention, and outcomes.

Results

Characteristics of the studies
A total of 152 articles were retrieved through the literature search (Figure 1). Of these, 80 articles were retained after removing duplicates; 51 were excluded due to irrelevance based on their titles and abstracts, and 29 were retained for full-text evaluation. Finally, after a detailed full-text evaluation, 25 articles published between 2019 and 2024 were included. 

Studies included after full-text evaluation
Table 1 shows the distribution of studies included after full-text evaluation. In terms of study design, of the 25 articles, 10 were retrospective studies, 5 were case-control studies/reports, 5 were cross-sectional studies, and 2 were observational studies. There was 1 randomized controlled trial, 1 experimental study, and 1 cohort stud.  The studies included in this review were conducted in various countries, including Asia (India, Pakistan, Bangladesh, Sri Lanka, China, and Nepal), Africa (Ethiopia and South Africa), Europe (Turkey), and potentially North America (US or Canada). Data on the consequences of OP poisoning from this study range from muscarinic effects (salivation, lacrimation, urination, defecation, miosis, and bradycardia), nicotinic effects (muscle weakness, fasciculations, and paralysis), and central nervous system effects (confusion, seizures, and coma). In severe cases, respiratory failure and death were reported. The pooled study reported India as the country with the highest mortality rate from OP poisoning (11.5%). The management of OP poisoning in this review involves a combination of antidotal therapy and supportive care. Antidotal therapy includes the administration of atropine to block muscarinic effects and pralidoxime to reactivate inhibited acetylcholinesterase. Supportive care measures, such as mechanical ventilation and fluid and electrolyte management, were also reported. 

Sociodemographic attributes of participating populations in the studies 
Three studies specifically focused on pediatric populations, while 7 studies specifically highlighted the risks faced by agricultural workers. Eight studies highlighted the impact of rural residence on OP poisoning (Table 2).
Thematic overview of OP poisoning: Epidemiology, Clinical manifestations, treatment strategies, and barriers to management based on recent studies
Table 3 presents a synthesis of key studies on OP poisoning, summarizing the epidemiological trends, clinical manifestations, and treatment modalities across diverse geographical regions. The table consolidates findings from verified research, offering insights into the global scope of OP poisoning, highlighting regional variations, and emphasizing gaps in clinical management and intervention strategies.

Discussion
This systematic review highlights significant research on the management of OP poisoning in rural communities. While notable progress has been made, challenges persist, particularly in low-resource areas. Key findings underscore the need for improved healthcare infrastructure, preventive measures, and better access to treatment in agricultural regions, where OP exposure is most prevalent. 

Geographical distribution and sociodemographic vulnerabilities
OP poisoning is most common in developing countries, particularly across Asia and Africa, where agriculture is central to the economy. The vulnerability of rural populations is compounded by limited healthcare access and insufficient awareness about the risks of pesticide exposure. Although many studies emphasize the importance of infrastructure improvements and education campaigns, it is clear that these interventions are not uniformly implemented, and their impact remains inconsistent. 
Particular attention should be paid to younger individuals, especially children and men working in agricultural settings, as these groups are at the highest risk. Children’s higher metabolic rates and increased hand-to-mouth contact make them especially vulnerable to pesticide exposure [17, 23, 24]. Agricultural workers, predominantly males, face the greatest occupational risks, with direct exposure to pesticides during spraying, mixing, and storage. Gender-related disparities also persist, although some studies highlight increased risks for women in domestic settings, particularly those involved in cleaning or gardening activities [16]. Studies also point to the critical role of education and income in the risk of OP poisoning. Low educational levels and poverty often correlate with increased exposure due to limited knowledge of safety practices and reduced access to healthcare [9]. A strong regulatory framework is essential to manage pesticide use effectively, but its enforcement varies widely across countries, further exacerbating risks in regions with weak oversight.

Types of OPs and health consequences
The diverse range of OPs used in agriculture, from less toxic variants, like malathion, to highly toxic compounds, like parathion, contributes to a broad spectrum of health effects. Acute toxicity can result in muscarinic, nicotinic, and central nervous system symptoms, while chronic exposure is linked to neurological, reproductive, and potentially carcinogenic health problems [11]. The severity of poisoning depends on several factors, including the type of OP, the dose, and the route of exposure, with children and individuals with preexisting health conditions being at greater risk. 

Management of OP poisoning
The treatment of OP poisoning remains a challenge, with atropine and pralidoxime being the primary interventions. However, their effectiveness can vary depending on the type of OP and the timing of administration. While atropine continues to be crucial in neutralizing the toxic effects of acetylcholine, the role of pralidoxime remains debated, with mixed findings regarding its effectiveness in improving outcomes [31]. Severe cases require intensive care, including mechanical ventilation and hemodialysis, to support vital functions [9]. Further research into alternative therapies, such as enzymes to detoxify OPs, may provide more targeted and effective treatments in the future [29]. Although many studies provide valuable insights into the prevalence, risk factors, and management of OP poisoning, there are notable limitations in the existing literature. The majority of studies have focused on short-term clinical outcomes, with limited attention given to long-term health consequences. Additionally, while many studies are concentrated on rural agricultural populations, their findings often lack generalizability to other settings due to variability in healthcare infrastructure and pesticide use practices. There is also a need for more robust, randomized clinical trials to assess the effectiveness of treatment protocols, particularly for pralidoxime and other emerging therapies. 

Conclusions
OP poisoning remains a critical public health issue with significant morbidity and mortality, especially in rural settings. The systematic review of 25 studies highlights the effectiveness of early diagnosis and timely intervention, particularly with the use of antidotes, such as atropine and pralidoxime. While acute management strategies are well-documented, there is a conspicuous gap in research regarding the long-term health outcomes and preventive strategies in rural and underserved populations. Additionally, while clinical management is relatively well-established, the accessibility of care in rural regions continues to pose significant barriers to optimal treatment. The review underscores the need for innovative approaches in both the prevention and management of OP poisoning, with a particular focus on leveraging technology and community-based interventions in rural areas.

Limitations of the study
The main limitation of this review was the potential for publication bias, which may have led to an over-representation of studies with positive findings. Many studies did not report detailed information on sociodemographic characteristics, particularly education and income levels. This lack of data hinders a comprehensive understanding of the factors influencing vulnerability to OP poisoning. Additionally, the quality of some studies may have been limited, which could affect the overall reliability of the findings. 

Recommendations
It is recommended to improve access to care by enhancing healthcare infrastructure in rural areas, including mobile clinics and telemedicine, to ensure timely treatment. Additionally, research should focus on the long-term outcomes of OP poisoning, particularly neurological and psychological effects. Preventive interventions should be developed and evaluated, with an emphasis on educational programs and safer pesticide handling in rural communities. The integration of digital health tools and telemedicine should be prioritized to improve access to diagnosis and care in underserved areas. Finally, community-based interventions should be implemented to empower local communities with the training and resources needed to prevent and manage OP poisoning effectively.

Implications for policymakers
Policymakers should prioritize investments in rural healthcare access, including mobile healthcare units, telemedicine, and local training programs to ensure timely care in underserved regions. Funding should be allocated for research into the long-term effects of OP poisoning, the development of new antidotes, and preventive strategies tailored to rural populations. Policies should strengthen the regulation of pesticide use, emphasizing safe handling and disposal to minimize exposure risks. Additionally, efforts should be made to support the integration of digital health tools and telemedicine into rural healthcare systems to improve care accessibility.

Implications for the public
The public should be educated about the risks of OP poisoning and the importance of seeking immediate medical treatment upon exposure. Awareness campaigns promoting the safe handling, storage, and disposal of OP pesticides should be encouraged to reduce accidental exposure. Communities should be empowered to take proactive steps in recognizing the symptoms of OP poisoning and accessing care, thereby reducing mortality. Furthermore, the public should advocate for improvements in healthcare infrastructure, including support for telemedicine and digital health solutions, to ensure timely care in rural areas.

Ethical Considerations

Compliance with ethical guidelines
There were no ethical considerations to be considered in this research. 

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
Conceptualization: Odochi O. Chukwu and Raphael C. Anakwue; Methodology, writing, review, and editing: Odochi O. Chukwu, Raphael C. Anakwue and Abdullateef I. Alagbonsi; Supervision: Raphael C. Anakwue and Abdullateef I. Alagbonsi; Data collection and data analysis: Odochi O. Chukwu and Cordilia O. Iyare; Final approval: All authors.

Conflict of interest
The authors declared no conflicts of interest.

Acknowledgments
The authors wish to acknowledge the support provided by their respective institutions during the course of this research. 




References