Jacquelyn H. Clower

A Review of Disaster-Related Carbon Monoxide Poisoning: Surveillance, Epidemiology, and Opportunities for Prevention

OBJECTIVES We conducted a systematic literature review to better understand aspects of disaster-related carbon monoxide (CO) poisoning surveillance and determine potentially effective prevention strategies. METHODS This review included information from 28 journal articles on disaster-related CO poisoning cases occurring between 1991 and 2009 in the United States. RESULTS We identified 362 incidents and 1888 disaster-related CO poisoning cases, including 75 fatalities. Fatalities occurred primarily among persons who were aged 18 years or older (88%) and male (79%). Hispanics and Asians accounted for 20% and 14% of fatal cases and 21% and 7% of nonfatal cases, respectively. Generators were the primary exposure source for 83% of fatal and 54% of nonfatal cases; 67% of these fatal cases were caused by indoor generator placement. Charcoal grills were a major source of exposure during winter storms. Most fatalities (94%) occurred at home. Nearly 89% of fatal and 53% of nonfatal cases occurred within 3 days of disaster onset. CONCLUSIONS Public health prevention efforts could benefit from emphasizing predisaster risk communication and tailoring interventions for racial, ethnic, and linguistic minorities. These findings highlight the need for surveillance and CO-related information as components of disaster preparedness, response, and prevention.

Carbon monoxide poisoning deaths in the United States, 1999 to 2012

BACKGROUND Unintentional, non-fire related (UNFR) carbon monoxide (CO) poisoning deaths are preventable. Surveillance of the populations most at-risk for unintentional, non-fire related (UNFR) carbon monoxide (CO) poisoning is crucial for targeting prevention efforts. OBJECTIVE This study provides estimates on UNFR CO poisoning mortality in the United States and characterizes the at-risk populations. METHODS We used 1999 to 2012 data to calculate death rates. We used underlying and multiple conditions variables from death records to identify UNFR CO poisoning cases. RESULTS For this study, we identified 6136 CO poisoning fatalities during 1999 to 2012 resulting in an average of 438 deaths annually. The annual average age-adjusted death rate was 1.48 deaths per million. Fifty four percent of the deaths occurred in a home. Age-adjusted death rates were highest for males (2.21 deaths per million) and non-Hispanic blacks (1.74 deaths per million). The age-specific death rate was highest for those aged ≥85 years (6.00 deaths per million). The annual rate of UNFR CO poisoning deaths did not change substantially during the study period, but we observed a decrease in the rate of suicide and unintentional fire related cases. CONCLUSION CO poisoning was the second most common non-medicinal poisonings death. Developing and enhancing current public health interventions could reduce ongoing exposures to CO from common sources, such as those in the residential setting.

Carbon monoxide-related hospitalizations in the U.S.: evaluation of a web-based query system for public health surveillance.

Objective. Carbon monoxide (CO) poisoning is preventable, yet it remains one of the most common causes of poisoning in the U.S. In the absence of a national data reporting system for CO-poisoning surveillance, the burden of CO-related hospitalizations is unknown. Our objective was to generate the first national estimates of CO-related hospitalizations and to evaluate the use of a Web-based query system for public health surveillance. Methods. The Healthcare Cost and Utilization Projects (HCUPs) 2005 Nationwide Inpatient Sample (NIS) data were used for CO-related hospitalization estimates. Data for confirmed, probable, and suspected cases were generated using the HCUPnet Web-based query system. We used data from 1993 through 2005 NIS to describe trends in CO-related hospitalizations. We used the Centers for Disease Control and Preventions surveillance evaluation guidelines to evaluate the system. Results. In 2005, there were 24,891 CO-related hospitalizations nationwide: 16.9% (n=4,216) were confirmed, 1.1% (n=279) were probable, and 81.9% (n=20,396) were suspected CO-poisoning cases. Of the confirmed cases (1.42/100,000 population), the highest hospitalization rates occurred among males, older adults (aged ≥85 years), and Midwestern residents. CO-related hospitalization rates declined from 1993 through 2000 and plateaued from 2001 through 2005. The simplicity, acceptability, sensitivity, and representativeness of the HCUPnet surveillance system were excellent. However, HCUPnet showed limited flexibility and specificity. Conclusions. Nationwide, the burden of CO exposure resulting in hospitalization is substantial. HCUPnet is a useful surveillance tool that efficiently characterized CO-related hospitalizations for the first time. Public health practitioners can utilize this data source for state-level surveillance.

Carbon Monoxide Poisoning After an Ice Storm in Kentucky, 2009

Objectives. Carbon monoxide (CO) poisoning is a leading cause of morbidity and mortality during natural disasters. On January 26–27, 2009, a severe ice storm occurred in Kentucky, causing widespread, extended power outages and disrupting transportation and communications. After the storm, CO poisonings were reported throughout the state. The objectives of this investigation were to determine the extent of the problem, identify sources of CO poisoning, characterize cases, make recommendations to reduce morbidity and mortality, and develop prevention strategies. Methods. We obtained data from the Kentucky Regional Poison Center (KRPC), hyperbaric oxygen treatment (HBOT) facilities, and coroners. Additionally, the Kentucky Department for Public Health provided statewide emergency department (ED) and hospitalization data. Results. During the two weeks after the storm, KRPC identified 144 cases of CO poisoning; exposure sources included kerosene heaters, generators, and propane heaters. Hospitals reported 202 ED visits and 26 admissions. Twenty-eight people received HBOT. Ten deaths were attributed to CO poisoning, eight of which were related to inappropriate generator location. Higher rates of CO poisoning were reported in areas with the most ice accumulation. Conclusions. Although CO poisonings are preventable, they continue to occur in postdisaster situations. Recommendations include encouraging use of CO alarms, exploring use of engineering controls on generators to decrease CO exposure, providing specific information regarding safe use and placement of CO-producing devices, and using multiple communication methods to reach people without electricity.

National carbon monoxide poisoning surveillance framework and recent estimates.

Objectives. Unintentional, non-fire-related (UNFR) carbon monoxide (CO) poisoning is a leading cause of poisoning in the United States. A comprehensive national CO poisoning surveillance framework is needed to obtain accurate estimates of CO poisoning burden and guide prevention efforts. This article describes the current national CO poisoning surveillance framework and reports the most recent national estimates. Methods. We analyzed mortality data from the National Vital Statistics System multiple cause-of-death file, emergency department (ED) and hospitalization data from the Healthcare Cost and Utilization Projects Nationwide Emergency Department Sample and Nationwide Inpatient Sample, hyperbaric oxygen treatment (HBOT) data from HBOT facilities, exposure data from the National Poison Data System, and CO alarm prevalence data from the American Housing Survey and the National Health Interview Survey. Results. In the United States, 2,631 UNFR CO deaths occurred from 1999 to 2004, an average of 439 deaths annually. In 2007, there were 21,304 (71 per one million population) ED visits and 2,302 (eight per one million population) hospitalizations for confirmed cases of CO poisoning. In 2009, 552 patients received HBOT, and from 2000 to 2009, 68,316 UNFR CO exposures were reported to poison centers. Most nonfatal poisonings were among children (<18 years of age) and females; hospitalizations and deaths occurred more frequently among males and elderly people (>65 years of age). More poisonings occurred during winter months and in the Midwest and Northeast. Conclusions. UNFR CO poisoning poses a significant public health burden. Systematic evaluation of data sources coupled with modification and expansion of the surveillance framework might assist in developing effective prevention strategies.

Recipients of hyperbaric oxygen treatment for carbon monoxide poisoning and exposure circumstances

BACKGROUND Unintentional carbon monoxide poisoning is preventable. Severe cases are often referred for hyperbaric oxygen treatment. To guide prevention efforts and treatment practices, this study provides some of the most detailed current information about patients with carbon monoxide poisoning who have been treated at hyperbaric facilities across the United States and the circumstances surrounding their exposures. This study can help improve efforts to prevent carbon monoxide poisoning and enhance treatment practices. METHODS From August 2008 to January 2010, nonidentifiable, patient-level data were reported by 87 hyperbaric facilities in 39 states via an online reporting system. This reporting system was developed collaboratively by the Undersea and Hyperbaric Medical Society and the Centers for Disease Control and Prevention. RESULTS Among the 864 patients reported to receive hyperbaric oxygen treatment for unintentional, non-fire-related, carbon monoxide poisoning, most of the patients were white men aged between 18 and 44 years. Only 10% of patients reported the presence of a carbon monoxide alarm at their exposure location, and 75% reported being part of a group exposure. Nineteen patients (2%) reported a prior carbon monoxide exposure. About half (55%) of the patients treated were discharged after treatment; 41% were hospitalized. CONCLUSIONS The findings in this report expand the knowledge about patients with carbon monoxide poisoning. These results suggest that prevention efforts, such as educating the public about using carbon monoxide alarms and targeting the most at-risk populations, may help reduce the number of exposures, the number of persons with chronic cognitive sequelae, and the resulting burden on the health care system.

Residential Carbon Monoxide Alarm Prevalence and Ordinance Awareness

OBJECTIVE Unintentional carbon monoxide (CO) poisoning is a leading cause of poisoning in the United States. Most poisoning cases occur in residential settings and a working CO alarm may prevent many of these events. The use of a CO alarm is mandated in many parts of the country; however, little is known about the compliance and adoption of such ordinances at the population level. This study determined the prevalence of residential CO alarm and awareness of a 2001 CO alarm ordinance in Mecklenburg County, North Carolina in 2009. METHODS A random sample of households stratified by housing type (eg, single-family homes, multifamily homes) was included in a cross-sectional survey conducted. One adult respondent from each household was administered a questionnaire that included information on sociodemographic and household characteristics, presence of a CO alarm, and CO alarm ordinance awareness. Data were analyzed using multivariate stratified conditional logistic regression. RESULTS Among 214 participating households (response rate, 23.4%), 145 (67.8%) reported having a working CO alarm and 79 (36.9%) of the respondents were aware of the CO alarm ordinance. Respondents who were aware of the ordinance had 9 times higher odds (95% confidence interval, 3.3-25.9) of having a CO alarm than those who were unaware. Also, households with an attached garage had more than 2 times higher odds (95% confidence interval, 1.0-6.2) of having a CO alarm than those without an attached garage. Awareness of the CO alarm ordinance was not associated with any sociodemographic (eg, age, sex, race, education, income) or household (eg, home ownership, home construction year) characteristics. CONCLUSIONS Carbon monoxide alarm prevalence in Mecklenburg County households was higher than the national average and was associated with CO alarm ordinance awareness. Public health efforts might benefit from regulations aimed at population-level adoption of preventive health behaviors.