Josh Schier

Notes from the field: Kratom (Mitragyna speciosa) exposures reported to poison centers - United States, 2010-2015

Kratom (Mitragyna speciosa) is a plant consumed throughout the world for its stimulant effects and as an opioid substitute (1). It is typically brewed into a tea, chewed, smoked, or ingested in capsules (2). It is also known as Thang, Kakuam, Thom, Ketum, and Biak (3). The Drug Enforcement Administration includes kratom on its Drugs of Concern list (substances that are not currently regulated by the Controlled Substances Act, but that pose risks to persons who abuse them), and the National Institute of Drug Abuse has identified kratom as an emerging drug of abuse (3,4). Published case reports have associated kratom exposure with psychosis, seizures, and deaths (5,6). Because deaths have been attributed to kratom in the United States (7), some jurisdictions have passed or are considering legislation to make kratom use a felony (8). CDC characterized kratom exposures that were reported to poison centers and uploaded to the National Poison Data System (NPDS) during January 2010-December 2015. The NPDS is a national database of information logged by the countrys regional poison centers serving all 50 United States, the District of Columbia, and Puerto Rico and is maintained by the American Association of Poison Control Centers. NPDS case records are the result of call reports made by the public and health care providers.

Severe Illness Associated with Reported Use of Synthetic Cannabinoids - Mississippi, April 2015.

On April 2, 2015, four patients were evaluated at the University of Mississippi Medical Center (UMMC) in Jackson, Mississippi, for agitated delirium after using synthetic cannabinoids. Over the next 3 days, 24 additional persons went to UMMC with illnesses suspected to be related to synthetic cannabinoid use; one patient died. UMMC notified the Mississippi State Department of Health, which issued a statewide alert via the Health Alert Network on April 5, requesting that health care providers report suspected cases of synthetic cannabinoid intoxication to the Mississippi Poison Control Center (MPCC). A suspected case was defined as the occurrence of at least two of the following symptoms: sweating, severe agitation, or psychosis in a person with known or suspected synthetic cannabinoid use. A second statewide alert was issued on April 13, instructing all Mississippi emergency departments to submit line lists of suspected patients to MPCC each day. By April 21, 16 days after the first alert was issued, MPCC had received reports of approximately 400 cases, including eight deaths possibly linked to synthetic cannabinoid use; in contrast, during April 2012–March 2015, the median number of telephone calls to MPCC regarding synthetic cannabinoid use was one per month (range = 0–11). The Mississippi State Department of Health, with the assistance of CDC, initiated an investigation to better characterize the outbreak, identify risk factors associated with severe illness, and prevent additional illnesses and deaths.

Hepatotoxicity associated with weight loss or sports dietary supplements, including OxyELITE Pro™ — United States, 2013

In September 2013, the Hawaii Department of Health (HDOH) was notified of seven adults who developed acute hepatitis after taking OxyELITE Pro™, a weight loss and sports dietary supplement. CDC assisted HDOH with their investigation, then conducted case-finding outside of Hawaii with FDA and the Department of Defense (DoD). We defined cases as acute hepatitis of unknown etiology that occurred from April 1, 2013, through December 5, 2013, following exposure to a weight loss or muscle-building dietary supplement, such as OxyELITE Pro™. We conducted case-finding through multiple sources, including data from poison centers (National Poison Data System [NPDS]) and FDA MedWatch. We identified 40 case-patients in 23 states and two military bases with acute hepatitis of unknown etiology and exposure to a weight loss or muscle building dietary supplement. Of 35 case-patients who reported their race, 15 (42.9%) reported white and 9 (25.7%) reported Asian. Commonly reported symptoms included jaundice, fatigue, and dark urine. Twenty-five (62.5%) case-patients reported taking OxyELITE Pro™. Of these 25 patients, 17 of 22 (77.3%) with available data were hospitalized and 1 received a liver transplant. NPDS and FDA MedWatch each captured seven (17.5%) case-patients. Improving the ability to search surveillance systems like NPDS and FDA MedWatch for individual and grouped dietary supplements, as well as coordinating case-finding with DoD, may benefit ongoing surveillance efforts and future outbreak responses involving adverse health effects from dietary supplements. This investigation highlights opportunities and challenges in using multiple sources to identify cases of suspected supplement associated adverse events. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Evaluation of Exposure-Type Stratification to Improve Poison Center Surveillance

Objective Our objective was to determine if the detection performance of current surveillance algorithms to detect call clusters is improved by stratifying by exposure category. Introduction The Centers for Disease Control and Prevention (CDC) uses the National Poison Data System (NPDS) to conduct surveillance of calls to United States poison centers (PCs) to identify clusters of reports of hazardous exposures and illnesses. NPDS stores basic information from PC calls including call type (information request only or call reporting a possible chemical exposure), exposure agent, demographics, clinical, and other variables. CDC looks for anomalies in PC data by using automated algorithms to analyze call and clinical effect volume, and by identifying calls reporting exposures to pre-specified high priority agents. Algorithms analyzing call and clinical effect volume identify anomalies when the number of calls exceeds a threshold using the historical limits method (HLM). Clinical toxicologists and epidemiologists at the American Association of Poison Control Centers and CDC apply standardized criteria to determine if the anomaly is a potential incident of public health significance (IPHS) and then notify the respective health departments and PCs as needed. Discussions with surveillance system users and analysis of past IPHS determined that call volume-based surveillance results in a high proportion of false positive anomalies. A study assessing the positive predictive value (PPV) of this approach determined that fewer than four percent of anomalies over a five-year period were IPHS. 1 A low PPV can cause an unnecessary waste of staff time and resources. We hypothesized that first stratifying call volume by exposure category would reduce the number of false positives. With the help of medical toxicologists, we created 20 toxicologically-relevant exposure categories to test this hypothesis. Methods To compare cluster detection performance between the two approaches, we used a historical testbed of hourly exposure call counts with and without initial stratification by exposure category from 10 selected PCs from Jan 1, 2006 - Jul 31, 2015. We ran the HLM for both non-stratified and stratified testbeds to estimate the monthly number of anomalies triggered (i.e., alert burden). Our target signals to assess detection performance consisted of call samples from three large public health events: the 2009 Salmonella food poisoning event from contaminated peanut butter, the 2012 Hurricane Sandy- associated carbon monoxide poisonings in New Jersey, and the 2014 Elk River contaminated water spill in West Virginia (WV). For each event, we chose 30 random calls one thousand times to obtain 1000 random sets of inject clusters. Each inject cluster was iteratively added into the testbed with and without initial stratification by exposure category. We then applied the HLM for each iteration to see if the algorithm identified the inject cluster. The sensitivity for each approach for each PC was calculated as the proportion of iterations where the algorithm identified the inject cluster. We reported median sensitivities from the ten PCs for each of the time windows of 1, 2, 4, 8, and 24 hours. Results Figure 1 summarizes results for the WV event with markers showing anomaly burden (x-axis) and sensitivity (y-axis) using the stratified ( Δ ) and the non-stratified (o) approach by different time windows (hrs). The results from the other two events are not shown but established similar patterns. Anomaly burden is shown as the estimated monthly anomaly count for each approach. For example, markers linked by the arrow show that with a 4-hour time window, the stratified approach achieves nearly perfect sensitivity with ~10 anomalies as the monthly anomaly burden while sensitivity of the non-stratified approach is below 20% with ~40 monthly anomalies. The stratified approach gave improved overall sensitivity across all time windows, and reduced anomaly burden for 1-, 2-, and 4-hour time windows. Conclusions We found a consistent detection advantage (higher sensitivity and lower anomaly burden) for the stratified vs traditional non- stratified approach for 1-, 2-, and 4-hour time windows. Further research should focus on refining the stratified approach and the specific surveillance parameters (such as time windows) that increase algorithm performance. Figure 1: Detection performance comparison: stratified vs non-stratified approach; 2014 Elk River contaminated water spill in West Virginia scenario

Characterization of Carbon Monoxide Exposure During Hurricane Sandy and Subsequent Nor’easter

OBJECTIVE Carbon monoxide (CO) is an odorless, colorless gas produced by fossil fuel combustion. On October 29, 2012, Hurricane Sandy moved ashore near Atlantic City, New Jersey, causing widespread morbidity and mortality,

Increase in Adverse Health Effects Related to Synthetic Cannabinoid Use

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Notes from the field: increase in reported adverse health effects related to synthetic cannabinoid use - United States, January-May 2015

50 billion in economic damage, and 8.5 million households to be without power. The combination of power outages and unusually low temperatures led people to use alternate power sources, placing many at risk for CO exposure. METHODS We examined Hurricane Sandy-related CO exposures from multiple perspectives to help identify risk factors and develop strategies to prevent future exposures. This report combined data from 3 separate sources (health departments, poison centers via the National Poison Data System, and state and local public information officers). RESULTS Results indicated that the number of CO exposures in the wake of Hurricane Sandy was significantly greater than in previous years. The persons affected were mostly females and those in younger age categories and, despite messaging, most CO exposures occurred from improper generator use. CONCLUSIONS Our findings emphasize the continued importance of CO-related communication and ongoing surveillance of CO exposures to support public health response and prevention during and after disasters. Additionally, regional poison centers can be a critical resource for potential on-site management, public health promotion, and disaster-related CO exposure surveillance. (Disaster Med Public Health Preparedness. 2017;11:562-567).

Use of the National Poison Data System after the 2011 Japan radiological incident for surveillance of incident-related exposures in the United States

Introduction Synthetic cannabinoids include various psychoactive chemicals that are sprayed onto plant material, which is then smoked or ingested to achieve a “high.” These products are sold under a variety of names (e.g., synthetic marijuana, spice, K2, black mamba, and crazy clown) and are sold in retail outlets as herbal products and are often labeled not for human consumption. Law enforcement agencies regulate many of these substances; however, manufacturers may frequently change the formulation and mask their intended purpose to avoid detection and regulation. On April 6, 2015, automated surveillance algorithms via surveillance through the National Poison Data System (NPDS), a web-based surveillance system of all calls to United States (US) poison centers (PCs), identified an increase in calls to PCs related to synthetic cannabinoid use. To identify risk factors and adverse health effects, CDC analyzed all calls to PCs about synthetic cannabinoid use from January to May, 2015.