1. Review of state-level laws requiring carbon monoxide alarms in residential settings Presented by: Fuyuen Yip, PhD, MPH Air Pollution and Respiratory Health Branch, NCEH, CDC Co-authored by: J. Clower, S. Kershner, T. Boehmer, L. Caucci, S. Iqbal, Y. Wing Council of State and Territorial Epidemiologist’s Annual Conference June 5, 2012 National Center for Environmental Health Division of Environmental Hazards and Health Effects

2. Carbon Monoxide (CO)  Colorless, odorless gas  Produced due to incomplete combustion of hydrocarbons  Common sources:  Home heating & cooking appliances  Gas powered equipment  Motor vehicles  A leading cause of poisoning in the US

3. Epidemiology of Unintentional, Nonfire-related CO Exposures  Mortality & morbidity  >20,000 emergency department visits  ~2,300 hospitalizations  ~450 deaths  Populations affected  Non-fatal: Children (<5 years), Females  Fatal: Elderly (>65 years), Males  Season  Winter  Region  Midwest  Northeast

4. CO Poisoning Health Effects & Prevention  Non-specific flu-like symptoms:  Fatigue, dizziness, headache, confusion, nausea, vomiting  Collapse, coma, cardio-respiratory failure, & death  15%−49% develop neuro-cognitive sequelae  Most cases occur in residential settings  Preventable with installation of CO alarm  37% of U.S. households report having a CO alarm (2009 NHIS, National Household Interview Survey)

5. CO Alarm Guidance  Underwriter’s Laboratory (UL) approved  Battery-operated or have battery-back up  Located outside of sleeping areas in homes  In homes with fuel burning appliances  In homes with attached garages/parking

6. Public Health Law  Law can be an important tool to affect public health outcomes  States have powers to enact legislation and promulgate regulations to protect the public health, welfare, and morals, and to promote the common good  State laws include  Statutes that are adopted by legislature  Regulations that are promulgated by executive agencies

7. CO Alarm Laws  Sometimes adopted in response to CO poisoning events  CO alarm provision can be adopted as part of  Public health and safety laws  Landlord/tenant laws  More recently, through state adoption of large national or international code(s):  International Code Council (ICC) building, residential, and fire codes  National Fire Protection Agency (NFPA) codes and standards

8. International Code Council (ICC)  Nonprofit organization that develops comprehensive, coordinated building safety and fire prevention model codes (I-Codes)  I-Codes updated every 3 years  CO alarm provisions first included in 2009 IRC  I-Codes relevant to CO alarms:  International Residential Code (IRC)  International Building Code (IBC)  International Fire Code (IFC)  I-Codes must be adopted by state or local governments through statute or regulation

9. 2009 IRC SECTION R315 – CARBON MONOXIDE ALARMS ** IRC applies to detached one- and two-family dwellings and townhouses not more than three stories  R315.1 Carbon monoxide alarms. For new construction, an approved carbon monoxide alarm shall be installed outside of each separate sleeping area in the immediate vicinity of the bedrooms in dwelling units within which fuel-fired appliances are installed and in dwelling units that have attached garages.  R315.2 Where required in existing dwellings. Where work requiring a permit occurs in existing dwellings that have attached garages or in existing dwellings within which fuel-fired appliances exist, carbon monoxide alarms shall be provided in accordance with Section R315.1.  R315.3 Alarm requirements. Single station carbon monoxide alarms shall be listed as complying with UL 2034 and shall be installed in accordance.

10. Objectives  Describe state-level laws that require CO alarms in residential dwellings  Assess provisions of CO alarm laws pertaining to public health guidance for CO poisoning prevention

11. Methods  Collaboration between Air Pollution and Respiratory Health Branch/NCEH and Public Health Law Program  CDC attorneys conducted search to identify state laws:  WestlawNext database  International Code Council (ICC) website  Individual state legislative and building code websites  Inclusion criteria  State-level statute or regulation  Adopted as of December 31, 2011  Address CO alarms in traditional residential dwellings

12. Methods  Collected important provisions of laws:  Applicable building types  Responsibility for installation and repair  Alarm type, operation, and installation specifications  Penalty and compliance issues  Data abstraction  Two researchers independently abstracted each law and resolved inconsistencies in coding  Coding reviewed by an attorney for accuracy  Data analysis  Frequency of states with specific CO alarm law provisions  Percentages calculated using the number of states with CO alarm laws as the denominator

13. Number of CO Alarm Laws  71 CO alarm laws identified as of Dec. 31, 2011  36 states (72%) have a CO alarm law  Number of laws per state ranged from 1 to 6  17 states have 1 law; 11 states have 2 laws; 8 states have 3+ laws

14. Type of CO Alarm Laws (n=71) Number of Laws % of Laws I-Codes, modified or verbatim3448% Independent State Building Codes811% Landlord/Tenant laws710% Public Health or Safety laws2231%

15. CO Alarm Law Type by State (n=36) Number of States % of States I-Code only, verbatim or modified1233% I-Code plus another law1542% Independent State Building or Fire Code only 26% Landlord/Tenant or Public Health or Safety laws only 719%

16. Effective Date of First CO Alarm Law per State, 1998 – 2011 (n=36) Year first CO alarm law became effective Number of states

17. Alarm Requirements by Dwelling Characteristics

18. 64% 31% 6%

19. Alarm Requirements by Dwelling Characteristics Presence of CO Source

20. Alarm Location within Dwelling Number of states 19% 89% 6%

21. Alarm Type, Installation, and Power Source Number of states 92% 28% 89%

22. Additional Alarm Installation Requirements Provision Number of States (n) % Specifies who is responsible for installation (e.g., owner, landlord) 1541.7 Alarm required upon new lease1027.8 Alarm required upon sale/transfer719.4

23. Compliance and Penalty Issues Provision Number of States (n) % Installation compliance check2980.6 Penalty for not installing1130.6 Prohibit tampering or disabling1233.3 Penalty for tampering or disabling822.2

24. Summary  36 states adopted a CO alarm law as of Dec. 31, 2011  14 (28%) states do NOT have a state-level CO alarm law  Local jurisdictions within these states may have CO alarm laws  Addition of CO alarm provision to 2009 IRC substantially increased the coverage of CO alarm requirements across US  25 states adopted the IRC since 2009  12 states only address CO alarm requirements via the IRC

25. Summary: CO Alarm Guidance  Provisions of public health CO alarm guidance:  7 states included all five provisions  2 states included zero provisions  Some state laws included provisions about installing CO alarms near fossil fuel-burning appliances, which is against manufacturer’s instructions 92%UL approved 89%Installed outside of sleeping areas 89%In homes with fossil fuel burning appliances 86%In homes with attached garages/parking 28%Operates on battery or has battery backup

26. Summary: Compliance  CO alarm law compliance is complicated and can vary widely from state to state  New and renovated dwellings  CO alarm requirements that are a part of the state building code entail a compliance check for permitting purposes  Existing dwellings  Several (7) states made the alarm requirement contingent upon the sale of the dwelling to increase compliance

27. Limitations  Only used legal resources available in the public domain  Did not address how law interpreted and used  Understanding content and provisions of law doesn’t reflect how it is being used  States without state-level CO alarm laws might have local laws

28. Next Steps  Increase awareness of public health guidance for CO alarm installation  Work with ICC and NFPA to  revise model, national building codes  incorporate aspects of public health guidance  decrease variability among CO alarm laws  Possible future efforts  Work towards building model legislation  Examine effectiveness of state CO alarm laws in the reduction of CO exposures and poisonings

29. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Environmental Health Division of Environmental Hazards and Health Effects Thank you.

31. National Fire Protection Association  NFPA provides and advocates consensus codes and standards, research, training, and education  NFPA develops, publishes, and disseminates more than 300 consensus codes and standards aimed to minimize the possibility and effects of fire and other risks  NFPA 720: Standard for the Installation of Carbon Monoxide(CO) Detection and Warning Equipment

32. Example Modifications to IRC  Limited code to “new construction” only (less comprehensive)  Added provisions about location of alarms  “one on each story including basements and cellars”  Added provisions allowing use of combination smoke/CO detectors  Added provisions about alarm power source

33. Discussion  Impact of public health laws varies depending on:  breadth of the law  funding  implementation  Enforcement  Laws of narrower scope may:  limit the ability to prevent CO poisonings  may be the result of industry resistance  Recent adoptions and revisions provide opportunity to strengthen existing laws and bring them into alignment with public health guidance