1. National Surveillance Estimates of Unintentional, Non-fire Related Carbon Monoxide Poisoning Jackie Clower, MPH Contractor, Air Pollution & Respiratory Health Branch June 13, 2011 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 routine sources:  Home heating & cooking appliances  Gas powered equipment  Motor vehicles  A leading cause of poisoning in the US

3. EPIDEMIOLOGY OF UNINTENTIONAL, NON-FIRE-RELATED EXPOSURES  Mortality & Morbidity  >20, 000 emergency department visits  ~450 deaths  Populations  Non-fatal: Children (<5 years), Females  Fatal: Elderly (>65 years), Males  Season  Winter  Region  Midwest  Northeast

4. 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 alarms

5. CO SURVEILLANCE Frequency of events Severity of outcome Preventability of exposures + Effectiveness of simple preventive measures =Critical Issue for Public Health Surveillance CDC developed a national surveillance framework for unintentional, non-fire related CO poisoning from several data sources

6. CO SURVEILLANCE FRAMEWORK Mortality Hospitalization Hyperbaric oxygen treatment Emergency department visits Poison center National Fire Protection Association Health Behaviors (e.g., presence of CO alarm at home) National Vital Statistics System – ~ 450 deaths annually (1999 –2004) Nationwide Inpatient Sample, 2007 – ? Nationwide Emergency Department Sample, 2007 – ? Hyperbaric Oxygen, 2009 – ? American Housing Survey, 2009 – 33.4% U.S. households with working CO alarm National Health Interview Survey, 2009 – 40.3% U.S. households with CO alarm National Poison Data System – ? (2000 – 2009) National Fire Protection Association, 2005 – 61,100 non-fire CO incidents

7. CO HOSPITALIZATIONS AND ED VISITS: METHODS Healthcare Cost and Utilization Project (HCUP)  Sponsored by Agency for Healthcare Research and Quality  Largest data repository of hospital discharges  Short-term, non-federal, general hospitals  Nationally representative samples are drawn

8. CO HOSPITALIZATION AND ED VISITS: METHODS  HCUP:  Nationwide Emergency Department Sample (NEDS)  Nationwide Inpatient Sample (NIS)  CSTE’s case definition used to classify confirmed, probable, & suspected cases  Rates were calculated with Census Bureau population estimates

9. CO HOSPITALIZATION AND ED VISITS: RESULTS  Highest rate of ED visits among those 18-44 years (87 visits/million)  Highest rate of hospitalization among those ≥85 years (18 stays/million)  Females visited EDs more than males  Males more likely to be hospitalized  CO-related hospitalization cost was >$26 million

10. CO SURVEILLANCE FRAMEWORK Mortality Hospitalization Hyperbaric oxygen treatment Emergency department visits Poison center National Fire Protection Association Health Behaviors (e.g., presence of CO alarm at home) National Vital Statistics System – ~ 450 deaths annually (1999 –2004) Nationwide Inpatient Sample, 2007 – 2,302 confirmed cases Nationwide Emergency Department Sample, 2007 – 21,304 confirmed cases Hyperbaric Oxygen, 2009 – ? American Housing Survey, 2009 – 33.4% U.S. households with working CO alarm National Health Interview Survey, 2009 – 40.3% U.S. households with CO alarm National Poison Data System – ? (2000 – 2009) National Fire Protection Association, 2005 – 61,100 non-fire CO incidents

11. HYPERBARIC OXYGEN TREATMENT: METHODS  Database of hyperbaric oxygen treatments administered for severe CO poisoning  Undersea and Hyperbaric Medical Society (UHMS) physicians contribute data on patients receiving treatment  August 2008 - January 2010: patient-level data were reported by 87 facilities in 39 states  Case definition: an individual treated with hyperbaric oxygen at a participating facility in the US

12. HYPERBARIC OXYGEN TREATMENT: METHODS  Panel of 38 questions:  Patient demographics  Treatment regimens  Circumstances surrounding poisonings  Example variables:  Number of others treated with hyperbaric oxygen in the same incident  Duration of exposure  Symptoms  Duration of loss of consciousness  % blood carboxyhemoglobin

13. HYPERBARIC OXYGEN TREATMENT: RESULTS  Among the 864 patients, most were:  White (54.3%)  Male (57.3%)  Aged 18 -44 years (43.5%)  75% exposed along with others  55% of patients were discharged after treatment  41% were hospitalized  10% of patients reported a CO alarm at their exposure location

14. CO SURVEILLANCE FRAMEWORK Mortality Hospitalization Hyperbaric oxygen treatment Emergency department visits Poison center National Fire Protection Association Health Behaviors (e.g., presence of CO alarm at home) National Vital Statistics System – ~ 450 deaths annually (1999 –2004) Nationwide Inpatient Sample, 2007 – 2,302 confirmed cases Nationwide Emergency Department Sample, 2007 – 21,304 confirmed cases Hyperbaric Oxygen, 2009 – 552 cases American Housing Survey, 2009 – 33.4% U.S. households with working CO alarm National Health Interview Survey, 2009 – 40.3% U.S. households with CO alarm National Poison Data System – ? (2000 – 2009) National Fire Protection Association, 2005 – 61,100 non-fire CO incidents

15. POISON CENTER CALLS: METHODS  Nationally, 61 Poison Centers upload call data to the National Poison Data System (NPDS)  2.2 million reports annually  Includes 36 million reports over last 30 years  Case definition: A call:  Regarding a human CO exposure  Coded as “unintentional” exposure  Example variables:  Demographics  Call type: informational vs. exposures  Clinical effects: symptoms  Exposure site  Level of care  Outcome

16. POISON CENTER CALLS: RESULTS  68,316 (23 calls/million/year) CO exposure calls to US poison centers from 2000-2009  28% of calls was regarding persons <18 years (18,896)  50% (34,356) of women & 44% of men (30,257) reported being exposed  235 deaths captured  NPDS provides data regarding CO exposed populations who would not be captured by administrative health records  53.7% (36,691) managed at a healthcare facility  45.1% (30,798) managed onsite & not otherwise identified

17. CO SURVEILLANCE FRAMEWORK Mortality Hospitalization Hyperbaric oxygen treatment Emergency department visits Poison center National Fire Protection Association Health Behaviors (e.g., presence of CO alarm at home) National Vital Statistics System – ~ 450 deaths annually (1999 –2004) Nationwide Inpatient Sample, 2007 – 2,302 confirmed cases Nationwide Emergency Department Sample, 2007 – 21,304 confirmed cases Hyperbaric Oxygen, 2009 – 552 cases American Housing Survey, 2009 – 33.4% U.S. households with working CO alarm National Health Interview Survey, 2009 – 40.3% U.S. households with CO alarm National Poison Data System – 68,312 exposure calls (2000 – 2009) National Fire Protection Association, 2005 – 61,100 non-fire CO incidents

18. SUMMARY AND CONCLUSIONS  These analyses expand CO surveillance to include:  Most comprehensive, recent national estimates of ED visits & hospitalizations  Most detailed information on patients treated with hyperbaric oxygen  First summary that includes a 10-year period of poison center calls  Findings from this surveillance framework are critical for prevention efforts as the results contribute to a better understanding of CO poisoning

19. ACKNOWLEDGEMENTS: Shahed Iqbal Jeneita Bell Fuyuen Yip 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