A review of disaster-related carbon monoxide poisoning: surveillance, epidemiology, and opportunities for prevention

Practical Recommendations for the Evaluation and Management of Cardiac Injury Due to Carbon Monoxide Poisoning

Carbon monoxide (CO) is a relatively frequent cause of poisoning evaluated in emergency departments. The risk of neurologic injuries, such as cognitive, psychological, vestibular, and motor deficits, is 25% to 50%. However, the risk of cardiac injuries should also be considered. Among patients with CO poisoning, the mortality in patients with myocardial injury is approximately 3 times greater than that in patients without myocardial injury. In large-scale studies, up to 69.2% of patients with acute CO poisoning exhibiting elevated troponin I levels and no underlying cardiovascular illnesses had late gadolinium enhancement on cardiac magnetic resonance, suggesting covert CO-induced myocardial fibrosis. Myocardial damage can be evaluated using electrocardiography, echocardiography, computed tomography, and cardiac magnetic resonance. This paper offers recommendations for cardiac evaluations based on our collective experience of managing >2,000 cases of acute CO poisoning with supporting information taken from peer-reviewed published reports on CO poisoning.

Carbon monoxide poisoning cases in the emergency department are increasing in the last decade in Jerusalem

BACKGROUND AND AIMS

The aim of our study was to describe the epidemiology of Carbon monoxide poisoning in the Emergency Department.

METHODS

A retrospective descriptive analysis of patients with Carbon monoxide poisoning who were presented to the Emergency Department of Hadassah hospital in Jerusalem from 2007 to 2016. All patients that were included are confirmed cases [carboxyhemoglobin level > 5%]. Sources of exposure, seasonal variation, and demographic characteristics were analyzed.

RESULTS

There were 244 patients (60% males) with 37 family clusters that accounted for 135 (55.3%) patients. One hundred seventy-three (70.9%) patients presented during the winter months. The main sources of exposure were: non-gas residential heating system, mainly charcoal grills and kerosene stoves (n = 100, 41%). Other sources were fires (n = 70, 28.7%), faulty gas heater (n = 34, 13.9%) and smoking (n = 15, 6.1%). The estimated annual incidence increased from an average of 20.8 cases a year between 2007-2011 to an average of 34 cases in 2011-2016. High-risk poisoning (levels > 25%) occurred in 28 patients (11.5%). Factors associated with severe poisoning were female gender and exposure in clusters compared with individual patients.

CONCLUSION

Our current study has showed an increase of Carbon Monoxide poisoning in contrary to our study performed in the previous decade. Fortunately, we did find a lower rate of cases with severe poisoning. Beside the implementation of safer standards for residential heating systems, customized public education is advised in order to lower rates of poisoning in the future. A predicted heavy snow fall should be considered a trigger for a public health warning regarding the risk of CO poisoning.

The diagnostic accuracy of carbon monoxide pulse oximetry in adults with suspected acute carbon monoxide poisoning: a systematic review and meta-analysis

Introduction

Acute carbon monoxide poisoning (COP) is one of the leading causes of intoxication among patients presenting to the emergency department (ED). COP symptoms are not always specific and may vary from mild to critical. In the last few years, COHb pulse oximeters have been developed and applied to the setting of suspected COP. The aim of this systematic review is to assess the diagnostic accuracy of CO pulse oximetry (SpCO) with carboxyhemoglobin (COHb) levels measured by blood gas analysis, used as a reference standard, in patients with suspected COP.

Methods

We developed our search strategy according to the PICOS framework, population, index/intervention, comparison, outcome, and study, considering the diagnostic accuracy of SpCO compared to COHb levels measured by blood gas analysis, used as a reference standard, in patients with suspected COP enrolled in cross-sectional studies in English. The search was performed on MEDLINE/PubMed and EMBASE in February 2022. Quality assessment was performed using the QUADAS-2 methodology. A COHb cutoff of 10% was chosen to test the sensitivity and specificity of the index test. A bivariate model was used to perform the meta-analysis. The protocol was registered on PROSPERO (CRD42022359144).

Results

A total of six studies (1734 patients) were included. The pooled sensitivity of the test was 0.65 (95% CI 0.44-0.81), and the pooled specificity was 0.93 (95% CI 0.83-0.98). The pooled LR+ was 9.4 (95% CI 4.4 to 20.1), and the pooled LR- was 0.38 (95% CI 0.24 to 0.62).

Conclusion

Our results show that SpCO cannot be used as a screening tool for COP in the ED due to its low sensitivity. Because of its high LR+, it would be interesting to evaluate, if SpCO could have a role in the prehospital setting as a tool to quickly identify COP patients and prioritize their transport to specialized hospitals on larger samples with a prospective design.

Mortality Surveillance During Winter Storm Uri, United States - 2021

OBJECTIVE

On February 12, 2021, Winter Storm Uri hit the United States. To understand the disaster-related causes and circumstances of death, the Centers for Disease Control and Prevention (CDC) activated media mortality surveillance.

METHODS

The team searched the internet daily for key terms related to Uri and compiled the information into a standardized media mortality surveillance database to conduct descriptive statistics.

RESULTS

Between February 12 and March 2, 2021, the accessed media reported 136 Uri-related deaths from nine states. Most decedents were male (39%) and adults (62.5%). Exposure to extreme temperatures (47.1%) was the most common cause of death. Among indirect deaths, motor vehicle collision (12.5%), and carbon monoxide poisoning (7.4%) represented the top two circumstances.

CONCLUSION

This was the first time CDC activated media mortality surveillance for a winter storm. Media mortality surveillance is useful in assessing the impact of a disaster and provides timely data for an all-hazards response approach.

Global, regional, and national mortality due to unintentional carbon monoxide poisoning, 2000-2021: results from the Global Burden of Disease Study 2021

BACKGROUND

Unintentional carbon monoxide poisoning is a largely preventable cause of death that has received insufficient attention. We aimed to conduct a comprehensive global analysis of the demographic, temporal, and geographical patterns of fatal unintentional carbon monoxide poisoning from 2000 to 2021.

METHODS

As part of the latest Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), unintentional carbon monoxide poisoning mortality was quantified using the GBD cause of death ensemble modelling strategy. Vital registration data and covariates with an epidemiological link to unintentional carbon monoxide poisoning informed the estimates of death counts and mortality rates for all locations, sexes, ages, and years included in the GBD. Years of life lost (YLLs) were estimated by multiplying deaths by remaining standard life expectancy at age of death. Population attributable fractions (PAFs) for unintentional carbon monoxide poisoning deaths due to occupational injuries and high alcohol use were estimated.

FINDINGS

In 2021, the global mortality rate due to unintentional carbon monoxide poisoning was 0·366 per 100 000 (95% uncertainty interval 0·276-0·415), with 28 900 deaths (21 700-32 800) and 1·18 million YLLs (0·886-1·35) across all ages. Nearly 70% of deaths occurred in males (20 100 [15 800-24 000]), and the 50-54-year age group had the largest number of deaths (2210 [1660-2590]). The highest mortality rate was in those aged 85 years or older with 1·96 deaths (1·38-2·32) per 100 000. Eastern Europe had the highest age-standardised mortality rate at 2·12 deaths (1·98-2·30) per 100 000. Globally, there was a 53·5% (46·2-63·7) decrease in the age-standardised mortality rate from 2000 to 2021, although this decline was not uniform across regions. The overall PAFs for occupational injuries and high alcohol use were 13·6% (11·9-16·0) and 3·5% (1·4-6·2), respectively.

INTERPRETATION

Improvements in unintentional carbon monoxide poisoning mortality rates have been inconsistent across regions and over time since 2000. Given that unintentional carbon monoxide poisoning is almost entirely preventable, policy-level interventions that lower the risk of carbon monoxide poisoning events should be prioritised, such as those that increase access to improved heating and cooking devices, reduce carbon monoxide emissions from generators, and mandate use of carbon monoxide alarms.

FUNDING

Bill & Melinda Gates Foundation.

Effects of different fresh gas flows on carboxyhemoglobin levels: non-invasive carbon monoxide monitoring: A randomized clinical trial

OBJECTIVES

To observe the effect of different fresh gas flows (FGF) on carboxyhemoglobin (COHb) levels non-invasively and continuously and to determine the contribution of the smoking status to intraoperative carbon monoxide (CO) accumulation and respiratory complications.

METHODS

A total of 64 patients were included in the study. Carboxyhemoglobin level was monitored non-invasively from the fingertip. Patients were divided into 2 according to the FGF as low-flow anesthesia (LFA; Group L) and high flow anesthesia (Group H). Each group was divided again into 2 groups as smokers and non-smokers. Carboxyhemoglobin and and the respiratory complications that occurred in the post-anesthesia care unit were recorded.

RESULTS

The mean COHb values were significantly higher in Group L between 30th and 210th minutes. Furthermore, in Group L, intraoperative COHb levels were significantly higher in smokers compared to non-smokers in all periods. In group H, no difference was observed between smokers and non-smokers in terms of COHb levels after 60 minutes and also preoperative COHb levels of the patients developed respiratory complication was higher.

CONCLUSION

If the CO₂ absorbent is properly preserved in patients who are administered LFA, there will be no risk of CO accumulation even in chronic smokers.ClinicalTrials.gov REG. No.: NCT04832256.

Trends in carbon monoxide poisoning deaths in high frequency hurricane states from 2014-19: the need for prevention intervention strategies

INTRODUCTION

Hurricanes often result in power outages, which increase generator usage and carbon monoxide (CO) deaths. We aim to identify states with the highest frequency of hurricanes and evaluate the number of unintentional CO poisoning deaths by region, age, race and metropolitan distribution.

METHODS

The number of hurricanes was determined using the FEMA database, and the number of unintentional CO poisoning deaths was determined using the CDC WONDER database from 2014-19. Hurricane-associated consumer outages were obtained from the Department of Energy.

RESULTS

The number of unintentional CO poisoning deaths was as follows: Florida, South Carolina, North Carolina, Georgia and Alabama. Adults displayed a significantly higher number of unintentional CO poisoning deaths than pediatrics (P < 0.001). The total number of unintentional CO poisoning deaths was highest in the White population (P < 0.001); however, unintentional CO poisoning death rates were nearly two times higher among Black population in adults (0.5 versus 0.3) and pediatrics (0.2 versus 0.1). Medium metropolitan areas exhibited significantly more unintentional CO poisoning deaths (P < 0.001).

CONCLUSIONS

Hurricanes and unintentional CO poisoning deaths were most common in Florida. Death rates were higher among Black individuals. Medium metropolitan areas displayed significantly more unintentional CO poisoning deaths than all other areas.

Fatal Unintentional Non-Fire Related Carbon Monoxide Poisoning: Data from Narrative Verdicts in England and Wales, 1998-2019

Unintentional non-fire related (UNFR) carbon monoxide (CO) poisoning continues to cause fatalities. The narrative verdicts from coroners concerning fatal UNFR CO poisoning in England and Wales, 1998–2019, were collated by the Office for National Statistics. Search terms related to CO exposure were used to obtain information regarding the circumstances of death. Findings were grouped by the location of death, the source of CO, and the reason or behaviour underlying the exposure. There were 750 deaths (77% male). The annual number of deaths decreased over the period studied. Two thirds (68%) of the deaths occurred in the autumn or winter. From the records with information, 59% of deaths occurred within a dwelling (67% male). Males also predominated deaths within vehicles (91%) and garages or outbuildings (95%). From the deaths with information, domestic piped gas was the most common source of CO (36%) and the most frequent underlying factor was inadequate ventilation of exhaust gases (39%, 91% male). Despite the decrease in the annual number of deaths over the study period, there remains a clear need for measures that raise awareness of the dangers of CO poisoning, especially amongst men working alone in garages or outbuildings. Education campaigns and fitting and maintaining CO alarms in high-risk areas should be encouraged.

Endogenous carbon monoxide due to hemolytic anemia: A forensic red herring

Carbon monoxide (CO) toxicity associated with exposure to an environmental, exogenous source, is routinely investigated in the field of forensics. Paramedics responded to the home of a 60-year-old woman who complained of persistent nausea, dizziness, and fatigue. Her initial carboxyhemoglobin (COHb) saturation was 25% as measured by paramedics in the field via pulse CO-oximetry (SpCO) and was, 2 hours later, confirmed by hospital laboratory spectrophotometric analysis to be 16% after initial treatment in the emergency department. The clinical presentation of environmental CO exposure and subsequent death notification to the North Carolina Office of the Chief Medical Examiner prompted an extensive investigation into the suspected residential source of CO, which ultimately ruled out all exogenous sources. The medicolegal death investigator later discovered an updated hematology consultation note, which determined the actual source of the CO to be endogenously produced from disease. Herein, we report an unusual fatality involving enhanced endogenous CO production caused by warm autoimmune hemolytic anemia. This unique case report and brief literature review of disease-related elevation of endogenous CO will shed light on this lesser-known phenomenon alerting the forensic community to its potential occurrence and need for consideration when sources of environmental exposure have been exhausted.

Temporal trends of carbon monoxide poisoning mortality at the global, regional and national levels: a cross-sectional study from the Global Burden of Disease study, 1990 and 2017

OBJECTIVES

Carbon monoxide (CO) poisoning is one of the most frequent causes of fatal poisoning worldwide. Few studies have explored the mortality trends of CO poisoning grouped by age and gender, at the regional, national and global levels. We therefore aimed to determine the pattern of CO poisoning mortality, as well as temporal trends at all levels.

DESIGN

A cross-sectional survey design was used in this study.

SETTING

CO poisoning data collected from the Global Burden of Diseases (GBDs), from 1990 to 2017, was arranged by sex, age, region and country. In addition, we used human development index data at the national level from the World Bank.

PARTICIPANTS

We collected over 100 000 information on CO poisoning mortality between 1990 and 2017, derived from the GBD study in 2017.

MAIN OUTCOMES AND MEASURES

We have calculated the estimated annual percentage changes in CO poisoning age-standardised mortality rate (ASR), by sex and age at different regions and countries to quantify the temporal trends in CO poisoning ASR.

RESULTS

Globally, death cases of CO poisoning decreased 7.2% from 38 210 in 1990 to 35 480 in 2017. The overall ASR decreased by an average of 1.83% (95% CI 2.10% to 1.56%) per year in this period. This decreasing pattern was heterogeneous across ages, regions and countries. The most pronounced decreases were generally observed in countries with a high sociodemographic index, including Estonia, South Korea and Puerto Rico.

CONCLUSIONS

Current prevention strategies should be reoriented, and much more targeted and specific strategies should be established in some countries to forestall CO poisoning.

Assessing the effects of disasters and their aftermath on pregnancy and infant outcomes: A conceptual model

Although many studies have examined broad patterns of effects on pregnancy and infant outcomes after disasters, the causes of adverse outcomes are not always clear. Disasters cause interrelated exposure to environmental pollutants, psychological stressors, and lack of health care, and interacts with other social determinants of health. This topical review examines the short- and long-term effects of disasters on pregnancy and how they are mediated by social, behavioral, and environmental effects. In the short term, disasters are associated with physical trauma, adverse environmental exposures, and unstable housing. In the longer term, disasters may lead to relocation, changes in family functioning, and negative economic effects. These aspects of disaster exposure, in turn, lead to lack of access to health care, increased stress and negative mental health outcomes, and negative behavioral changes, including smoking and substance use, poor nutrition, physical overexertion and limited activity, and reduction in breastfeeding. All of these factors interact with social determinants of health to worsen effects on the most vulnerable women, infants, and communities. Few interventions after disasters have been tested. With the increase in disasters due to climate change and the ongoing coronavirus pandemic, the models of effects of disasters and their human health consequences need increasing refinement, and, more importantly, should be applied to interventions that improve disaster prevention, mitigation, and response.

Power Outages and Community Health: a Narrative Review

PURPOSE OF REVIEW

Power outages, a common and underappreciated consequence of natural disasters, are increasing in number and severity due to climate change and aging electricity grids. This narrative review synthesizes the literature on power outages and health in communities.

RECENT FINDINGS

We searched Google Scholar and PubMed for English language studies with titles or abstracts containing "power outage" or "blackout." We limited papers to those that explicitly mentioned power outages or blackouts as the exposure of interest for health outcomes among individuals living in the community. We also used the reference list of these studies to identify additional studies. The final sample included 50 articles published between 2004 and 2020, with 17 (34%) appearing between 2016 and 2020. Exposure assessment remains basic and inconsistent, with 43 (86%) of studies evaluating single, large-scale power outages. Few studies used spatial and temporal control groups to assess changes in health outcomes attributable to power outages. Recent research linked data from electricity providers on power outages in space and time and included factors such as number of customers affected and duration to estimate exposure. The existing literature suggests that power outages have important health consequences ranging from carbon monoxide poisoning, temperature-related illness, gastrointestinal illness, and mortality to all-cause, cardiovascular, respiratory, and renal disease hospitalizations, especially for individuals relying on electricity-dependent medical equipment. Nonetheless the studies are limited, and more work is needed to better define and capture the relevant exposures and outcomes. Studies should consider modifying factors such as socioeconomic and other vulnerabilities as well as how community resiliency can minimize the adverse impacts of widespread major power outages.

Poisonings After a Hurricane: Lessons From the New Jersey Poison Information and Education System (NJPIES) During and Following Hurricane Sandy

OBJECTIVE

Hurricane Sandy made landfall in New Jersey on October 29, 2012, resulting in widespread power outages and gasoline shortages. These events led to potentially toxic exposures and the need for information related to poisons/toxins in the environment. This report characterizes the New Jersey Poison Information and Education System (NJPIES) call patterns in the days immediately preceding, during, and after Hurricane Sandy to identify areas in need of public health education and prevention.

METHODS

We examined NJPIES case data from October through December 2012. Most Sandy-related calls had been coded as such by NJPIES staff. Additional Sandy-related cases were identified by performing a case narrative review. Descriptive analyses were performed for timing, case frequencies, exposure substances, gender, caller site, type of information requests, and other data.

RESULTS

The most frequent Sandy-related exposures were gasoline and carbon monoxide (CO). Gasoline exposure cases were predominantly males and CO exposure cases, females (P < 0.0001). Other leading reasons for Sandy-related calls were poison information, food poisoning/spoilage information, and water contamination.

CONCLUSIONS

This analysis identified the need for enhanced public health education and intervention to improve the handling of gasoline and encourage the proper use of gasoline-powered generators and cleaning and cooking equipment, thus reducing toxic exposures.

Potentially Reversible and Recognizable Acute Encephalopathic Syndromes: Disease Categorization and MRI Appearances

"Encephalopathy" is a vague term that encompasses varying definitions, often with a nonspecific clinical presentation and numerous possible pathophysiologic causes. Hence, MR imaging plays a crucial role in the early diagnosis and treatment by identifying imaging patterns when there is limited clinical history in such patients with acute encephalopathy. The aim of this review was to aid in remembrance of etiologies of potentially reversible acute encephalopathic syndromes on MR imaging. The differential includes vascular (reversible cerebral vasoconstriction syndrome, transient global amnesia, disseminated intravascular coagulation, and thrombotic microangiopathy), infection (meningitis, encephalitis), toxic (posterior reversible encephalopathy syndrome, acute toxic leukoencephalopathy; carbon monoxide, alcohol-related, medication- and illicit drug-related toxic encephalopathies), autoimmune, metabolic (osmotic demyelination syndrome, uremic, acute hepatic encephalopathy), idiopathic/inflammatory (stroke-like migraine attacks after radiation therapy syndrome), neoplasm-related encephalopathy, and seizure-related encephalopathy.

Four-type of Masks and its Effectiveness Based on Reduced Level of Expiratory Carbon-monoxide

Introduction

Carbon-monoxide (CO) is a major component of motor-vehicles related air pollution. Motor-vehicles emissions are a major source of air pollution in urban areas and give significant adverse effects on human life.

Aim

This study aimed to assess the change of expiratory carbon-monoxide levels after using four-type of masks in people around Universitas Sumatera Utara.

Methods

This was an experimental study with a consecutive sampling technique involved 100 non-smoker subjects. They were divided into four groups based on masks given: fabric, surgical, carbon, and an N95 mask. Expiratory CO was measured by a smokerlyzer device. Data were analyzed using SPSS software with Wilcoxon and Kruskal Wallis Test.

Results

There was a significant change of carbon-monoxide mean level after using the mask for 8 hours in a surgical mask, N95 mask, and carbon mask (p-value: 0.002; 0.000; 0.000). After analyzed using Kruskal Wallis Test, there was a significant difference in the change of mean of pre and post wearing mask (ΔCO) among four-type of masks with p-value < 0.001. Post Hoc Analysis showed the significant difference was in the comparison between N95 mask vs Fabric Mask and Carbon Mask vs Fabric Mask (p-value: 0.002; 0.021).

Conclusion

All three type of masks such as surgical mask, N95 mask, and carbon mask was effective to reduce CO levels from air pollution with the most significant was N95 and carbon mask. Fabric mask has the poorest protection from CO levels.

Disaster-related carbon monoxide poisoning after the Great East Japan Earthquake, 2011: a nationwide observational study

Aim

To investigate disaster-related carbon monoxide (CO) poisoning after the Great East Japan Earthquake using a nationwide inpatient database in Japan.

Methods

This was a retrospective cohort study. We identified adult patients with CO poisoning who were registered in the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2017. We evaluated trends in the numbers of patients with CO poisoning each month from disaster (Tohoku region) and non-disaster areas. In the disaster area, we compared the numbers of patients with CO poisoning during pre- and post-earthquake periods. We also compared the numbers of CO poisonings after the earthquake (<30 days) and 1 year later.

Results

Eligible patients (n = 7,814) were categorized into disaster area (n = 988) and non-disaster area (n = 6,826) groups. The numbers of CO-poisoned patients in the non-disaster area showed a seasonal variation, and there was a significant peak registered on March 11 in the disaster area. In the disaster area, the number of patients with CO poisoning in the post-earthquake period was significantly higher than that in the pre-earthquake period (135 versus 18; odds ratio, 7.50; 95% confidence interval, 4.59-12.3). The number of patients in the post-earthquake period was also significantly higher than that on April 9, 2012, which was one month after the annual follow-up (135 versus 10; odds ratio, 13.5; 95% confidence interval, 7.10-25.7).

Conclusion

This study showed that CO poisoning significantly increased in the affected area after the Great East Japan Earthquake, underlining the importance of providing information regarding the hazard of earthquake-related CO poisoning.

National unintentional carbon monoxide poisoning estimates using hospitalization and emergency department data

Unintentional non-fire-related (UNFR) carbon monoxide (CO) poisoning is a leading cause of poisoning in the US and a preventable cause of death. We generated national estimates of accidental CO poisoning and characterized the populations most at risk. UNFR CO poisoning cases were assessed using hospitalization and emergency department (ED) data from the Healthcare Costs and Utilization Project National Inpatient Sample and Nationwide Emergency Department Sample databases. We used hospitalization data from 2003 to 2013 and ED data from 2007 to 2013. We calculated trends using a linear regression of UNFR CO poisonings over the study period and age-adjusted rates using direct standardization and U.S. Census Bureau estimates. During 2003-2013, approximately 14,365 persons (4.1 cases/million annually) with confirmed or probable UNFR CO poisoning were admitted to hospitals and the annual rate of poisonings showed a weak downward trend (p = 0.12). During 2007-2013, approximately 101,847 persons (48.3 visits/million annually) visited the ED and the annual rate of poisonings showed a significant downward trend (p ≤ 0.01). Most UNFR CO hospital cases involved patients who were older (aged 45-64 years), white, male, or living in the South or Midwest. Overall, the rate of hospitalizations did not change over the study period. Unintentional CO poisoning is preventable and these cases represent the most recent national estimates. ED visits declined over the study period, but the hospitalization rates did not change. This emphasizes the need for prevention efforts, such as education in the ED setting, increased use of CO alarms, and proper use and maintenance of fuel-powered household appliances.

Surveillance of carbon monoxide-related incidents - Implications for prevention of related illnesses and injuries, 2005-2014

BACKGROUND

Carbon monoxide (CO) is an insidious gas responsible for approximately 21,000 emergency department visits, 2300 hospitalizations, and 500 deaths in the United States annually. We analyzed 10 combined years of data from two Agency for Toxic Substances and Disease Registry acute hazardous substance release surveillance programs to evaluate CO incident-related injuries.

METHODS

Seventeen states participated in these programs during 2005-2014.

RESULTS

In those 10years, the states identified 1795 CO incidents. Our analysis focused on 897 CO incidents having injured persons. Of the 3414 CO injured people, 61.0% were classified as general public, 27.7% were employees, 7.6% were students, and 2.2% were first responders. More than 78% of CO injured people required hospital or pre-hospital treatment and 4.3% died. The location for most injured people (39.9%) were homes or apartments, followed by educational facilities (10.0%). Educational services had a high number of people injured per incident (16.3%). The three most common sources of CO were heating, ventilation, and air conditioning systems; generators; and motor vehicles. Equipment failure was the primary contributing factor for most CO incidents.

CONCLUSIONS

States have used the data to evaluate trends in CO poisoning and develop targeted public health outreach. Surveillance data are useful for setting new policies or supporting existing policy such as making CO poisoning a reportable condition at the state level and requiring CO alarms in all schools and housing. Public health needs to remain vigilant to the sources and causes of CO to help reduce this injury and death.

Economic implications of unintentional carbon monoxide poisoning in the United States and the cost and benefit of CO detectors

BACKGROUND

Unintentional non-fire-related (UNFR) carbon monoxide (CO) poisoning has been among the leading causes of poisoning in the United States. Current estimation of its economic burden is important for an optimal allocation of resources for UNFR CO poisoning prevention.

OBJECTIVE

This study was to estimate the morbidity costs of UNFR CO poisoning. We also compared the costs and benefits of installing CO detectors in residences.

METHODS

We used 2010-2014 charges and cost data from Healthcare Cost and Utilization Project (HCUP), and Truven© Health MarketScan Commercial Claims and Encounters and Medicare Supplemental data. We directly measured the morbidity cost as the summation of costs for different healthcare services. Benefit of installing CO detector was estimated by summing up the avoidable morbidity cost and mortality cost (value of life). Cost of CO detectors was calculated using the average market price of CO detectors. We also calculated the benefit-to-cost ratio by dividing the benefit by its cost. All expenditures were converted into 2013 U.S. dollars.

RESULTS

For UNFR CO poisoning, total annual medical cost ranged from $33.6 to $37.7 million. Annual non-health-sector costs varied from $3.7 to almost $4.4 million. The benefit-to-cost ratio can be as high as 7.2 to 1.

CONCLUSION

UNFR CO poisoning causes substantial economic burden in the U.S. The benefit of using CO detectors in homes to prevent UNFR CO poisoning can considerably exceed the cost of installation. Public health programs could use these findings to promote broad installation of CO detectors in homes.

Anesthesia-Related Carbon Monoxide Exposure: Toxicity and Potential Therapy

Exposure to carbon monoxide (CO) during general anesthesia can result from volatile anesthetic degradation by carbon dioxide absorbents and rebreathing of endogenously produced CO. Although adherence to the Anesthesia Patient Safety Foundation guidelines reduces the risk of CO poisoning, patients may still experience subtoxic CO exposure during low-flow anesthesia. The consequences of such exposures are relatively unknown. In contrast to the widely recognized toxicity of high CO concentrations, the biologic activity of low concentration CO has recently been shown to be cytoprotective. As such, low-dose CO is being explored as a novel treatment for a variety of different diseases. Here, we review the concept of anesthesia-related CO exposure, identify the sources of production, detail the mechanisms of overt CO toxicity, highlight the cellular effects of low-dose CO, and discuss the potential therapeutic role for CO as part of routine anesthetic management.

Medicolegal Death Scene Investigations After Natural Disaster- and Weather-Related Events: A Review of the Literature

BACKGROUND

The number of disaster-related deaths recorded by vital statistics departments often differs from that reported by other agencies, including the National Oceanic and Atmospheric Administration-National Weather Service storm database and the American Red Cross. The Centers for Disease Control and Prevention (CDC) has launched an effort to improve disaster-related death scene investigation reporting practices to make data more comparable across jurisdictions, improve accuracy of reporting disaster-related deaths, and enhance identification of risk and protective factors. We conducted a literature review to examine how death scene data are collected and how such data are used to determine disaster relatedness.

METHODS

Two analysts conducted a parallel search using Google and Google Scholar. We reviewed published peer-reviewed articles and unpublished documents including relevant forms, protocols, and worksheets from coroners, medical examiners, and death scene investigators.

RESULTS

We identified 177 documents: 32 published peer-reviewed articles and 145 other documents (grey literature). Published articles suggested no consistent approach for attributing deaths to a disaster. Researchers generally depended on death certificates to identify disaster-related deaths; several studies also drew on supplemental sources, including medical examiner, coroner, and active surveillance reports.

CONCLUSIONS

These results highlight the critical importance of consistent, accurate data collection during a death investigation. Review of the grey literature found variation in use of death scene data collection tools, indicating the potential for widespread inconsistency in data captured for routine reporting and public health surveillance. Findings from this review will be used to develop guidelines and tools for capturing disaster-related death investigation data.

Health risk of inhalation exposure to sub-10 µm particulate matter and gaseous pollutants in an urban-industrial area in South Africa: an ecological study

OBJECTIVE

To assess the health risks associated with exposure to particulate matter (PM10), sulphur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO) and ozone (O3).

DESIGN

The study is an ecological study that used the year 2014 hourly ambient pollution data.

SETTING

The study was conducted in an industrial area located in Pretoria West, South Africa. The area accommodates a coal-fired power station, metallurgical industries such as a coke plant and a manganese smelter.

DATA AND METHOD

Estimate of possible health risks from exposure to airborne PM10, SO2, NO2, CO and O3 was performed using the US Environmental Protection Agency human health risk assessment framework. A scenario-assessment approach where normal (average exposure) and worst-case (continuous exposure) scenarios were developed for intermediate (24-hour) and chronic (annual) exposure periods for different exposure groups (infants, children, adults). The normal acute (1-hour) exposure to these pollutants was also determined.

OUTCOME MEASURES

Presence or absence of adverse health effects from exposure to airborne pollutants.

RESULTS

Average annual ambient concentration of PM10, NO2 and SO2 recorded was 48.3±43.4, 11.50±11.6 and 18.68±25.4 µg/m3, respectively, whereas the South African National Ambient Air Quality recommended 40, 40 and 50 µg/m3 for PM10, NO2 and SO2, respectively. Exposure to an hour's concentration of NO2, SO2, CO and O3, an 8-hour concentration of CO and O3, and a 24-hour concentration of PM10, NO2 and SO2 will not likely produce adverse effects to sensitive exposed groups. However, infants and children, rather than adults, are more likely to be affected. Moreover, for chronic annual exposure, PM10, NO2 and SO2 posed a health risk to sensitive individuals, with the severity of risk varying across exposed groups.

CONCLUSIONS

Long-term chronic exposure to airborne PM10, NO2 and SO2 pollutants may result in health risks among the study population.

Protective Effect of Edaravone against Carbon Monoxide Induced Apoptosis in Rat Primary Cultured Astrocytes

Objective. To observe the protective effect of edaravone (Eda) on astrocytes after prolonged exposure to carbon monoxide (CO) and further to investigate the potential mechanisms of Eda against CO-induced apoptosis. Methods. The rat primary cultured astrocytes were cultured in vitro and exposed to 1% CO for 24 h after being cultured with different concentrations of Eda. MTT assay was used to detect the cytotoxicity of CO. Flow cytometry was used to detect the apoptosis rate, membrane potential of mitochondria, and ROS level. The mRNA and protein expressions of Bcl-2, Bax, and caspase-3 were assessed by real-time PCR and Western blotting analysis, respectively. Results. Eda can significantly suppress cytotoxicity of CO, and it can significantly increase membrane potential of mitochondria and Bcl-2 expressions and significantly suppress the apoptosis rate, ROS level, Bax, and caspase-3 expressions. Conclusion. Eda protects against CO-induced apoptosis in rat primary cultured astrocytes through decreasing ROS production and subsequently inhibiting mitochondrial apoptosis pathway.

Carbon monoxide and anesthesia-induced neurotoxicity

The majority of commonly used anesthetic agents induce widespread neuronal degeneration in the developing mammalian brain. Downstream, the process appears to involve activation of the oxidative stress-associated mitochondrial apoptosis pathway. Targeting this pathway could result in prevention of anesthetic toxicity in the immature brain. Carbon monoxide (CO) is a gas that exerts biological activity in the developing brain and low dose exposures have the potential to provide neuroprotection. In recent work, low concentration CO exposures limited isoflurane-induced neuronal apoptosis in a dose-dependent manner in newborn mice and modulated oxidative stress within forebrain mitochondria. Because infants and children are routinely exposed to low levels of CO during low-flow general endotracheal anesthesia, such anti-oxidant and pro-survival cellular effects are clinically relevant. Here we provide an overview of anesthesia-related CO exposure, discuss the biological activity of low concentration CO, detail the effects of CO in the brain during development, and provide evidence for CO-mediated inhibition of anesthesia-induced neurotoxicity.

Assessing health impacts of the December 2013 Ice storm in Ontario, Canada

Background

Ice, or freezing rain storms have the potential to affect human health and disrupt normal functioning of a community. The purpose of this study was to assess acute health impacts of an ice storm that occurred in December 2013 in Toronto, Ontario, Canada.

Methods

Data on emergency department visits were obtained from the National Ambulatory Care Reporting System. Rates of visits in Toronto during the storm period (December 21, 2013 – January 1, 2014) were compared to rates occurring on the same dates in the previous five years (historical comparison) and compared to those in a major unaffected city, Ottawa, Ontario (geographic comparison). Overall visits and rates for three categories of interest (cardiac conditions, environmental causes and injuries) were assessed. Rate ratios were calculated using Poisson regression with population counts as an offset. Absolute counts of carbon monoxide poisoning were compared descriptively in a sub-analysis.

Results

During the 2013 storm period, there were 34 549 visits to EDs in Toronto (12.46 per 1000 population) compared with 10 794 visits in Ottawa (11.55 per 1000 population). When considering year and geography separately, rates of several types of ED visits were higher in the storm year than in previous years in both Toronto and Ottawa. Considering year and geography together, rates in the storm year were higher for overall ED visits (RR: 1.10, 95 % CI: 1.09-1.11) and for visits due to environmental causes (RR: 2.52, 95 % CI: 2.21-2.87) compared to previous years regardless of city. For injuries, visit rates were higher in the storm year in both Toronto and Ottawa, but the increase in Toronto was significantly greater than the increase in Ottawa, indicating a significant interaction between geography and year (RR: 1.23, 95 % CI: 1.16-1.30).

Conclusions

This suggests that the main health impact of the 2013 Ice Storm was an increase in ED visits for injuries, while other increases could have been due to severe weather across Ontario at that time. This study is one of the first to use a population-level database and regression modeling of emergency visit codes to identify acute impacts resulting from ice storms.

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 pollution and neurodevelopment: A public health concern

Although an association between air pollution and adverse systemic health effects has been known for years, the effect of pollutants on neurodevelopment has been underappreciated. Recent evidence suggests a possible link between air pollution and neurocognitive impairment and behavioral disorders in children, however, the exact nature of this relationship remains poorly understood. Infants and children are uniquely vulnerable due to the potential for exposure in both the fetal and postnatal environments during critical periods in development. Carbon monoxide (CO), a common component of indoor and outdoor air pollution, can cross the placenta to gain access to the fetal circulation and the developing brain. Thus, CO is of particular interest as a known neurotoxin and a potential public health threat. Here we review overt CO toxicity and the policies regulating CO exposure, detail the evidence suggesting a potential link between CO-associated ambient air pollution, tobacco smoke, and learning and behavioral abnormalities in children, describe the effects of subclinical CO exposure on the brain during development, and provide mechanistic insight into a potential connection between CO exposure and neurodevelopmental outcome. CO can disrupt a number of critical processes in the developing brain, providing a better understanding of how this specific neurotoxin may impair neurodevelopment. However, further investigation is needed to better define the effects of perinatal CO exposure on the immature brain. Current policies regarding CO standards were established based on evidence of cardiovascular risk in adults with pre-existing comorbidities. Thus, recent and emerging data highlighted in this review regarding CO exposure in the fetus and developing child may be important to consider when the standards and guidelines are evaluated and revised in the future.

Salvianolic acids attenuate rat hippocampal injury after acute CO poisoning by improving blood flow properties

Carbon monoxide (CO) poisoning causes the major injury and death due to poisoning worldwide. The most severe damage via CO poisoning is brain injury and mortality. Delayed encephalopathy after acute CO poisoning (DEACMP) occurs in forty percent of the survivors of acute CO exposure. But the pathological cause for DEACMP is not well understood. And the corresponding therapy is not well developed. In order to investigate the effects of salvianolic acid (SA) on brain injury caused by CO exposure from the view point of hemorheology, we employed a rat model and studied the dynamic of blood changes in the hemorheological and coagulative properties over acute CO exposure. Compared with the groups of CO and 20% mannitol + CO treatments, the severe hippocampal injury caused by acute CO exposure was prevented by SA treatment. These protective effects were associated with the retaining level of hematocrit (Hct), plasma viscosity, fibrinogen, whole blood viscosities and malondialdehyde (MDA) levels in red blood cells (RBCs). These results indicated that SA treatment could significantly improve the deformation of erythrocytes and prevent the damage caused by CO poisoning. Meanwhile, hemorheological indexes are good indicators for monitoring the pathological dynamic after acute CO poisoning.

Two Storm-Related Carbon Monoxide Poisoning Outbreaks—Connecticut, October 2011 and October 2012

Storm-related carbon monoxide (CO) poisoning outbreaks occurred in Connecticut in 2011 and 2012, despite efforts to improve public messaging. We describe the cases and incidents and identify possible preventive interventions. We defined cases as blood carboxyhemoglobin ≥9.0% among persons exposed to alternative power or heat sources because of storm-related losses. We identified 133 cases, including 3 deaths, in 2011 and 30 in 2012, associated with 72 and 11 incidents, respectively. Racial/ethnic minorities were overrepresented (60% of 2011 patients; 48% in 2012), compared with Connecticut's minority population (29%). Generator or charcoal misuse (83% in 2011; 100% in 2012) caused the majority of incidents. Few CO-source operators recalled media or product CO warnings. Incorrect generator and charcoal use, racial/ethnic disparities, and incomplete penetration of warning messages characterized both outbreaks. A multifaceted approach is needed to decrease postdisaster CO poisonings.

Using the exhibited generalization approach to evaluate a carbon monoxide alarm ordinance

Current interests in enhancing the focus of external validity or transferability call for developing practical evaluation approaches and illustrating their applications in this area for meeting the need. This study takes the challenge by introducing an innovative evaluation approach, named the exhibited generalization approach, and applying it in evaluating the carbon monoxide (CO) alarm ordinance passed by Mecklenburg County, North Carolina. The stakeholders specifically asked evaluators to determine the answers to the following two questions: (1) Does the alarm ordinance work? (2) What generalizable information can the Mecklenburg experience provide to other jurisdictions trying to decide if the alarm ordinance's planning, implementation, adoption, and outcomes are transferable to their communities? This study illustrates how to apply the exhibited generalization approach to provide the stakeholders with answers to these questions. Our results indicate that the alarm ordinance was effective in increasing CO alarm ownerships and reducing CO poisoning cases. The evaluation provides potential users and other interested parties with the necessary information on contextual factors and the causal mechanism underlying the CO alarm ordinance, so that these parties and users could decide whether the Mecklenburg alarm ordinance would be transferable to their own communities. Discussions include implications of this study for contributing in further advancing evaluation theory in addressing transferability or external validity issues.

Carbon monoxide poisoning in Beirut, Lebanon: Patient's characteristics and exposure sources

Background:

Carbon monoxide (CO) poisoning is a preventable disease. Patients present with nonspecific symptoms post CO exposure. Causal factors are well described in developed countries, but less in developing countries.

Objectives:

This study examined the characteristics of patients with CO poisoning treated at a tertiary care center in Beirut, Lebanon, and their association with the CO poisoning source.

Materials and Methods:

A retrospective chart review of all patients who presented to the Emergency Department (ED) of the American University of Beirut Medical Center (AUBMC) over 4-year period and for whom a carboxyhemoglobin (CO-Hb) level was available. Patients with CO poisoning diagnosis were included in the study. Patients’ characteristics and their association with CO poisoning source were described.

Results:

Twenty-seven patients were treated for CO poisoning during the study period, 55% of whom were males. Headache was the most common presenting symptom (51.9%). Burning charcoal indoors was the most common causal factor (44.4%), whereas fire-related smoke was another causal factor. The median arterial CO-Hb level on presentation for all cases was 12.0% (interquartile range (IQR) 7.3–20.2). All patients received normobaric oxygen therapy. No complications were documented in the ED. All patients were discharged from the ED with a median ED length of stay of 255 min (IQR 210-270). Young females were more likely to present with CO poisoning from burning charcoal indoors than from another cause.

Conclusion:

CO poisoning in Beirut, Lebanon is mainly due to charcoal burning grills used indoors and to fire-related smoke. A clinically significant association was present between gender and CO poisoning source. An opportunity for prevention is present in terms of education and increased awareness regarding CO emission sources.

Using poison center data for postdisaster surveillance

The role of public health surveillance in disaster response continues to expand as timely, accurate information is needed to mitigate the impact of disasters. Health surveillance after a disaster involves the rapid assessment of the distribution and determinants of disaster-related deaths, illnesses, and injuries in the affected population. Public health disaster surveillance is one mechanism that can provide information to identify health problems faced by the affected population, establish priorities for decision makers, and target interventions to meet specific needs. Public health surveillance traditionally relies on a wide variety of data sources and methods. Poison center (PC) data can serve as data sources of chemical exposures and poisonings during a disaster. In the US, a system of 57 regional PCs serves the entire population. Poison centers respond to poison-related questions from the public, health care professionals, and public health agencies. The Centers for Disease Control and Prevention (CDC) uses PC data during disasters for surveillance of disaster-related toxic exposures and associated illnesses to enhance situational awareness during disaster response and recovery. Poison center data can also be leveraged during a disaster by local and state public health to supplement existing surveillance systems. Augmenting traditional surveillance data (ie, emergency room visits and death records) with other data sources, such as PCs, allows for better characterization of disaster-related morbidity and mortality. Poison center data can be used during a disaster to detect outbreaks, monitor trends, track particular exposures, and characterize the epidemiology of the event. This timely and accurate information can be used to inform public health decision making during a disaster and mitigate future disaster-related morbidity and mortality.

A comparison of carbon monoxide exposures after snowstorms and power outages

BACKGROUND

Unintentional carbon monoxide poisoning occurs frequently after natural disasters. Although the epidemiology of carbon monoxide exposures that occur after power loss storms has been reported, few publications detail the characteristics of carbon monoxide exposures after massive snowstorms.

PURPOSE

To compare the differences in patient characteristics of carbon monoxide exposures after a snowstorm and power loss storm.

METHODS

In 2013, a retrospective review was conducted of patient characteristics and exposure data from all carbon monoxide cases reported to the Connecticut Poison Control Center in the days following both a major snowstorm in 2013 and a winter storm that caused extensive power outages in 2011.

RESULTS

Portable generators were the most common source of carbon monoxide exposure after a storm that resulted in power losses; car exhaust was the most frequent source of exposure after an extensive snowstorm. Most exposures occurred within the first day after the snowstorm, and on the second and third days after the power outage storm. There were no significant differences between the two storms in terms of patient age, gender, or median carboxyhemoglobin concentration.

CONCLUSIONS

Future public health and medical education regarding the dangers of carbon monoxide in the aftermath of storms should include attention to the differences in the typical exposure sources and timing.

Power outages, extreme events and health: a systematic review of the literature from 2011-2012

Background Extreme events (e.g. flooding) threaten critical infrastructure including power supplies. Many interlinked systems in the modern world depend on a reliable power supply to function effectively. The health sector is no exception, but the impact of power outages on health is poorly understood. Greater understanding is essential so that adverse health impacts can be prevented and/or mitigated. Methods We searched Medline, CINAHL and Scopus for papers about the health impacts of power outages during extreme events published in 2011-2012. A thematic analysis was undertaken on the extracted information. The Public Health England Extreme Events Bulletins between 01/01/2013 - 31/03/2013 were used to identify extreme events that led to power outages during this three-month period. Results We identified 20 relevant articles. Power outages were found to impact health at many levels within diverse settings. Recurrent themes included the difficulties of accessing healthcare, maintaining frontline services and the challenges of community healthcare. We identified 52 power outages in 19 countries that were the direct consequence of extreme events during the first three months of 2013. Conclusions To our knowledge, this is the first review of the health impacts of power outages. We found the current evidence and knowledge base to be poor. With scientific consensus predicting an increase in the frequency and magnitude of extreme events due to climate change, the gaps in knowledge need to be addressed in order to mitigate the impact of power outages on global health.

Epidemic gasoline exposures following Hurricane Sandy

INTRODUCTION

Major adverse climatic events (MACEs) in heavily-populated areas can inflict severe damage to infrastructure, disrupting essential municipal and commercial services. Compromised health care delivery systems and limited utilities such as electricity, heating, potable water, sanitation, and housing, place populations in disaster areas at risk of toxic exposures. Hurricane Sandy made landfall on October 29, 2012 and caused severe infrastructure damage in heavily-populated areas. The prolonged electrical outage and damage to oil refineries caused a gasoline shortage and rationing unseen in the USA since the 1970s. This study explored gasoline exposures and clinical outcomes in the aftermath of Hurricane Sandy.

METHODS

Prospectively collected, regional poison control center (PCC) data regarding gasoline exposure cases from October 29, 2012 (hurricane landfall) through November 28, 2012 were reviewed and compared to the previous four years. The trends of gasoline exposures, exposure type, severity of clinical outcome, and hospital referral rates were assessed.

RESULTS

Two-hundred and eighty-three gasoline exposures were identified, representing an 18 to 283-fold increase over the previous four years. The leading exposure route was siphoning (53.4%). Men comprised 83.0% of exposures; 91.9% were older than 20 years of age. Of 273 home-based calls, 88.7% were managed on site. Asymptomatic exposures occurred in 61.5% of the cases. However, minor and moderate toxic effects occurred in 12.4% and 3.5% of cases, respectively. Gastrointestinal (24.4%) and pulmonary (8.4%) symptoms predominated. No major outcomes or deaths were reported.

CONCLUSIONS

Hurricane Sandy significantly increased gasoline exposures. While the majority of exposures were managed at home with minimum clinical toxicity, some patients experienced more severe symptoms. Disaster plans should incorporate public health messaging and regional PCCs for public health promotion and toxicological surveillance.

Storm-Related Carbon Monoxide Poisoning: An Investigation of Target Audience Knowledge and Risk Behaviors

Carbon monoxide (CO) poisonings in the United States consistently occur when residents improperly use portable gasoline-powered generators and other tools following severe storms and power outages. However, protective behaviors-such as installing CO alarms and placing generators more than 20 feet away from indoor structures-can prevent these poisonings. This study identified knowledge, attitudes, and beliefs that lead consumers to adopt risk and protective behaviors for storm-related CO poisoning and post-storm generator use. Four focus groups (32 participants in total) were conducted with generator owners in winter and summer storm-prone areas to explore home safety, portable generator use, CO poisoning knowledge, and generator safety messages. Discussions were transcribed, and findings analyzed using an ordered meta-matrix approach. Although most generator owners were aware of CO poisoning, many were unsure what constitutes a safe location for generator operation and incorrectly stated that enclosed areas outside the home-such as attached garages, sheds, and covered porches-were safe. Convenience and access to appliances often dictated generator placement. Participants were receptive to installing CO alarms in their homes but were unsure where to place them. These findings suggest a deficit in understanding how to operate portable generators safely and a need to correct misconceptions around safe placement. In terms of behavioral price, the simple installation and maintenance of inexpensive CO alarms may be the most important strategy for ultimately protecting homes from both storm-related and other CO exposures.

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 Project's 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.