Increasing severity of medical outcomes and associated substances in cases reported to United States poison centers

INTRODUCTION

Poison centers provide free expert recommendations on the treatment of a wide variety of toxicological emergencies. Prior studies have called attention to the increasing complexity of cases reported to poison centers. We aimed first, to evaluate the trends in medical outcome severity, over a 15-year period in both the adult and pediatric populations. Second, we described the most frequently reported substances associated with major effect or death.

METHODS

This is a retrospective review of exposures reported to the National Poison Data System from 1 January 2007 through 31 December 2021. All closed cases, for human exposures, reported during the study period were included. We assessed trends in frequencies and rates of medical outcomes and level of care received, among the adult (age greater than 19 years) and pediatric (age 19 years and younger) populations by reason for exposure.

RESULTS

During the study period, the number of adult unintentional exposures resulting in major effect (37.4 percent) and death (65.3 percent) increased. The number of adult intentional exposures resulting in death increased by 233.9 percent and those resulting in a major effect increased by 133.1 percent. The rates of exposures resulting in major effect and death increased among both intentional and unintentional adult exposures. The number of pediatric unintentional exposures resulting in a major effect increased by 76.6 percent and the number of pediatric intentional exposures resulting in death and major effect increased by 122.7 and 190.1 percent, respectively. Moderate, major effect, and death rates increased in pediatric unintentional exposures and moderate and major effect rates increased in pediatric intentional exposures.

CONCLUSIONS

We found a worsening severity of medical outcomes in adult and pediatric cases reported to poison centers. Poison centers are increasingly managing complex cases. Monitoring trends in which substances are associated with severe outcomes is imperative for future strategic prevention efforts.

Oral potassium poisoning: a retrospective review of the National Poison Data System 2010-2021

INTRODUCTION

Oral potassium poisoning can be life-threatening. The study aimed to describe patterns of oral potassium poisoning in adult and pediatric populations and characterize its clinical presentation and management as reported by United States poison centers.

METHODS

This is a retrospective review of the National Poison Data System from 1 January 2010 through 30 June 2021. We descriptively analyzed cases involving single substance, oral potassium salts. In a second step, we requested a subset of case-specific narratives for cases that resulted in major outcome or death, as well as cases where patients received any of the following therapies: whole bowel irrigation, sodium bicarbonate, calcium, insulin or hemodialysis. We classified hyperkalemia by expected toxicity: mild (peak potassium concentration <6.5 mEq/L), moderate (peak potassium concentration 6.5 to <8 mEq/L) or severe (peak potassium concentration ≥ 8mEq/L).

RESULTS

The National Poison Data System included 1,820 cases, 52.3 percent being adults. Among adult cases, 20% (n = 189) resulted in a moderate effect, major effect or death. Among pediatric cases aged <10 years, all exposures were unintentional. Analysis of 49 case narratives showed a median peak potassium concentration of 7.1 mEq/L (interquartile range 5.4-8.6) and a moderate correlation with the dose ingested (r = 0.66). Severe hyperkalemia was associated with QRS complex widening (P < 0.001), peaked T-waves (P = 0.001), and neurological symptoms (P = 0.04). Whole bowel irrigation was associated with mild hyperkalemia (P = 0.011), and hemodialysis was associated with severe hyperkalemia (P < 0.001).

DISCUSSION

Analysis of data showed that therapy to promote intracellular shift of potassium is the mainstay of management of oral potassium poisoning, followed by hemodialysis.

LIMITATIONS

Poison center data are susceptible to reporting bias. National Poison Data System data are affected by completeness and accuracy of reporting from health care providers and the lay public.

CONCLUSIONS

Single substance, oral potassium poisoning, reported to United States poison centers, is mostly unintentional and rarely results in hyperkalemia.

Occupational Carbon Monoxide Poisoning in Wisconsin: Results From a Statewide Electronic Disease Surveillance System and From the Wisconsin Poison Center, 2018-2021

OBJECTIVES

Prevention methods for carbon monoxide (CO) poisoning in Wisconsin address occupational and nonoccupational exposures together, but differences between the settings could inform new approaches to preventing occupational CO poisonings. We described occupational CO poisonings in Wisconsin from July 1, 2018, through July 1, 2021, using surveillance data from the Wisconsin Electronic Disease Surveillance System and Wisconsin Poison Center.

METHODS

We identified cases of CO poisoning from the Wisconsin Electronic Disease Surveillance System and Wisconsin Poison Center. Occupational CO poisonings were records where "workplace" was recorded as the location of exposure. We excluded records classified as suspect/not a case, those missing laboratory results or information on exposure source/location, and intentional poisonings. We compared characteristics between occupational and nonoccupational settings using odds ratios (ORs), and we estimated crude incidence rates of occupational exposures by occupation.

RESULTS

We identified 614 cases of CO poisoning, of which 168 (27.4%) were occupational exposures. When compared with patients with nonoccupational exposures, patients with occupational exposures were more likely to be male (OR = 3.8; 95% CI, 2.4-6.1), Hispanic (OR = 2.4; 95% CI, 1.4-4.2), and younger (mean difference [SD] = 6.6 [20.9]). Several CO sources were significantly associated with occupational poisonings: forklifts (OR = 58.4; 95% CI, 13.9-246.1; P < .001), pressure sprayers (OR = 2.4; 95% CI, 1.3-4.4; P = .003), and other gasoline-powered tools (OR = 3.8; 95% CI, 2.3-6.3; P < .001). The natural resources, construction, and maintenance occupation group had the highest crude incidence rate-45.0 poisonings per 100 000 full-time equivalent employees.

CONCLUSIONS

Incorporating data from the Wisconsin Poison Center improved data quality, but surveillance is limited by underreporting. Creating strategies to increase reporting would allow for a more comprehensive understanding of occupational CO poisoning.

Pediatric hand sanitizer exposures reported to United States poison centers, 2017-2021

INTRODUCTION

The COVID-19 pandemic increased demand for alcohol-based hand sanitizers. We aimed to describe the epidemiological trends in pediatric alcohol-based hand sanitizer cases reported to United States poison centers. We characterized clinically significant pediatric reports involving alcohol-based hand sanitizer products before and during the pandemic and methanol-containing hand sanitizers during the pandemic.

METHODS

We included all single-substance cases involving alcohol-based hand sanitizers reported to the National Poison Data System among children ≤ 19 years from 1 January 2017 to 31 December 2021, and methanol-containing hand sanitizers from 23 June 2020 to 31 December 2021. Multiple product exposures and non-human exposures were excluded. Clinically significant outcomes included moderate or major effects or death.

RESULTS

There were 95,718 alcohol-based hand sanitizer pediatric cases during the study period. Most (n = 89,521; 94%) were unintentional, occurred by ingestion (n = 89,879; 93.9%), occurred at home, and were managed at the exposure site (n = 89,774; 93.8%). Common symptoms were vomiting (n = 2,969; 3.1%), coughing (n = 1,102; 1.2%), ocular irritation (n = 1,244; 1.3%), and drowsiness (n = 981; 1.0%). Most children (n = 3,937; 66.2%) managed at a health care facility were treated and released; a minority were admitted (n = 527; 9.0%). Few children (n = 81; 1.4%) were admitted to the intensive care unit. The prevalence of clinically significant cases increased in 2020 and 2021, compared to 2017. Population-adjusted rates, by state, of alcohol-based hand sanitizer cases ranged from 280 to 2,700 per million children. Of the 540 reported cases involving methanol-containing hand sanitizers, the majority (n = 255) occurred in July 2020. Thirteen cases (2.4%) had clinically significant outcomes. The prevalence of clinically significant cases remained similar in 2020 and 2021 and exhibited lower prevalence compared to alcohol-based products. Population-adjusted rates, by state, ranged from fewer than 0.9 to 40 per million children.

CONCLUSIONS

Clinically significant pediatric cases involving alcohol-based hand sanitizers increased during the pandemic and remained elevated in 2021. Cases involving methanol-containing products were less frequent. Our findings may inform heightened product quality control and regulatory oversight.

Profile of incidental exposures to e-cigarette liquids in Europe, 2018-2019

BACKGROUND

Following the implementation of the European Union Tobacco Product Directive (EU TPD) regulations on e-cigarette products in 2016, we assessed the current profile of e-cigarette liquid exposure incidents and their associated health outcomes.

METHODS

De-identified data were received from poison centers in eight EU Member States (Sweden, the Netherlands, Italy, Hungary Austria, Finland, Spain and Croatia) reporting on e-cigarette liquid exposure incidents between August 2018 to December 2019. Descriptive analysis was conducted to present incident characteristics and health outcomes. Chi-square tests and multivariable logistic regression analysis were used to test associations.

RESULTS

Of the 223 e-liquid exposure incidents recorded by poison centers in multiple EU MS, 64.7% of the cases were unintentional exposures, ranging from 48.4% among adults aged ≥19 years to 100.0% among children aged 0-5 years (p < 0.05). The most frequent route of exposure was ingestion (73.5%) while55.2% experienced any clinical symptoms, including nausea (16.6%), vomiting (11.1%), and dizziness (9.0%). 57.8% of the cases were treated at the residence or on-site.

CONCLUSION

Further monitoring is warranted, using uniform reporting requirements, to ensure the continued compliance to the EU TPD and assess its long-term impact on related incident characteristics.

Poison Centers, 2001-2017

Introduction: We described calls to U.S. poison centers (PCs) related to potential exposure to substances through breast milk. Materials and Methods: We analyzed National Poison Data System calls between 2001 and 2017 with "Exposure through breast milk" or "Drug use during breastfeeding" as the coded scenario. Data handling and descriptive statistics were carried out using SAS JMP 12.01. Results: U.S. PCs received 76,416 information calls and 2,319 exposure calls related to breast milk. Exposure calls were from a residence in 76% (n = 1,758), from health care facilities (HCFs) in 15.5% (n = 360), and from a workplace in 0.6% (n = 15). A total of 466 exposures (20.1%) were subsequently managed at a HCF: 269 were evaluated and released (58%), 38 were admitted to intensive care unit (8.2%), and 53 were admitted to hospital floor (11%). Medical outcomes included 1 death (0.04%), 8 major effect (0.3%), 43 moderate effect (1.9%), 170 minor effect (7.3%), and 390 no effect (16.8%). Exposure calls that reported major effects involved opioids, benzodiazepines, ethanol, cyclobenzaprine, insulin, and amphetamines. Exposure calls most commonly involved antibiotics, antifungals, benzodiazepines, opioids, and selective serotonin reuptake inhibitors (SSRIs). A total of 1,192 exposures (51.4%) had reported signs/symptoms including drowsiness, agitation, rash, and vomiting/diarrhea. Information calls most commonly involved systemic antibiotics, SSRIs, antihistamines, corticosteroids, and benzodiazepines. Conclusions: Substances common to both exposure and information calls included antibiotics, benzodiazepines, and SSRIs. Most cases of severe toxicity included potential exposures through breast milk to benzodiazepines and opioids. These data may help inform educational outreach, risk assessment, and bedside care for breastfeeding mothers.

Noninfectious Foodborne Exposures Reported to 2 National Reporting Systems, United States, 2000-2010

OBJECTIVES

Foodborne disease is a pervasive problem caused by consuming food or drink contaminated by infectious or noninfectious agents. The 55 US poison centers receive telephone calls for advice on foodborne disease cases that may be related to a foodborne disease outbreak (FBDO). Our objective was to assess whether poison center call records uploaded to the National Poison Data System (NPDS) can be used for surveillance of noninfectious FBDOs in the United States.

METHODS

We matched NPDS records on noninfectious FBDO agents in the United States with records in the Foodborne Disease Outbreak Surveillance System (FDOSS) for 2000-2010. We conducted multivariable logistic regression analysis comparing NPDS matched and unmatched records to assess features of NPDS records that may indicate a confirmed noninfectious FBDO.

RESULTS

During 2000-2010, FDOSS recorded 491 noninfectious FBDOs of known etiology and NPDS recorded 8773 calls for noninfectious foodborne disease exposures. Of 8773 NPDS calls, 469 (5.3%) were matched to a noninfectious FBDO reported to FDOSS. Multivariable logistic regression indicated severity of medical outcome, whether the call was made by a health care professional, and etiology as significant predictors of NPDS records matching an FDOSS noninfectious FBDO.

CONCLUSIONS

NPDS may complement existing surveillance systems and response activities by providing timely information about single cases of foodborne diseases or about a known or emerging FBDO. Prioritizing NPDS records by certain call features could help guide public health departments in the types of noninfectious foodborne records that most warrant public health follow-up.

Sex- and Age-specific Increases in Suicide Attempts by Self-Poisoning in the United States among Youth and Young Adults from 2000 to 2018

OBJECTIVE

To evaluate the incidence and outcomes from intentional suspected-suicide self-poisoning in children and young adults ages 10-24 years old from 2000 to 2018.

STUDY DESIGN

Retrospective review of intentional suspected-suicide self-poisoning cases reported to the National Poison Data System from US poison centers from 2000 to 2018 for patients 10-24 years old. For comparison of annual rates, population data by year of age were obtained from the US Census Bureau. We evaluated changes in the annual incidence, the annual rate per 100 000 population, and the medical outcome by patient age and sex.

RESULTS

There were 1 627 825 intentional suspected-suicide self-poisoning cases, of which 1 162 147 (71%) were female. In children 10-15 years old from 2000 to 2010, there was a decrease in number and rate per 100 000 population followed by a significant increase (from 125% to 299%) from 2011 to 2018. In children 10-18 years old, the increase from 2011 to 2018 was driven predominantly by females. In 19-24 years old age groups, there was a temporal delay and reduced increase in slope compared with the younger groups. There were 340 563 moderate outcomes, 45 857 major outcomes, and 1404 deaths. The percentage of cases with a serious outcome, major effect, or death increased over time and with age.

CONCLUSIONS

The incidence and rate of suicide attempts using self-poisoning in children less than 19 years old increased significantly after 2011, occurring predominantly in young girls. There has been an increase in the severity of outcomes independent of age or sex.

Poison control centers and alternative forms of communicating with the public: what's all the chatter about?

Context: Short messaging service (SMS or text messaging) allows for the exchange of electronic text messages. Online chatting refers to Internet-based transmission of messages for real-time conversation. Poison Control Centers (PCCs) in the United States communicate with the public primarily via telephone. However, people increasingly prefer the convenience of SMS and chatting. Our objective is to describe the use of SMS and chatting by PCCs in the United States. Methods: An electronic survey questionnaire was distributed to all 55 US poison control center members of the American Association of Poison Control Centers. The survey assessed protocols for SMS and chatting, inquiry volume, and staff satisfaction. Centers reporting use of SMS or chatting services were administered follow-up questions, which further documented SMS and chatting interfaces and startup and maintenance costs. Descriptive statistics were used to describe the data. No statistical analysis was performed. Results: Of the 55 PCCs, 51 (93%) responded to the survey, 6 (12%) of which currently use or formerly used SMS and/or chatting. Inquiry volume ranged from 0 to 1 per day for SMS and 0 to 20 per day for chats. Startup costs ranged from $0 to $25,000. The most beneficial aspect, reported by 4 of the 6 PCCs (66.6%), was providing an alternative contact for inquiries. Most SMS and chatting interactions were completed within 10 and 30 min, respectively. All six centers completed telephone interactions within 10 min. The most disadvantageous aspects, reported by 2 of the 6 PCCs (33.3%), were staff apprehension and interaction length. Technology, such as syncing with existing call queuing software and databases, presented the greatest barrier to implementation. Conclusions: A minority of PCCs in the United States use SMS and chatting. Further research may investigate the economic feasibility of these systems, if SMS and chatting effectively expands public access, and patient comfort in contacting PCCs.

Changes in oxycodone and heroin exposures in the National Poison Data System after introduction of extended-release oxycodone with abuse-deterrent characteristics

PURPOSE

Abuse and misuse of prescription opioids are serious public health problems. Abuse-deterrent formulations are an intervention to balance risk mitigation with appropriate patient access. This study evaluated the effects of physicochemical barriers to crushing and dissolving on safety outcomes associated with extended-release oxycodone (ERO) tablets (OxyContin) using a national surveillance system of poison centers. Other single-entity (SE) oxycodone tablets and heroin were used as comparators and to assess substitution effects.

METHODS

The National Poison Data System covering all US poison centers was used to measure changes in exposures in the year before versus the 2 years after introduction of reformulated ERO (7/2009-6/2010 vs 9/2010-9/2012). Outcomes included abuse, therapeutic errors affecting patients, and accidental exposures.

RESULTS

After ERO reformulation, abuse exposures decreased 36% for ERO, increased 20% for other SE oxycodone, and increased 42% for heroin. Therapeutic errors affecting patients decreased 20% for ERO and increased 19% for other SE oxycodone. Accidental exposures decreased 39% for ERO, increased 21% for heroin, and remained unchanged for other SE oxycodone. During the study period, other interventions to reduce opioid abuse occurred, for example, educational and prescription monitoring programs. However, these have shown small effects and do not explain a drop for ERO exposures but not for other opioids.

CONCLUSIONS

After ERO reformulation, calls to poison centers involving abuse, therapeutic errors affecting patients, and accidental exposures decreased for ERO, but not for comparator opioids. Abuse-deterrent formulations of opioid analgesics can reduce abuse, but switching to other accessible non abuse-deterrent opioids might occur.