For Submission to the Journal of Community Health: Carbon Monoxide Awareness and Detector Use in the State of Wisconsin

Carbon monoxide (CO) is a leading cause of poisoning. CO detectors are a known-effective prevention strategy, however, little is known about use of detectors or knowledge of risk. This study assessed awareness of CO poisoning risk, detector laws, and detector use among a statewide sample. Data collected from the Survey of the Health of Wisconsin (SHOW) included a CO Monitoring module added to the in-home interview for 466 participants representing unique households across Wisconsin in 2018-2019. Univariate and multivariable logistic regression models examined associations between demographic characteristics, awareness of CO laws and detector use. Less than half of households had a verified CO detector. Under 46% were aware of the detector law. Those aware had 2.82 greater odds of having a detector in the home compared to those unaware of the law. Lack of CO law awareness may lead to less frequent detector use and result in higher risk of CO poisoning. This highlights the need for CO risk and detector education to decrease poisonings.

Prevention against carbon monoxide poisoning emanating from burning coal briquettes - Generation rate of carbon monoxide and ventilation requirement

Carbon monoxide (CO) poisoning accidents occur every year in Japan, most of which are caused by the incomplete combustion of fuel, such as gasoline, light oil, and coal briquettes. To prevent CO poisoning in workers, it is essential to reduce the CO concentration in a working environment below the criteria threshold through ventilation. Although proper ventilation requirements for enclosed spaces are estimated from the generation rate of air pollutants, there is no empirical research evaluating the CO generation rate of coal briquettes. In this study, the author evaluated the CO generation rate of burning coal briquettes under controlled laboratory conditions and estimated the appropriate corresponding ventilation requirements. Despite the coal briquettes were burned under sufficient oxygen supply, the CO generation rates and the briquettes' consumption rates were 146-316 mL/min/kW and 1.65-3.61 g/min, respectively. Assuming the CO concentration limit was 50 ppm, the corresponding ventilation requirement was 174.9-378.7 m³/h/kW. The ventilation requirement was 43.7-94.7 m³/h/kW when the critical CO concentration was set at 200 ppm. Adopting the ventilation requirements set out in this study could facilitate proper ventilation and reduce the risk of CO poisoning.

Severe carbon monoxide poisonings in scuba divers: Asia-Pacific cases and causation

AIM

Reports of fatal incidents in recreational scuba divers from carbon monoxide (CO) poisoning are rare. This study aimed to identify scuba fatalities in the Asia-Pacific region caused by breathing-gas contamination to better understand the likely sources of contamination and reduce such preventable deaths.

METHODS

A hand search of Project Stickybeak reports, subsequent Australian fatality series reports, and of published New Zealand diving fatality reports and associated data was conducted, as well as key word searches of the National Coronial Information System for scuba fatalities in Australia and New Zealand. Cases identified were matched with the Australasian Diving Safety Foundation diving fatality database. Available reports were examined.

RESULTS

Four scuba deaths resulting from CO poisoning were identified from 645 scuba fatalities, including one report from each of Australia, New Zealand, Singapore, and the Maldives. A near-fatal incident was also identified in Indonesia. Two of the fatal incidents and the near-fatal incident involved internal combustion engine exhaust gases from the compressor system or elsewhere entering the air intake. Two deaths likely resulted from combustion within compressor systems.

CONCLUSIONS

Scuba fatalities from CO poisoning are uncommon, albeit likely under-reported. Sources of CO include exhaust gases entering the compressor and CO production by pyrolysis or gasification within the compressor or its filter system. Preventive measures include proper installation (including positioning of the air intake relative to combustion exhaust), appropriate maintenance, fitting of pressure-maintaining valves and avoidance of overheating. Formal training of compressor operators, improved diver education, mandatory requirements for installation compliance assessments, safety inspections, and the use of carbon monoxide alarms are recommended.

Preventing carbon monoxide poisoning in the Hudson River Tunnel in 1921: recounting history

The New York Bridge and Tunnel Commission began planning for a tunnel beneath the lower Hudson river to connect Manhattan to New Jersey in 1919. At 8,300 feet, it would be the longest tunnel for passenger vehicles in the world. A team of engineers and physiologists at the Yale University Bureau of Mines Experiment Station was tasked with calculating the ventilation requirements that would provide safety from exposure to automobile exhaust carbon monoxide (CO) while balancing the cost of providing ventilation. As the level of ambient CO which was comfortably tolerated was not precisely defined, they performed human exposures breathing from 100 to 1,000 ppm CO, first on themselves and subsequently on Yale medical students. Their findings continue to provide a basis for carbon monoxide alarm requirements a century later.

Smoke Alarms and Carbon Monoxide Alarms in Households With Children, Puerto Rico, 2010

In 2017, Puerto Rico sustained extensive damage from Hurricane Maria, increasing the risk of fires and carbon monoxide (CO) poisonings. Using a population-based, in-person survey of households with children less than 6 years old in Puerto Rico, we collected data in 2010 concerning the presence of smoke alarms and CO alarms in these households. We generated national estimates by extrapolating the number of households in each stratum using data from the 2010 Census. We determined which household characteristics predicted the presence of these alarms. Of 355 households analyzed, 31% had functional smoke alarms, or an estimated 109,773 households territory wide. The presence of smoke alarms was associated with living in multifamily housing and no child in the household receiving government medical insurance. Public housing or publicly subsidized housing, as compared to owner-occupied housing and unsubsidized rental housing, was associated with having a functional smoke alarm in households with children aged less than 6 years. Based on only six houses having CO alarms, we estimated only 7685 (2%) households had CO alarms. The low prevalence of functional smoke or CO alarms 7 years before Hurricane Maria is unfortunate and should be remedied by ensuring that such alarms are widely installed in current rebuilding activities.

Measured carbon monoxide concentrations from stock and reduced-emission prototype portable generators operated in an attached garage

There is concern about the hazard of acute residential CO exposures from portable gasoline-powered generators, which can result in death or serious adverse health effects in exposed individuals. To address this hazard, the U.S. Consumer Product Safety Commission has developed low CO emission prototype generators by adapting off-the-shelf emission control technologies onto commercially available generators. A series of tests was conducted to characterize the indoor CO concentrations resulting from portable generators operating in the attached garage of a research house under seven different test house/garage configurations. The tested generators include both unmodified and modified low CO emission prototypes. It was found that CO concentrations varied widely, with peak house CO concentrations ranging from under 10 ppm to over 10,000 ppm. The highest concentrations in the house resulted from operation of the unmodified generator in the garage with the garage bay door closed and the house access door open. The lowest concentrations resulted from operation of a modified low CO emission prototype in the garage with the garage bay door open and the house access door closed. These tests documented reductions of up to 98% in CO concentrations due to emissions from two low CO emission portable generators compared to a stock generator.

IMPLICATIONS

Improper portable generator use has caused 800 U.S. deaths in the past 14 years. Generators operated in attached garages can cause CO to quickly reach deadly levels. Two low-emission prototypes generators were tested and had CO emissions reduced by up to 98%. Low-emission generators can reduce the risk of consumer poisonings and deaths.

Distribution and Evaluation of a Carbon Monoxide Detector Intervention in Two Settings: Emergency Department and Urban Community

The objective of this study was to describe changes in carbon monoxide (CO) safety knowledge and observed CO detector use following distribution of a CO detector use intervention in two environments, a pediatric emergency department (Ohio) and an urban community (Maryland). A total of 301 participants completed the 6-month follow up (Ohio: n = 125; Maryland: n = 176). The majority of participants was female, 25–34 years of age, and employed (full or part time). We found that CO safety knowledge did not differ between settings at enrollment, but significantly improved at the follow-up visits. The majority of CO detectors observed were functional and installed in the correct location. Of those with CO detectors at follow up, the majority had not replaced the battery. The success of the intervention varied between settings and distribution methods. The majority of participants showed improved knowledge and behaviors. Improved device technology may be needed to eliminate the need for battery replacement.

Cost effectiveness of residential carbon monoxide alarms

BACKGROUND

While residential carbon monoxide (CO) alarms are now required in a majority of states, the cost effectiveness of the devices is unknown. This analysis was performed to determine the degree of prevention efficacy necessary from home carbon monoxide alarms for their expense to be cost-effective.

METHODS

Data regarding numbers of individuals affected in the United States annually from accidental, non-fire, residential non-fatal and fatal carbon monoxide poisoning were obtained from published literature. Federal governmental estimates of societal costs associated with medical care, lost wages and earnings, value of pain and suffering, and value of a statistical life were applied. The cost of uniform residential carbon monoxide alarm installation was compared to those societal costs in order to calculate what degree of efficiency makes alarms cost-effective.

RESULTS

Societal costs for accidental, non-fire, residential CO poisoning are approximately $3.47 billion annually. With an estimated cost of $348 million annually for alarms, prevention of greater than 10% of residential CO poisoning costs must be achieved in order for alarms to be cost-effective.

CONCLUSIONS

While the true effectiveness of residential carbon monoxide alarms has yet to be determined, current state legislation requiring residential installation of CO alarms is probably cost-effective. .

G-CSF administration attenuates brain injury in rats following carbon monoxide poisoning via different mechanisms

Acute severe carbon monoxide (CO) poisoning induces hypoxia that leads to cardiovascular and nervous systems disturbances. Different complex mechanisms lead to CO neurotoxicity including lipid peroxidation, inflammatory and immune-mediated reactions, myelin degeneration and finally neuronal apoptosis and necrosis. Granulocyte colony-stimulating factor (G-CSF) is considered to be a novel neuroprotective agent. In this study, we evaluated the efficacy of G-CSF therapy on CO neurotoxicity in rats with acute CO poisoning. Rats were exposed to 3000 ppm CO in air (0.3%) for 1 h, and then different doses (50,100, and 150 µg/kg) of G-CSF or normal saline were administrated intraperitoneally. Water content of brain as an indicator for total edema and blood brain barrier integrity (Evans blue extravasation) were evaluated. Malondialydehyde was determined in order to evaluate the effect of G-CSF on CO-induced lipid peroxidation in brain tissues. Also, the effect of G-CSF on myeloperoxidase activity in the brain tissue was evaluated. The effect of G-CSF administration on induced apoptosis in the brain was measured using TUNEL method. To evaluate the level of MBP, STAT3 and pSTAT3 and HO-1 proteins and the effect of G-CSF on these proteins Western blotting was carried out. G-CSF reduced water content of the edematous poisoned brains (100 µg/kg) and BBB permeability (100 and 150 µg/kg) (P < 0.05). G-CSF (150 µg/kg) reduced the MDA level in the brain tissues (P < 0.05 as compared to CO poisoned animals). G-CSF did not decrease the MPO activity after CO poisoning in any doses. G-CSF significantly reduced the number of apoptotic neurons and Caspase 3 protein levels in the brain. Western blotting results showed that G-CSF treatment enhanced expression of HO-1 and MBP, STAT3 and pSTAT3 proteins in the brain tissues. Based on our results, a single dose of G-CSF immediately after CO poisoning significantly attenuates CO neurotoxicity via different mechanisms. © 2015 Wiley Periodicals, Inc. Environ Toxicol 32: 37-47, 2017.

Avoid Toxic Gas Exposures

Two 2016 OSHA enforcement cases are object lessons in the importance of using the latest gas monitoring technology to protect workers.

Carbon monoxide poisoning in Utah: 1996-2013

INTRODUCTION

The true incidence of carbon monoxide (CO) poisoning is not clearly known, but a description of possible trends could aid in prevention.

METHODS

Investigators searched Utah state databases for emergency department (ED) visits and admissions for CO poisoning and medical examiner records for CO-related fatalities.

RESULTS

From 1996-2013, 7,590 individuals were diagnosed with CO poisoning: 6,469 were treated/ released from EDs; 596 were admitted; 525 died. Of 7,065 non-fatal poisonings, 5,950 (84%) were accidental and 498 (7%) were suicide attempts. Few patients (9.7%) were treated with hyperbaric oxygen. For accidental poisonings, internal combustion engines accounted for 43%, smoke inhalation, 34%, and heating sources, 22%. Internal combustion engines were implicated in 97% of suicide attempts. Non-fatal poisonings declined following a 2008 legislative change requiring CO alarms in residences, but we do not know if legislation caused the decline. One hundred forty-one (27%) fatal poisonings were accidental, 361 (70%) suicides and two (0.4%) homicides. Victims with cardiovascular autopsy findings/past cardiovascular history had lower carboxyhemoglobin levels (mean 51.2%, n=53) compared to those without (70.8%, n=472). Mean postmortem carboxyhemoglobin was highest in ages 20-29 years (72.5%).

CONCLUSIONS

The incidence of CO poisoning in Utah is declining, but CO poisoning is still common. Alarm legislation may aid prevention efforts. An educational campaign addressing the many causes and circumstances of CO poisoning is required for prevention.

Effects of resveratrol on carbon monoxide-induced cardiotoxicity in rats

Carbon monoxide (CO) poisoning leads to tissue hypoxia resulting in cardiovascular disturbances. Resveratrol (RES) is considered a natural cardioprotective agent especially in the setting of ischemia/reperfusion injury. In the present study, the cardioprotective potential of RES against CO-induced cardiotoxicity was evaluated. 45 male Wistar rats, animals were randomly assigned to 5 experimental groups. The first group served as negative control and was not exposed to CO. All remaining rats were exposed to CO 3000ppm for 60min. The second group received normal saline following CO exposure, while groups 3, 4 and 5 were injected intraperitoneally with different doses of RES (1, 5 and 10mg/kg, respectively). Histopathological examination showed that RES administration reduced myocardial lesions compared to control groups. Myocardial Akt expression was significantly increased in rats treated with the highest dose of RES (p<0.05) compared to CO-exposed non-treated animals. Caspase-3 activity in rat cardiomyocytes of RES-treated animals was significantly decreased in a dose-dependent manner. ECG findings did not differ significantly among CO-exposed groups. In conclusion, the present study offers evidence of a protective effect of RES administration on CO-induced cardiotoxicity via Akt up-regulation and attenuation of caspase-3 activity in rat hearts.

Decreasing carbon monoxide in the diving air of artisanal fishermen in the Yucatán peninsula by separation of engine exhaust from compressor intake

Artisanal fishermen in the Yucatán Peninsula utilize hookah dive systems (HDS). The air compressors in these HDS are not filtered, and the intake is near the engine exhaust. This proximity allows carbon monoxide (CO) from the exhaust to directly enter the HDS volume tank and contaminate the fishermen diver's air supply. Conservative safety standards permit a diver's air supply to contain 10 parts per million (ppm) of CO. This study quantified the levels of CO in the diver's air supply both before and after physical separation of the engine exhaust from the compressor intake. CO levels in seven volume tanks were analyzed before and after a 1-inch hose was attached to the compressor intake and elevated 5 feet above the engine exhaust. The tanks were drained and refilled before collecting each set of pre- and post-intervention gas samples. Four CO measurements were collected before and after the intervention from each volume tank. A C-Squared© CO Analyzer (± 1 ppm), calibrated with a Praxair 70 ppm CON2 gas (± 5%), was used to analyze the gas samples. A paired samples t-test shows a statistically significant difference in average CO values before and after the intervention (t = 6.8674, df: 27; p⟨0.0001). The physical separation of the engine exhaust from the compressor intake reduced the CO contamination of the diver air supply by 72%. This intervention could be applied to the hookah systems in the rest of the fishing cooperative to reduce the divers' risk of CO poisoning.

[Carbon monoxide poisoning by a heating system]

A case of accidental carbon monoxide poisoning in several occupants of two neighboring residential buildings in Hamburg-Harburg (Germany) caused by a defective gas central heating system is described. Because of leaks in one of the residential buildings and the directly adjacent wall of the neighboring house, the gas could spread and accumulated in both residential buildings, which resulted in a highly dangerous situation. Exposure to the toxic gas caused mild to severe intoxication in 15 persons. Three victims died still at the site of the accident. Measures to protect the occupants were taken only with a great delay. As symptoms were unspecific, it was not realized that the various alarms given by persons involved in the accident were related to the same cause. In order to take appropriate measures in time it is indispensible to recognize, assess and check potential risks, which can be done by using carbon monoxide warning devices and performing immediate COHb measurements with special pulse oximeters on site. Moreover, the COHb content in the blood should be routinely determined in all patients admitted to an emergency department with unspecific symptoms.

Characteristics of Children with Acute Carbon Monoxide Poisoning in Ankara: A Single Centre Experience

The purpose of the study was to define characteristics of children with acute carbon monoxide poisoning. Eighty children hospitalized with acute carbon monoxide poisoning were recruited prospectively over a period of 12 months. Sociodemographic features, complaints and laboratory data were recorded. When the patient was discharged, necessary preventive measures to be taken were explained to parents. One month later, the parents were questioned during a control examination regarding the precautions that they took. The ages of the cases were between one month and 16 yr. Education levels were low in 86.2% of mothers and 52.6% of fathers. All families had low income and 48.8% did not have formal housing. The source of the acute carbon monoxide poisoning was stoves in 71.2% of cases and hot-water heaters in 28.8% of cases. Three or more people were poisoned at home in 85.1% of the cases. The most frequent symptoms of poisoning were headache and vertigo (58.8%). Median carboxyhemoglobin levels at admission to the hospital and discharge were measured as 19.5% and 1.1% (P < 0.001). When families were called for re-evaluation, it was determined that most of them had taken the necessary precautions after the poisoning incident (86.3%). This study determined that children with acute childhood carbon monoxide poisoning are usually from families with low socioeconomic and education levels. Education about prevention should be provided to all people who are at risk of carbon monoxide poisoning before a poisoning incident occurs.

Data to action: using environmental public health tracking to inform decision making

CONTEXT

Public health surveillance includes dissemination of data and information to those who need it to take action to prevent or control disease. The concept of data to action is explicit in the mission of the Centers for Disease Control and Prevention's (CDC's) National Environmental Public Health Tracking Program (Tracking Program). The CDC has built a National Environmental Public Health Tracking Network (Tracking Network) to integrate health and environmental data to drive public health action (PHA) to improve communities' health.

OBJECTIVE

To assess the utility of the Tracking Program and Tracking Network in environmental public health practice and policy making.

DESIGN

We analyzed information on how Tracking (all program components hereafter referred to generally as "Tracking") has been used to drive PHAs within funded states and cities (grantees). Two case studies are presented to highlight Tracking's utility.

SETTING

Analyses included all grantees funded between 2005 and 2013.

PARTICIPANTS

Twenty-seven states, 3 cities, and the District of Columbia ever received funding.

MAIN OUTCOME MEASURES

We categorized each PHA reported to determine how grantees became involved, their role, the problems addressed, and the overall action.

RESULTS

Tracking grantees reported 178 PHAs from 2006 to 2013. The most common overall action was "provided information in response to concern" (n = 42), followed by "improved a public health program, intervention, or response plan" (n = 35). Tracking's role was most often either to enhance surveillance (24%) or to analyze data (23%). In 47% of PHAs, the underlying problem was a concern about possible elevated rates of a health outcome, a potential exposure, or a potential association between a hazard and a health outcome. PHAs were started by a request for assistance (48%), in response to an emergency (8%), and though routine work by Tracking programs (43%).

CONCLUSION

Our review shows that the data, expertise, technical infrastructure, and other resources of the Tracking Program and Tracking Network are driving state and local PHAs.

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.

When bad things happen to bad people: using disposition theory to explore the effects of cautionary tales

Cautionary tales are a prevalent form of entertainment narrative in media-saturated environments, yet they have received little empirical examination. Using disposition theory, this study manipulated affective disposition toward the protagonist in order to explore the effects of exposure to a cautionary tale on adoption of prosocial attitudes and behavioral intentions. A between-subjects experimental design was used with 2 conditions (positive/negative) and a control group (n = 305). Results provide evidence that exposure to cautionary tales positively influences adoption of attitudes and intentions to purchase a carbon monoxide detector and talk about accidental carbon monoxide poisoning. Affective disposition influenced identification with the protagonist, and perceptions that the protagonist deserved the negative consequences experienced in the cautionary tale narrative. Findings also suggest that identification mediates the relationship between affective disposition and perceived risk.

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.

[Poisoning by exhaust gas of the imperfect combustion of natural gas: 22 cases study]

OBJECTIVE

To analyze the case characteristics of poisoning by exhaust gas of the imperfect combustion of natural gas and provide references for forensic identification and prevention of such accidents.

METHODS

Twenty-two cases of poisoning by exhaust gas of the imperfect combustion of natural gas in Minhang District during 2004 to 2013 were collected. Some aspects such as general conditions of deaths, incidence time, weather, field investigation, and autopsy were retrospectively analyzed.

RESULTS

In the 22 cases, there were 15 males and 16 females. The age range was between 2 and 82 years old. The major occurring time was in January or February (8 cases in each) and the cases almost occurred in small area room (21 cases). There was wide crack next to the exhaust port when the gas water heater was been used in all cases.

CONCLUSION

There are more prone to occurrence of exhaust gas poisoning of imperfect combustion of natural gas in small area room with a ventilation window near the exhaust port of gas water heated. It shows that the scene of combustion exhaust gas poisoning should be more concerned in the cold season.

Surface design of alloy protection against CO-poisoning from first principles

Pt-based alloy catalysts are of significant importance in fuel cells due to enhanced electrode reactivity and selectivity. Designing alloy surfaces suitable for catalyst via first-principles predictions has long played a central role in identifying promising candidates. We propose surface design for polymer electrolyte fuel cell (PEFC) based on the use of thermodynamically stable alloy surfaces. Using first-principles calculation, we have explored stable Pt alloy surfaces that possess superior catalytic properties for CO-despoisoning in hydrogen-related reactions of fuel cells. The stable Pt(25)M(75) (M = Rh, Cu) alloy surfaces both exhibited weaker CO and stronger H binding compared to the pure Pt surface, which yielded a significant increase in H coverage by around one order. These modifications of molecular adsorption are attributed to the deeper band centre of surface d electrons. Understanding the adsorption properties of the stable atomic structure at surfaces will help us to design suitable alloy surfaces with high-catalytic activity and prolonged actuation in fuel cells.

A summary of research and progress on carbon monoxide exposure control solutions on houseboats

Investigations of carbon monoxide (CO-related poisonings and deaths on houseboats were conducted by the Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. These investigations measured hazardous CO concentrations on and around houseboats that utilize gasoline-powered generators. Engineering control devices were developed and tested to mitigate this deadly hazard. CO emissions were measured using various sampling techniques which included exhaust emission analyzers, detector tubes, evacuated containers (grab air samples analyzed by a gas chromatograph), and direct-reading CO monitors. CO results on houseboats equipped with gasoline-powered generators without emission controls indicated hazardous CO concentrations exceeding immediately dangerous to life and health (IDLH) levels in potentially occupied areas of the houseboat. Air sample results on houseboats that were equipped with engineering controls to remove the hazard were highly effective and reduced CO levels by over 98% in potentially occupied areas. The engineering control devices used to reduce the hazardous CO emissions from gasoline-powered generators on houseboats were extremely effective at reducing CO concentrations to safe levels in potentially occupied areas on the houseboats and are now beginning to be widely used.

Are Iranians aware of carbon monoxide poisoning: symptoms and its prevention strategies?

Carbon monoxide (CO) poisoning is still a health problem all over the world. Informing users about symptoms and suggesting annual inspection of CO producing devices will result in CO poisoning reduction. The goal of this study was to evaluate awareness about CO poisoning symptoms and its prevention ways in Iranian population. In this study, a total of 700 patients' family members attended Imam Khomeni hospital were asked to enroll in the study. A structured questionnaire was used including demographic characteristics, devices which were used at home, awareness of CO poisoning symptoms, awareness of CO detectors, the last time that tubal patency of devices are checked, if it is helpful to open the window to fix gas leak and if surveying devices by an expert at the beginning of the cold season is recommended. A total of 635 participants completed questionnaires. The most used device was gas water heater followed by gas heater. Five hundred and nine reported that they are aware of CO poisoning symptoms (80.1%), 398 (62.6%) stated that it is possible to detect CO leak and 566 (89.1%) told CO detectors would be helpful for reduction of mortality from CO poisoning. Fifty percent of participants had not checked their devices since they have bought their devices. Five hundred and thirty-six (84.4%) reported that opening window could help CO leak, and 596 (93.8%) agreed that an expert checked their fuel-burning devices at the beginning of the winter. Iranian people are not aware of all CO poisoning symptoms. Developing a national strategy for CO surveillance and people education will be helpful.

Residential carbon monoxide (CO) poisoning risks: correlates of observed CO alarm use in urban households

The authors conducted a household survey and observation to assess carbon monoxide (CO) knowledge and risks as well as prevalence of CO alarms in an urban community prior to the enactment of a mandatory ordinance requiring CO alarms in one U.S. city. From July to December 2009, household surveys and observations were completed in 603 residences. Participants were mostly African-American (61%), women (70%), 25-54 years in age (66%), and with a high school education or less (51%). Most homes visited contained CO-producing appliances, including gas stoves (86%), gas furnaces (82%), and gas water heaters (79%). Participants' overall mean percentage correct knowledge score was 57%. CO alarms were reported by 33% of participants and observed among 28% of households. Low rates of CO knowledge and CO alarm ownership, combined with high rates of CO-producing sources in homes, suggests the need for widespread campaigns to promote CO alarms. Recommendations are also made to integrate the lessons learned from the public health community's experience promoting smoke alarms.

Mortality associated with exposure to carbon monoxide in WHO European Member States

In closed environments, the concentration of carbon monoxide (CO) can easily rise to health-threatening levels. CO-related incidents are often caused by poor condition or inappropriate use of indoor combustion devices as well as structure fires but are also due to suicides. To evaluate the incidence of CO poisoning in Europe, national data on CO-related mortality and morbidity were compiled from Member States of the WHO European Region using a standardized data collection form. National data on CO poisoning were provided by 28 Member States. Within the maximum reporting period (1980-2008), a total of 140 490 CO-related deaths were reported (annual death rate of 2.2/100 000). The number of hospital admissions available from six countries was 31 473. Unintentional CO deaths accounted for 54.7% of the CO-related deaths (35.9%: unintentional inhalation; 18.8%: related to structure fires). The intentional deaths related to CO exposure account for 38.6% of all CO-related deaths (38.1%: suicides; 0.5%: homicides). CO exposure is preventable but causes a substantial amount of deaths in many European countries. More efficient measures and policies to prevent CO poisoning and better reporting of CO mortality are necessary.

2005 hurricane surveillance: measures to reduce carbon monoxide poisoning in all Floridians

The 2005 Florida hurricanes caused widespread power outages, increasing generator use that directly resulted in a surge in carbon monoxide (CO) poisonings. Of the 126 CO poisonings documented, 77% were related to generator use and 43% of these generators were placed outside but near a window. African-Americans and Latinos had a higher incidence of CO poisoning. The strength of the authors' study described here was the inclusion of the first responder network in one surveillance system for hurricane response. Notable advances have occurred since the authors' study, including CO poisoning listed as a reportable condition, regulation requiring CO detectors, CO generator warning labeling, and the development of a local surveillance and classification program for the county health departments. To prepare for future multiple hurricane seasons, comprehensive outreach should be focused at the local level through the first responder network and community groups to reduce CO poisonings in all populations.

Should the placement of carbon monoxide (CO) detectors be influenced by CO's weight relative to air?

BACKGROUND

Numerous states and localities have recently passed legislation mandating the installation and use of residential carbon monoxide (CO) detectors/alarms. Interestingly, there seems to be confusion about the optimal placement, if any, of CO alarms inside the home.

OBJECTIVES

It was the goal of this study to demonstrate the behavior of CO in air and to help provide a data-based recommendation for CO alarm placement.

METHODS

CO was calculated to be slightly lighter than air. An 8-foot-tall airtight Plexiglas chamber was constructed and CO monitors placed within at the top, middle, and bottom. CO test gas (15 L, 3000 parts per million) was infused at each of the three heights in different trials and CO levels measured over time.

RESULTS

Contrary to a significant amount of public opinion, CO did not layer on the floor, float at the middle of the chamber, or rise to the top. In each case, the levels of CO equalized throughout the test chamber. It took longer to equalize when CO was infused at the top of the chamber than the bottom, but levels always became identical with time.

CONCLUSIONS

As would have been predicted by the Second Law of Thermodynamics, CO infused anywhere within the chamber diffused until it was of equal concentration throughout. Mixing would be even faster in the home environment, with drafts due to motion or temperature. It would be reasonable to place a residential CO alarm at any height within the room.

Residential carbon monoxide alarm use: opportunities for poisoning prevention

Prevalence of carbon monoxide (CO) alarm usage in localities where they are not required is poorly defined and the reasons for failing to have a home CO alarm have never been described. In this study, the authors conducted a computer-based survey among employees of similar major medical centers in Seattle, Washington, and Salt Lake City, Utah. Questions were asked about the prevalence of use of residential smoke and CO alarms with regard to home style and structure, ownership status, and energy use. Respondents not using home CO detectors were asked the reasons. Among 1,351 individuals participating in the survey, 98% reported residential use of smoke alarms, while only 51% used CO alarms. CO alarm use was more common among residents of Utah than Washington, among home owners than renters, and among those with single family homes rather than other styles. Reasons for failure to use CO alarms related largely to lack of knowledge about the devices and motivation.

Occupational carbon monoxide poisoning in Washington State, 2000-2005

Washington State workers' compensation data can be used to guide prevention efforts focused on occupational carbon monoxide (CO) poisoning. Between 2000 and 2005, a total of 345 individual claims comprising 221 different exposure incidents were identified for the 6-year time period. The construction industry had 43 (20%) CO incidents, followed by wholesale trade with 32 (15%), and agriculture with 27 (12%) incidents. Fuel-powered forklifts caused 29% of all incidents, while autos/trucks/buses were responsible for 26%. The number of forklift incidents in fruit packing and cold storage companies declined significantly from 1994 through 2007 (Spearman's rho = 0.6659, p < 0.01). While this study used multiple medical records from workers' compensation claims to identify CO poisoning, a surveillance system that lacks extensive medical records may rely principally on carboxyhemoglobin (COHb) tests. This study demonstrated that 71% of the identified workers' compensation claims had associated COHb tests. The recurrence and timing of CO poisoning as well as control of the CO-generating source were determined. Approximately 8% of all work sites had recurring CO poisoning incidents. Two percent experienced a recurrent incident within 16 days of the initial incident, and 6% experienced a recurrent incident between 16 days and 3 years after the initial incident. Sixty-seven percent of claimants exposed to CO were not in direct control of the CO-generating source; this has implications for CO prevention and underscores the need for all employees to be trained on CO hazards.

[Analysis of poisoning cases from Chinese National Injury Surveillance System, 2006 - 2008]

OBJECTIVE

To study the preventive strategies through analyzing the poisoning cases from the National Injury Surveillance System (NISS), from 2006 to 2008.

METHODS

Data of poisoning cases was descriptively analyzed from Chinese NISS, from 2006 to 2008.

RESULTS

The proportion of poisoning cases to all injuries cases from NISS were 2.57%, 2.48% and 2.52% from 2006 to 2008, which ranked sixth in all the injuries causes. Most people being poisoned had junior middle school education and most of them were agriculture/animal husbandry/fishery/water producers or commercial/service personnel. Most of the poisoning incidents were happened at home, always occurred in leisure time - around 8 PM, every day. The common types of poisoning were alcohol, clinical drugs, pesticide and carbon monoxide. Unintentional injuries were the main causes. Self-harm/suicidal cases in the rural areas were more than in the urban areas, with women more than men. The main type of self-harm/suicide related poisoning cases were through drugs or pesticide. ≥ 65, 15 - 29 and 30 - 44 year-olds were most commonly seen.

CONCLUSION

Alcoholism was the primary type of poisoning injuries which is the highest in young adults (15 - 29 years and 30 - 44 years). It's important to promote civilized drinking habits and limit access to alcohol for youth. Self-harm/suicide had close relationship with clinical drugs and pesticide. The key points to prevent pesticide and clinical drugs poisoning were safe storage of pesticides, universal security of pesticide, and the supervision on drug producing and marketing. Children and the elderly were the high risk people for carbon monoxide poisoning. Monitoring and intervention must be strengthened.

Centers for Disease Control and Prevention (CDC). Carbon monoxide exposures after hurricane Ike - Texas, September 2008

During power outages after hurricanes, survivors can be at risk for carbon monoxide (CO) poisoning if they use portable generators improperly. On September 13, 2008, Hurricane Ike struck the coast of Texas, leaving approximately 2.3 million households in the southeastern portion of the state without electricity. Six days later, 1.3 million homes were still without electrical power. To assess the impact of storm-related CO exposures and to enhance prevention efforts, CDC analyzed data from five disparate surveillance sources on CO exposures reported during September 13--26 in counties of southeast Texas that were declared disaster areas by the federal government. This report describes the results of that analysis, which indicated that one data source, Texas poison centers, received reports of 54 persons with storm-related CO exposures during the surveillance period. Another data source, the Undersea and Hyperbaric Medical Society (UHMS) hyperbaric oxygen treatment database, reported that 15 persons received hyperbaric oxygen treatment for storm-related CO poisoning. Medical examiners, public health officials, and hospitals in Texas reported that seven persons died from storm-related CO poisoning. Among the data sources, the percentage of reported storm-related CO exposures caused by improper generator use ranged from 82% to 87%. These findings underscore the need for effective prevention messages during storm preparation, warnings, and response periods regarding the correct use of generators and the installation and maintenance of battery-powered CO detectors.

[Suicide due to carbon monoxide poisoning-trends and preventive measures]

To lessen the number of suicide is a nationwide problem in Japan. Recently, suicide due to carbon monoxide poisoning with charcoal burning is increased. The information on this method seems to have spread via suicide-related websites. In addition, there are concerns about drugs and illegal substances that can be bought obtained via the internet. In Japan, the establishment of a voluntary internet guideline in 2005 was effective to save the lives of the persons with suicidal ideations.

[Carbon monoxide deaths caused by town gas in Denmark 1995-99]

INTRODUCTION

Over the years town gas has caused many fatal carbon monoxide poisonings. The aim of this paper is to document the circumstances surrounding town gas deaths in Denmark between 1995-1999 and to trace the development of these deaths in recent decades.

MATERIALS AND METHODS

A retrospective study of death certificates and report material concerning carbon monoxide deaths in Denmark between 1995-1999 caused by town gas. Of 449 non-fire related carbon monoxide poisonings, 22 (4.9%) were caused by town gas.

RESULTS

The deaths consisted of fourteen suicides, six accidents, and two with undetermined manner of death. Ten (71%) of the suicide victims were men and four (29%) were women, with an average age of 48 years (24-82 years); all had turned on two or more gas rings. The accident victims were one man and five women, with an average age of 84 years (77-92 years); all had only turned on one gas ring.

CONCLUSION

The number of town gas deaths has been drastically reduced since 1969, which can be explained by the reduced number of town gas installations containing carbon monoxide as well as preventive measures. Most deaths can probably be avoided when the town gas supply is switched to carbon monoxide-free town gas in 2007, but it is important to be aware that incomplete combustion of carbon monoxide-free town gas can still lead to carbon monoxide poisonings.

Results from a state-based surveillance system for carbon monoxide poisoning

OBJECTIVES

The purpose of this study was to describe results from a pilot surveillance system for carbon monoxide poisoning--a significant yet preventable public health issue for which most public health agencies do not conduct routine public health surveillance.

METHODS

The authors developed a rate-based statewide surveillance system. Cases were identified using the 1998 Council of State and Territorial Epidemiologists' case definition in hospital discharges, emergency department and hospital outpatient visits, and mortality data. Intentional and fire-related injuries were excluded. The system was supplemented with qualitative information from newspaper articles. Annual, age, and sex-specific incidence rates were estimated. Exposure source/setting was described using E-codes; occupational setting was assessed by combining E-codes and payer code. Cases occurring during a disaster-related power outage in January 1998 were compared with cases identified during routine surveillance from 1999 through 2003.

RESULTS

During the five years of routine surveillance, 740 cases were identified; 47 (6.4%) were hospitalized, 442 (59.7%) were seen in an emergency department, and 251 (34.3%) were seen in another outpatient setting. More cases were observed in fall/winter; 23.1% of patients aged 16 or older were classified as exposed in an occupational setting. Among disaster-related cases, more were older (> or =65 years of age; 11.9% vs. 4.2%) and female (61.6% vs. 45.3%); and fewer were in occupational settings (1.8% vs. 23.1%).

CONCLUSIONS

Establishing state-based public health surveillance for CO poisoning is feasible and essential for guiding prevention and control efforts. The finding that more than 20% of cases were classified as occupational should be investigated further.

Environments, indoor air quality, and children

This article addresses air-quality science in the indoor environments in which children and adolescents find themselves, including the home, the school, and other environments such as work and recreational situations. The home arena is covered extensively, presenting an analysis of the usual exposures such as environmental tobacco smoke and bioaerosols and also touching on discrete issues such as sudden infant death syndrome, carbon monoxide, and public housing. Recreation and work environments are covered as well.

Carbon monoxide exposure in households in Ciudad Juárez, México

This study assessed exposure to carbon monoxide from gas and wood heater emissions in a sample of 64 households in peri-urban residential areas in Ciudad Juárez, Chihuahua, México. Indoor and outdoor carbon monoxide concentrations and temperatures were monitored for a continuous period of 1 week at 1 and 6-min intervals, respectively. The moving average carbon monoxide concentrations were compared to the World Health Organization (WHO) standards for carbon monoxide. Sixty-seven percent of households with gas heaters and 60% of households with wood heaters exceeded a health-based standard at some point during the monitoring. The difference between indoor and outdoor temperatures was modestly correlated with average carbon monoxide exposure (r=0.35, p-value <0.01). Heater type may be a stronger determinant of exposure, as households with a particular heater model (the El Sol FM-210) were significantly more likely to be among the more highly exposed households (odds ratio of 4.8, p-value of 0.02). A variety of health effects were pooled and found at elevated frequency in the households that exceeded the 8-h standard of 9ppm (odds ratio=5.1, p-value=0.031). These results highlight the need for further efforts to identify and mitigate potentially hazardous carbon monoxide exposures, particularly in moderate-income countries with cooler climates.