Carbon monoxide poisoning in Florida during the 2004 hurricane season

Exposure Assessment for Tropical Cyclone Epidemiology

PURPOSE OF REVIEW

Tropical cyclones impact human health, sometimes catastrophically. Epidemiological research characterizes these health impacts and uncovers pathways between storm hazards and health, helping to mitigate the health impacts of future storms. These studies, however, require researchers to identify people and areas exposed to tropical cyclones, which is often challenging. Here we review approaches, tools, and data products that can be useful in this exposure assessment.

RECENT FINDINGS

Epidemiological studies have used various operational measures to characterize exposure to tropical cyclones, including measures of physical hazards (e.g., wind, rain, flooding), measures related to human impacts (e.g., damage, stressors from the storm), and proxy measures of distance from the storm's central track. The choice of metric depends on the research question asked by the study, but there are numerous resources available that can help in capturing any of these metrics of exposure. Each has strengths and weaknesses that may influence their utility for a specific study. Here we have highlighted key tools and data products that can be useful for exposure assessment for tropical cyclone epidemiology. These results can guide epidemiologists as they design studies to explore how tropical cyclones influence human health.

Emergency department visits associated with satellite observed flooding during and following Hurricane Harvey

BACKGROUND

Flooding following heavy rains precipitated by hurricanes has been shown to impact the health of people. Earth observations can be used to identify inundation extents for subsequent analysis of health risks associated with flooding at a fine spatio-temporal scale.

OBJECTIVE

To evaluate emergency department (ED) visits before, during, and following flooding caused by Hurricane Harvey in 2017 in Texas.

METHODS

A controlled before and after design was employed using 2016-2018 ED visits from flooded and non-flooded census tracts. ED visits between landfall of the hurricane and receding of flood waters were considered within the flood period and post-flood periods extending up to 4 months were also evaluated. Modified Poisson regression models were used to estimate adjusted rate ratios for total and cause specific ED visits.

RESULTS

Flooding was associated with increased ED visits for carbon monoxide poisoning, insect bite, dehydration, hypothermia, intestinal infectious diseases, and pregnancy complications. During the month following the flood period, the risk for pregnancy complications and insect bite was still elevated in the flooded tracts.

SIGNIFICANCE

Earth observations coupled with ED visits increase our understanding of the short-term health risks during and following flooding, which can be used to inform preparedness measures to mitigate adverse health outcomes and identify localities with increased health risks during and following flooding events.

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.

Carbon monoxide detector effectiveness in reducing poisoning, Wisconsin 2014-2016

Introduction: Carbon monoxide (CO) is a colorless, odorless, and nonirritating gas. The most common exposures are from gas powered appliances such as furnaces, water heaters, stoves, and vehicles. To prevent poisoning, CO detectors with audible alarms were developed. This study aims to evaluate the effectiveness of CO detectors in reducing poisoning in Wisconsin.Methods: Records were queried from National Poison Data System for unintentional CO exposures that occurred in residences in Wisconsin during 2014-2016 (N = 703). After applying sample exclusion criteria, notes were abstracted for cases where CO detector use was mentioned (n = 408). Logistic regression analyses were used to assess the association between having a CO detector alarm and CO poisoning. Linear regression analyses were used to assess the relationship between having a CO detector alarm and poisoning severity.Results: In logistic models, odds of CO poisoning were 3.2 times higher (95% CI: 1.5, 6.9) among those who had no CO detector compared to those who had a CO detector that alarmed. In linear models, not having a CO detector was associated with a 0.34 point (95% CI: 0.17, 0.54) change in outcome severity score compared to having a CO detector that alarmed.Discussion: Individuals who were exposed to CO in the absence of a CO detector were more likely to be poisoned and to have more severe medical outcomes than those that had a CO detector that alarmed.

The detection of occult CO poisoning through noninvasive measurement of carboxyhemoglobin: A cross-sectional study

OBJECTIVES

Carbon monoxide (CO) poisoning is one of the leading causes of preventable death in the world. Our primary objective was to identify and treat individuals who are unaware of their exposure to carbon monoxide in emergency departments (EDs). Our secondary goal was to reduce the costs of diagnosis and treatment by preventing unnecessary diagnostic testing in EDs.

METHODS

In this cross-sectional study, carboxyhemoglobin (COHb) levels of patients presented with the signs of CO poisoning to the Emergency Department of Kayseri Training and Research Hospital between November 2012 and May 2013 were noninvasively measured during triage. Patients with elevated COHb levels were suspected of CO poisoning and subjected to further investigation.

RESULTS

A total of 4073 patients were enrolled in the study, and 106 (2.6%) of them were diagnosed with CO poisoning. Initial evaluation revealed headache to be the most common presenting complaint in patients with occult CO poisoning. Further evaluations to determine the accuracy of noninvasive measurements showed that noninvasive pulse CO-oxymeter and arterial blood gas (ABG) measurement were compatible.

CONCLUSIONS

The use of noninvasive pulse CO-oxymeter might reduce the morbidity and mortality associated with occult CO poisoning in patients presented with suspected CO poisoning in emergency settings.

Carbon monoxide poisoning during camping in Korea

OBJECTIVE

The aim of this study was to evaluate the epidemiology and characteristics of unintentional carbon monoxide (CO) poisoning during camping in Korea.

METHODS

We performed a retrospective observational study on patients with unintentional camping-related CO poisoning who were admitted to the emergency department (ED) from 1 January 2010 to 31 December 2014. News reports about incidents of camping-related CO poisoning were collected using news search engines.

RESULTS

A total of 72 patients (29 patients involved in 12 incidents, who were admitted to our ED, and 43 victims involved in 17 incidents reported in the media) were identified. Accidental camping-related CO poisoning occurred most frequently in May, late spring in Korea. Gas stove use and the burning of charcoal for tent heating were responsible for camping-related CO exposure. Seventeen victims (39.5%) were found dead when an ambulance arrived at the scene, in the cases reported in the media. In contrast, all the victims at our hospital were alive on hospital discharge. Twelve of the 17 incidents (70.6%) reported in the media were accidental fatalities. The majority of our patients (83.4%) were not aware of the potential danger of charcoal as a source of CO.

CONCLUSION

Accidental camping-related CO poisoning occurred because of an ongoing lack of awareness about the potential danger of charcoal grills and stoves, and this caused prehospital mortality. Such accidents could be prevented by increasing the awareness of the potential danger of using charcoal grills and stoves during camping, as well as by establishing appropriate safety regulations.

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.

A fire department community health intervention to prevent carbon monoxide poisoning following a hurricane

Portable generators are commonly used during electrical service interruptions that occur following large storms such as hurricanes. Nearly all portable generators use carbon based fuels and produce deadly carbon monoxide gas. Despite universal warnings to operate these generators outside only, the improper placement of generators makes these devices the leading cause of engine related carbon monoxide deaths in the United States. The medical literature reports many cases of Carbon Monoxide (CO) toxicity associated with generator use following hurricanes and other weather events. This paper describes how Howard County, Maryland Fire and Rescue (HCFR) Services implemented a public education program that focused on prevention of Carbon Monoxide poisoning from portable generator use in the wake of events where electrical service interruptions occurred or had the potential to occur. A major challenge faced was communication with those members of the population who were almost completely dependent upon electronic and wireless technologies and were without redundancies. HCFR utilized several tactics to overcome this challenge including helicopter based surveillance and the use of geocoded information from the electrical service provider to identify outage areas. Once outage areas were identified, HCFR personnel conducted a door-to-door canvasing of effected communities, assessing for hazards and distributing information flyers about the dangers of generator use. This effort represents one of the first reported examples of a community-based endeavor by a fire department to provide proactive interventions designed to prevent carbon monoxide illness.

Tracking Deaths Related to Hurricane Ike, Texas, 2008

Background: On September 13, 2008, Hurricane Ike, a category 2 storm with maximum sustained winds of 110 mph, made landfall near Galveston, Texas. Ike produced a damaging, destructive, and deadly storm surge across the upper Texas and southwestern Louisiana coasts. Thirty-four Texas counties were declared disaster areas by the Federal Emergency Management Agency; 15 counties were under mandatory evacuation orders. To describe causes of death associated with this hurricane and identify prevention strategies during the response and recovery phases, the Texas Department of State Health Services (DSHS) monitored mortality data in 44 counties throughout the state. This report summarizes Ike-related deaths reported by Texas medical examiners, justices of the peace (coroners), forensic centers, public health officials, and hospitals.

Methods: Based on the Centers for Disease Control and Prevention (CDC) disaster-related mortality surveillance form, DSHS developed a state-specific 1-page form and collected (optimally daily) data on demographic, date and place of death, and cause and circumstance of deaths. A case was defined as any death that was directly or indirectly related to Ike among evacuees, residents, nonresidents, or rescue personnel in the declared disaster counties, counties along the Texas Gulf coast or counties known to have evacuation shelters occurring September 8, 2008, through October 13, 2008. Analyzed data were shared with the state emergency operation center and the CDC on a daily basis.

Results: The surveillance identified 74 deaths in Texas as directly (10 [14%]), indirectly (49 [66%]), or possibly (15 [20%]) related to Ike. The majority of deaths (n = 57) were reported by medical examiners. Deaths occurred in 16 counties of the 44 counties covered by the surveillance. The majority of deaths occurred in Harris and Galveston (28 [38%] and 17 [23%]), respectively. The deceased ranged in age from younger than 1 year to 85 years, with an average age of 46 years (median 50 years); 70% were male. Of the 74 deaths, 47 (64%) resulted from injuries, 23 (31%) from illnesses, and 4 (5%) were undetermined. Among the injuries, carbon monoxide poisoning (13 [18%]) and drowning (8 [11%]) were the leading causes of injury-related deaths. Cardiovascular failure (12 [16%]) was the leading cause of illness-related deaths.

Conclusions: Defining the relation of death to hurricane using an active mortality surveillance system is possible. The active mortality surveillance form used in Ike provided valuable daily information to DSHS, state emergency management officials, and the CDC regarding the characteristics of deaths in the state. Most of the Ike-related deaths were caused by injury (direct and indirectly related) such as carbon monoxide poisonings and drowning and may have been preventable by educating the public.

(Disaster Med Public Health Preparedness. 2011;5:23-28)

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.

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

OBJECTIVES

We conducted a systematic literature review to better understand aspects of disaster-related carbon monoxide (CO) poisoning surveillance and determine potentially effective prevention strategies.

METHODS

This review included information from 28 journal articles on disaster-related CO poisoning cases occurring between 1991 and 2009 in the United States.

RESULTS

We identified 362 incidents and 1888 disaster-related CO poisoning cases, including 75 fatalities. Fatalities occurred primarily among persons who were aged 18 years or older (88%) and male (79%). Hispanics and Asians accounted for 20% and 14% of fatal cases and 21% and 7% of nonfatal cases, respectively. Generators were the primary exposure source for 83% of fatal and 54% of nonfatal cases; 67% of these fatal cases were caused by indoor generator placement. Charcoal grills were a major source of exposure during winter storms. Most fatalities (94%) occurred at home. Nearly 89% of fatal and 53% of nonfatal cases occurred within 3 days of disaster onset.

CONCLUSIONS

Public health prevention efforts could benefit from emphasizing predisaster risk communication and tailoring interventions for racial, ethnic, and linguistic minorities. These findings highlight the need for surveillance and CO-related information as components of disaster preparedness, response, and prevention.

Environmental- and injury-related epidemic-assistance investigations, 1946-2005

This paper summarizes environmental investigations (n = 458) conducted during the first 60 years of the epidemic-assistance investigation program at the Centers for Disease Control and Prevention. These investigations were grouped into 10 categories: toxic chemicals (n = 102), indoor air quality and outdoor air toxics (n = 21), new or rare epidemic diseases and unexplained syndromes (n = 29), natural disasters (n = 81), terrorism and unintentional human-made disasters (n = 9), substance use and abuse (n = 13), environmental aspects of infectious disease (n = 132), those affecting neonates and infants (n = 11), violence and injuries (n = 51), and miscellaneous (n = 9). Among the most important or prominent were studies of lead and arsenic toxicity at smelters, mercury in paint and beauty creams, dioxin in waste oil in Missouri, polychlorinated biphenyls and multiple other toxic chemicals, global pesticide poisoning outbreaks, hepatic angiosarcoma among vinyl chloride workers, toxic oil syndrome in Spain, eosinophilia-myalgia syndrome from contaminated L-tryptophan, diethylene glycol poisoning in Haiti, aflatoxicosis in Kenya, Gulf War illness among veterans, impact and needs assessments during natural disasters (e.g., Hurricane Katrina (2005) and the Mount St. Helens volcano eruptions (1980)), risk factors for heat-related mortality, domestic and international terrorist attacks, Parkinsonism related to 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine in California, and unintentional injury- and violence-related events.

Attitudes about carbon monoxide safety in the United States: results from the 2005 and 2006 HealthStyles Survey

OBJECTIVES

We sought to identify attitudes and behaviors related to carbon monoxide (CO) safety that can be targeted with public health prevention strategies in the U.S.

METHODS

The Centers for Disease Control and Prevention added questions about (1) proper placement of gas-powered generators, (2) maintenance of fuel-burning appliances, and (3) use of CO detectors to the 2005 and 2006 HealthStyles national health marketing surveys.

RESULTS

In 2005, 63.3% of HealthStyles respondents agreed with or were uncertain about the incorrect statement, "It is safe to run a generator in a garage as long as the door is open," while 43.1% agreed with or were uncertain about the incorrect statement, "It is safe to run a generator in the basement." Most of the 2006 respondents (63.5%) agreed that it is important to have their furnace inspected annually. However, fewer than half of the 2006 respondents (42.0%)-most of whom were homeowners-reported owning a CO detector.

CONCLUSIONS

A large proportion of adults in the U.S. reported attitudes and behaviors that may place them at increased risk for unintentional, non-fire-related CO poisoning, suggesting that current safety messages may not be reaching much of the public. Prevention messages should continue to promote proper generator placement, maintenance of fuel-burning appliances, and use of CO detectors. Development of a comprehensive national strategy for CO surveillance and communication may help identify populations at increased risk and prevent future poisonings.

Carbon monoxide poisoning after an ice storm in Kentucky, 2009

OBJECTIVES

Carbon monoxide (CO) poisoning is a leading cause of morbidity and mortality during natural disasters. On January 26-27, 2009, a severe ice storm occurred in Kentucky, causing widespread, extended power outages and disrupting transportation and communications. After the storm, CO poisonings were reported throughout the state. The objectives of this investigation were to determine the extent of the problem, identify sources of CO poisoning, characterize cases, make recommendations to reduce morbidity and mortality, and develop prevention strategies.

METHODS

We obtained data from the Kentucky Regional Poison Center (KRPC), hyperbaric oxygen treatment (HBOT) facilities, and coroners. Additionally, the Kentucky Department for Public Health provided statewide emergency department (ED) and hospitalization data.

RESULTS

During the two weeks after the storm, KRPC identified 144 cases of CO poisoning; exposure sources included kerosene heaters, generators, and propane heaters. Hospitals reported 202 ED visits and 26 admissions. Twenty-eight people received HBOT. Ten deaths were attributed to CO poisoning, eight of which were related to inappropriate generator location. Higher rates of CO poisoning were reported in areas with the most ice accumulation.

CONCLUSIONS

Although CO poisonings are preventable, they continue to occur in postdisaster situations. Recommendations include encouraging use of CO alarms, exploring use of engineering controls on generators to decrease CO exposure, providing specific information regarding safe use and placement of CO-producing devices, and using multiple communication methods to reach people without electricity.

Review of unintentional non-fire-related carbon monoxide poisoning morbidity and mortality in Florida, 1999-2007

OBJECTIVE

Previous Florida evaluations of carbon monoxide (CO) poisoning have been disaster focused. The majority of prevention messages and risk-factor identification efforts have revolved around hurricane season (June-November). We evaluated the prevalence, risk factors, and causes of CO poisoning within Florida throughout the year to produce a more complete presentation of the burden of CO poisoning.

METHODS

We obtained data from death certificates, hospital discharge records, and emergency department records. We limited our analysis to unintentional poisonings, calculating rates for age, gender, race, and ethnicity, and reviewing poisoning chronology, location, and exposure situation.

RESULTS

From 1999 to 2007, 493 people were hospitalized, and 230 individuals died as a result of non-fire-related CO poisoning. From 2005 to 2007, 781 people visited emergency departments for non-fire-related CO poisoning. Rates of severe poisoning resulting in hospitalization or death were highest among the elderly (0.56 visits and 0.63 deaths per 100,000 Floridians). Acute poisoning rates were highest among people 25-34 years of age (2.48 visits per 100,000 Floridians). Poisonings were primarily due to motor vehicle exhaust (21%-69%) and generator exposure (12%-33%), and the majority (50%-70%) occurred within the home. A large number of poisonings (25%-29%) occurred during the winter months, outside of hurricane season.

CONCLUSION

The findings of this study indicate a need for additional prevention strategies in conjunction with current activities to more effectively reduce the number of CO poisonings in Florida. Prevention activities should be conducted year-round, and additional strategies should include public awareness of the hazards of motor vehicle exhaust.

Usefulness of syndromic data sources for investigating morbidity resulting from a severe weather event

OBJECTIVE

We evaluated emergency department (ED) data, emergency medical services (EMS) data, and public utilities data for describing an outbreak of carbon monoxide (CO) poisoning following a windstorm.

METHODS

Syndromic ED data were matched against previously collected chart abstraction data. We ran detection algorithms on selected time series derived from all 3 data sources to identify health events associated with the CO poisoning outbreak. We used spatial and spatiotemporal scan statistics to identify geographic areas that were most heavily affected by the CO poisoning event.

RESULTS

Of the 241 CO cases confirmed by chart review, 190 (78.8%) were identified in the syndromic surveillance data as exact matches. Records from the ED and EMS data detected an increase in CO-consistent syndromes after the storm. The ED data identified significant clusters of CO-consistent syndromes, including zip codes that had widespread power outages. Weak temporal gastrointestinal (GI) signals, possibly resulting from ingestion of food spoiled by lack of refrigeration, were detected in the ED data but not in the EMS data. Spatial clustering of GI-based groupings in the ED data was not detected.

CONCLUSIONS

Data from this evaluation support the value of ED data for surveillance after natural disasters. Enhanced EMS data may be useful for monitoring a CO poisoning event, if these data are available to the health department promptly.

Psychiatric issues in toxic exposures

Military, occupational, and environmental events can cause toxic injuries that require psychiatric diagnosis and treatment. This article reviews the psychiatric effects of neurotoxins, including nerve gases, ionizing radiation, insecticides, heavy metals, solvents, and other toxic agents. Diagnostic considerations and clinical tests for further evaluation of the numerous psychiatric conditions and symptoms caused by toxic exposures are discussed.

Carbon monoxide poisoning at motels, hotels, and resorts

BACKGROUND

Each year, more than 200 people in the United States die from carbon monoxide (CO) poisoning. Poisoning has occurred at motels, hotels, and resorts. Congressional mandate requires smoke alarms in all guest rooms; however, smoke alarms do not detect CO.

METHODS

Data on patients poisoned at hotels, motels, and resorts were evaluated at a hyperbaric medicine service. In 2005, legal databases and online news databanks were searched to discover additional incidents. Only victims evaluated in hospitals or declared dead at the scene were included. Cases of intentional poisoning and poisoning from fires were excluded.

RESULTS

Between 1989 and 2004, 68 incidents of CO poisoning occurring at hotels, motels, and resorts were identified, resulting in 772 accidentally poisoned: 711 guests, 41 employees or owners, and 20 rescue personnel. Of those poisoned, 27 died, 66 had confirmed sequelae, and 6 had sequelae resulting in a jury verdict. Lodging-operated, faulty room heating caused 45 incidents, pool/spa boilers 16, CO entrained from outdoors 5, and unreported sources caused 2 incidents. Public verdicts have averaged $4.8 million per incident (range, $1 million to $17.5 million). Poisoning occurred at hotels of all classes. Despite these incidents, most properties did not install CO alarms, and requirements for CO alarms at hotels, motels, and resorts are rare.

CONCLUSIONS

Guests of motels, hotels, and resorts remain at risk for injury or death from CO poisoning. Measures to prevent CO poisoning of guests and employees of the lodging industry should be evaluated.