What Exactly is a Poisoning

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What Exactly is a Poisoning?

• State Epidemiological Outcomes Workgroup webinar
  on drug overdoses and unintentional poisonings
• December 12, 2007
• by
• Monique A. Sheppard, Ph.D.
• Pacific Institute for Research and Evaluation
• Poison Center Technical Assistance Resource
  Center

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Organization

• Poisonings
• How many?
• What kinds?
• Who counts them?
• Poisoning definitions
• Poison Center Call data
• Traditional public health counts
• Whats missing?
• Recommendations
• Summary
• Questions at end of all presentations

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What is a poisoning?

• All things are poison and not without poison,
  only the dose makes a thing not a poison.
  Paracelsus (1493-1541)
• Adverse effects
• Food poisoning
• Venomous Bites / Stings
• Alcohol and Drugs
• Different definitions
• Different classification schemes

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Poisoning in the US
Number of Cases
30,308
Deaths
Hospital Discharges
233,000
828,900
Emergency Department
2.4 million
Poison Control Center Call Data
National Center for Health Statistics, CDC,
2004 Healthcare Cost Utilization Project,
2003 National Electronic Injury Surveillance
System, 2005 American Association of Poison
Control Centers (AAPCC) National Database, 2005
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U.S. Injury Death Rate
Non-poisoning injury death age adjusted rates,
all ages
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U.S. Poisoning Death Rate
Poisoning injury death age adjusted rates, all
ages
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Poisonings So what?

• At least 30,308 poisoning deaths in 2004
• 18 of all unintentional injury deaths 2nd
  leading mechanism following motor vehicles
• 17 of all suicide deaths 3rd leading mechanism
  following firearms suffocation
• One of the few injury types that is on the rise
• Deaths due to poisoning are even greater if the
  definition of a poison is broadened

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Poisonings by Manner
Unintentional Undetermined
Suicide
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Poisoning The Traditional Picture
Childhood Poisonings
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Poisoning Traditional Messages

• Read the label
• Prevent childhood poisonings by using
  child-resistant packaging, cabinet locks
  keeping things out of reach
• 1-800-222-1222 by every telephone
• Call poison control center immediately in case of
  possible poisoning
• Call poison control center for poison prevention
  education materials

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Poisoning What Else is Counted
Adolescent and Adult Poisonings
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Agencies who Collect Poison Data

• CDC Centers for Disease Control Prevention
• ATSDR Agency for Toxic Substances and Disease
  Registry
• NCEH National Center for Environmental Health
• NCHS National Center for Health Statistics
• NCIPC National Center for Injury Prevention
  Control
• CPSC Consumer Product Safety Commission
• FDA Food and Drug Administration
• EPA Environmental Protection Agency
• SAMHSA Substance Abuse Mental Health Services
  Administration
• AAPCC American Association of Poison Control
  Centers

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Selected Poison Data Sources

• Web-based Injury Statistics Query and Reporting
  System (WISQARS)
• Medical Examiner
• Child Death Review Teams
• Emergency Room
• Trauma Registries
• National Hospital Ambulatory Medical Care Survey
• National Health Interview Survey
• National Electronic Injury Surveillance System
• Drug Abuse Warning Network (DAWN)
• Mortality Data / WONDER
• State Hospital Discharge Data (HDD)
• AAPCC National Poison Data System (NPDS)
• Toxic Exposure Surveillance System (TESS)

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Review of Selected Poison Data Sources

• AAPCC National Poison Data System (NPDS) / Toxic
  Exposure Surveillance System (TESS)
• American Association of Poison Control Centers
  (AAPCC)
• Unique coding system
• Hospital Discharge data
• Provided by the state
• ICD-9(CM)
• Mortality
• National Center for Health Statistics (NCHS)
• ICD-9 / ICD-10

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American Association of Poison Control Centers
National Poisoning and Exposure Database cases
are poisoning exposures because the substance
implicated may not be severely toxic, or the
amount involved in the exposure may be
insufficient to cause toxicity. Many of these
patients develop no clinical manifestation of
poisoning.
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National Poison Data System (NPDS)

• Contains data from all telephone calls into
  poison control centers including, some
  demographics and circumstances surrounding poison
  exposures and fatalities.
• Strengths
• A comprehensive and cumulative database
• Timely
• Annual data collection and standardized reporting
• Coding facilitates identification of the toxin/
  product involved

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NPDS Limitations

• Limitations
• State-specific comparisons may be limited by
  geographic boundaries
• General phone reporting system problems.
• Captures few fatal cases
• May be biased against certain groups, or at least
  those without a telephone
• Not queried race or SES measures
• Not a complete census of poisoning exposures or
  overestimate of poisoning injuries

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State Hospital Discharge Data (HDD)
Data on demographics, length of stay, charges,
circumstances for all public hospitalized
patients. Strengths

• Entire census of public hospital discharges
• Compare hospitalization rates across different
  entities
• Uses ICD-9-CM classification scheme comparable
  to mortality data before 1999
• Validity
• Confirmed diagnoses, substances lab tested

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State Hospital Discharge Data (HDD)

• Limitations
• Availability
• Timeliness
• External cause coding is not mandated for all
  states
• Potential bias by severity of injury
• Different racial/ethnicity classification schemes
  used by states

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NCHS Mortality Data

• Data are available on underlying and
  contributory causes of death, demographics,
  circumstances surrounding poisoning, and nature
  of the poisoning.
• Strengths
• Publicly available
• Entire census of deaths captured
• Captures out of hospital deaths
• Can calculate poisoning-specific death rates for
  comparisons across time and space

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NCHS Mortality Data

• Limitations
• Timeliness of the data
• Contributing causes of death not ordered
• Lack of circumstance information

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Types of Poisonings Captured by Recognized Data
Definition
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What is a poison?
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Summary

• Traditional public health data sources present a
  limited view of the public health problem
  associated with toxic exposures.
• In addition to directly causing poisoning
  injury, indirect exposure to toxic substances can
  directly cause other injuries, disorders or
  disease, such as falls or motor vehicle crashes,
  neurological impairment, or cardiac arrest.

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Summary

• Multiple data sources may help to overcome
  several of the inadequacies of using a single
  source.
• An expanded poisoning case definition can reduce
  counting biases that challenge poisoning
  surveillance.
• Manner of death classification can be difficult.
  Most states classify poisonings of unclear intent
  as Accidents, not Undetermined (except in MA, MD,
  RI, and UT, although MA and RI recently changed)

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Recommendations

• STIPDA Injury Surveillance Work Group on
  Poisonings
• Uniform adaptable definition
• Identify potential biases in estimates (and
  direction of bias if possible)

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Recommendations

• Get to know your regional poison control center,
  www.aapcc.org
• Incorporate poison prevention messages into your
  epidemiological outcomes messages promote the
  services provided by poison control centers
• Know that poisonings occur at all ages

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Poisoning Problem . . .
Its Bigger than Me!
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Acknowledgements

• Funding for this presentation was provided by the
  Health Resources and Services Administration
  (HRSA), Poison Control Program.
• Please send questions or comments to Monique
  Sheppard at sheppard_at_pire.org or call 301-755-2728