2010 Annual Report of the American Association of Poison Control

203 Pages·2011·1.21 MB·English

Clinical Toxicology (2011), 49, 910–941
Copyright © 2011 Informa Healthcare USA, Inc.
ISSN: 1556-3650 print / 1556-9519 online
DOI: 10.3109/15563650.2011.635149
2010 Annual Report of the American Association
of Poison Control Centers ’ National Poison
Data System (NPDS): 28th Annual Report
ALVIN C. BRONSTEIN, MD ; DANIEL A. SPYKER, MD, PHD ; LOUIS R. CANTILENA, JR, MD, PHD; JODY L. GREEN, PHD ;
BARRY H. RUMACK, MD, and RICHARD C. DART, MD, PHD
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Address correspondence to Alvin C. Bronstein MD, FACEP, FACMT,
American Association of Poison Control Centers, 515 King Street,
Suite 510, Alexandria, VA 22314. E-mail: [email protected]
910
AAPCC 2010 Annual Report of the NPDS 911
Table of Contents
Abstract ......................................................................................................................................................................................5
Introduction ................................................................................................................................................................................5
What ’ s New in NPDS and the Annual Report .........................................................................................................................5
The NPDS Application ............................................................................................................................................................6
Limitations and Plans .............................................................................................................................................................6
Methods ......................................................................................................................................................................................7
Characterization of Participating Poison Centers and Population Served .............................................................................7
Call Management – Specialized Poison Exposure Emergency Providers. ..............................................................................7
NPDS – Near Real-time Data Capture ...................................................................................................................................7
Annual Report Case Inclusion Criteria ..................................................................................................................................8
Statistical Methods ..................................................................................................................................................................8
NPDS Surveillance .................................................................................................................................................................8
Fatality Case Review and Abstract Selection ..........................................................................................................................8
Pediatric Fatality Case Review ...............................................................................................................................................9
Results ........................................................................................................................................................................................9
1 Information Calls to Poison Centers .......................................................................................................................................9
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4/ Exposure Calls to Poison Centers .........................................................................................................................................10
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12/ Age and Gender Distributions ..............................................................................................................................................13
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o Caller Site and Exposure Site ...............................................................................................................................................13
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4.9 Exposures in Pregnancy ........................................................................................................................................................13
1
2 Chronicity ..............................................................................................................................................................................13
6.
4.1 Reason for Exposure .............................................................................................................................................................13
7
1 Scenarios ............................................................................................................................................................................14
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m b Reason by Age ....................................................................................................................................................................14
o Route of Exposure .................................................................................................................................................................15
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d fr Distribution of Suicides .........................................................................................................................................................18
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ad Plant Exposures ....................................................................................................................................................................19
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nl Deaths and Exposure-related Fatalities ................................................................................................................................19
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Do All fatalities – all ages .......................................................................................................................................................20
gy Pediatric fatalities – age (cid:2) 5 years ....................................................................................................................................27
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ol Pediatric fatalities – ages 6 – 12 years ................................................................................................................................28
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oxi Adolescent fatalities – ages 13 – 19 years ...........................................................................................................................28
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al Pregnancy and Fatalities ...................................................................................................................................................28
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ni AAPCC Surveillance Results ................................................................................................................................................29
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2010 Gulf of Mexico Oil Spill ............................................................................................................................................30
THC Homologs and Bath Salts ..........................................................................................................................................31
Discussion ................................................................................................................................................................................31
Summary ..................................................................................................................................................................................31
References ................................................................................................................................................................................31
Disclaimer ................................................................................................................................................................................32
Appendix A – Acknowledgments ..........................................................................................................................................172
NPDS Toxicology Quote of the Day ....................................................................................................................................172
Poison Centers (PCs) ..........................................................................................................................................................172
Fatality Review Team ..........................................................................................................................................................174
AAPCC Micromedex Joint Coding Group ..........................................................................................................................175
AAPCC Rapid Coding Team ...............................................................................................................................................175
AAPCC Surveillance Team .................................................................................................................................................175
Regional Poison Center (PC) Fatality Awards ....................................................................................................................175
Copyright © Informa Healthcare USA, Inc. 2011
912 A. C. Bronstein et al.
Appendix B – Data Defi nitions ..............................................................................................................................................176
Reason for Exposure ...........................................................................................................................................................176
Medical Outcome ................................................................................................................................................................176
Relative Contribution to Fatality (RCF) .............................................................................................................................177
Appendix C – Abstracts of Selected Cases ............................................................................................................................177
Selection of Abstracts for Publication ................................................................................................................................177
Abstracts .............................................................................................................................................................................177
Abbreviations & Normal ranges for Abstracts ...................................................................................................................201
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Clinical Toxicology vol. 49 no. 10 2011
AAPCC 2010 Annual Report of the NPDS 913
List of Figures and Tables
Figure 1. Human Exposure Calls, Information Calls and Animal Exposure Calls by Day since 1 January 2000 ..................10
Figure 2. All Drug Identifi cation and Law Enforcement Drug Identifi cation Calls by Day since 1 January 2000 .................12
Figure 3. Health Care Facility (HCF) Exposure Calls and HCF Information Calls by Day since 1 January 2000 .................13
Figure 4. Change in Encounters from 2009 to 2010 with Graphical Breakdown of Exposure Calls ......................................23
Figure 5. Gulf Oil Spill Encounters per Day ...........................................................................................................................24
Figure 6. Emerging Trends: Bath Salts and THC Homologs Exposures .................................................................................24
Figure 7. Human Exposure Calls By Year 2000 – 2010 – Top 4 Categories .............................................................................25
Table 1A. AAPCC Population Served and Reported Exposures (1983 – 2010) ..........................................................................9
Table 1B. Non-Human Exposures by Animal Type .................................................................................................................10
Table 1C. Distribution of Information Calls ............................................................................................................................10
Table 2. Site of Call and Site of Exposure, Human Exposure Cases .......................................................................................13
Table 3A. Age and Gender Distribution of Human Exposures ................................................................................................14
Table 3B. Population-Adjusted Exposures by Age Group .......................................................................................................14
Table 4. Distribution of Agea and Gender for Fatalitiesb .........................................................................................................15
Table 5. Number of Substances Involved in Human Exposure Cases .....................................................................................15
1 Table 6A. Reason for Human Exposure Cases ........................................................................................................................15
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4/ Table 6B. Scenarios for Therapeutic Errorsa by Age b ..............................................................................................................16
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12/ Table 7. Distribution of Reason for Exposure by Age .............................................................................................................17
on Table 8. Distribution of Reason for Exposure and Age for Fatalitiesa .....................................................................................18
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4.9 Table 9. Route of Exposure for Human Exposure Cases .........................................................................................................18
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2 Table 10. Management Site of Human Exposures ...................................................................................................................19
6.
4.1 Table 11. Medical Outcome of Human Exposure Cases by Patient Agea ................................................................................19
17 Table 12. Medical Outcome by Reason for Exposure in Human Exposuresa ..........................................................................20
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m b Table 13. Duration of Clinical Effects by Medical Outcome. ..................................................................................................20
o Table 14. Decontamination and Therapeutic Interventions .....................................................................................................21
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d fr Table 17D. Substance Categories Most Frequently Involved in Adult ((cid:3) 20 years) Exposures (Top 25)a ..............................27
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ad Table 17E. Substance Categories Most Frequently Involved in Pediatric ((cid:2) 5 years) Deathsa ...............................................27
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nl Table 17F. Substance Categories Most Frequently Identifi ed in Drug Identifi cation Calls (Top 25) ......................................28
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Do Table 17G. Substance Categories Most Frequently Involved in Pregnant Exposuresa (Top 25) .............................................28
gy Table 18. Categories Associated with Largest Number of Fatalities (Top 25)a .......................................................................29
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ol Table 19A. Comparisons of Death Data (1985 – 2010)a ...........................................................................................................29
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oxi Table 19B. Comparisons of Direct and Indirect Death Data (2000 – 2010)a ............................................................................30
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al Table 20. Frequency of Plant Exposures (Top 25)a ..................................................................................................................30
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ni Table 21. Listing of Fatal Nonpharmaceutical and Pharmaceutical Exposures .......................................................................33
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Table 22A. Demographic profi le of SINGLE SUBSTANCE Nonpharmaceuticals exposure cases
by generic category .............................................................................................................................................................130
Table 22B. Demographic profi le of SINGLE SUBSTANCE Pharmaceuticals exposure cases
by generic category .............................................................................................................................................................150
Copyright © Informa Healthcare USA, Inc. 2011
914 A. C. Bronstein et al.
Abstract morbidity and mortality in the US. The near real-time, always
current status of NPDS represents a national public health resource
to collect and monitor US exposure cases and information calls.
Background: This is the 28th Annual Report of the American
The continuing mission of NPDS is to provide a nationwide
Association of Poison Control Centers ’ (AAPCC) National
infrastructure for public health surveillance for all types of
Poison Data System (NPDS). All US poison centers upload case
exposures, public health event identifi cation, resilience response
data automatically with a median time interval of 19.0 [11.9,
and situational awareness tracking. NPDS is a model system for
40.6] (median [25%, 75%]) minutes, creating a near real-time
the nation and global public health.
national exposure and information database and surveillance
system.
Methodology: We analyzed the case data tabulating specifi c Introduction
indices from NPDS. The methodology was similar to that of
previous years. Where changes were introduced, the differences This is the 28th Annual Report of the American Association
are identifi ed. Poison center cases with medical outcomes of death of Poison Control Centers ’ (AAPCC; http://www.aapcc.org)
were evaluated by a team of 33 medical and clinical toxicologist National Poison Data System (NPDS).1 On 1 January 2010,
reviewers using an ordinal scale of 1 (Undoubtedly responsible) – 6 sixty regional Poison Centers (PCs) serving the entire popu-
(Unknown) to determine Relative Contribution to Fatality (RCF) lation of the 50 United States, American Samoa, District of
of the exposure to the death.
Columbia, Federated States of Micronesia, Guam, Puerto
11 Results: In 2010, 3,952,772 closed encounters were logged by Rico, and the US Virgin Islands submitted information and
4/ NPDS: 2,384,825, human exposures, 94,823 animal exposures,
1 exposure case data collected during the course of providing
2/ 1,466,253 information calls, 6537 human confi rmed nonexposures,
n 1 and 334 animal confi rmed nonexposures. Total encounters showed telephonic patient tailored exposure management and poison
o
94 a 7.7% decline from 2009 while health care facility calls i ncreased information. On 17 December 2010, the Western New York
14. by 2.7%. Human exposures with more serious outcomes (minor, Poison Center (Buffalo) serving Western New York ceased
2
6. moderate, major or death) increased 4.5% while those with less operations. The Ruth A. Lawrence Poison Center (Roches-
1
4. serious outcomes (all other medical outcome categories) decreased ter) closed on 30 December 2010. The Long Island Regional
7
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y 5.9%. All information calls decreased 12.6% and health care Poison Control Center (Mineola) ceased operations on 31
b
m facility (HCF) information calls decreased 13.6%, Drug ID calls December 2010. New York State is now served by two poi-
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oa foreign bodies/toys/miscellaneous (7.2%), and topical preparations PCs respond to questions from the public, health care pro-
nl
w (6.8%). THC homolog and designer amphetamine ( “ Bath Salts ” ) fessionals, and public health agencies. The continuous staff
o
y D exposures were identifi ed as emerging public health threats. Drug dedication at the regional PCs is manifest as the number of
og identifi cation requests comprised 64.3% of all information calls. exposure and information call encounters exceeds 3.9 million
oxicol N11P4D6S h udmocaunm faetnatleitdie 1s 7ju3d0g heudm realna teexdp woistuhr aens RreCsuFl toifn 1g- iUnn ddeoauthb tweditlhy annually. PC encounters either involve an exposed human
T or animal (EXPOSURE CALL) or a request for informa-
cal responsible, 2-Probably responsible, or 3-Contributory. tion (INFORMATION CALL) with no exposed person or
ni Conclusions: These data support the continued value of poison
Cli center expertise and need for specialized medical toxicology animal.
information to manage the more severe exposures, despite a
decrease in calls involving less severe exposures. Unintentional What ’ s New in NPDS and the Annual Report
and intentional exposures continue to be a signifi cant cause of
Several enhancements were made to the tables and fi gures
for this report. Continuing goals of the writing team have
WARNING: Comparison of exposure or outcome data been to remove inconsistencies, improve the reader ’ s abil-
from previous AAPCC Annual Reports is problematic. ity to clearly understand the data, and provide additional
In particular, the identifi cation of fatalities (attribution of data where appropriate. Two new tables have been added to
a death to the exposure) differed from pre-2006 Annual this year ’ s report: Table 3B Population-Adjusted Exposures
Reports (see Fatality Case Review — Methods). Poison by Age Groups and Table 17G Substance Categories Most
center death cases are described as all cases resulting in Frequently Involved in Pregnant Exposures (Top 25).
death and those determined to be exposure-related fatali- This year, the AAPCC Fatality Review team did not review
ties. Likewise, Table 22 (Exposure Cases by Generic Cat- death (indirect report) cases. Death (indirect report) cases
egory) since year 2006 restricts the breakdown including are reports identifi ed through other sources (news feeds,
deaths to single-substance cases to improve precision and medical examiner data or other) about which no inquiry to
avoid misinterpretation. the PC was made. In previous years, both death and death
(indirect report) cases were reviewed and included in the
Clinical Toxicology vol. 49 no. 10 2011
AAPCC 2010 Annual Report of the NPDS 915
tables. This year, all the tables related to fatalities contain The NPDS Application
only death cases with an AAPCC Relative Contribution of
In 2010, numerous enhancements were introduced in the
Fatality (RCF) of 1, 2,or 3, except Tables 11, 12, 19A, 19B,
NPDS web-based application. Many of these focused on
and 21 which also contain death (indirect report) cases — see
enhancing enterprise reports and surveillance functions. One
list below:
hundred sixty-nine (169) enterprise reports now return multi-
year results. The Case Log reports were expanded to support
Number any combination of 24 separate search parameters and nine
Table Fatalities Included RCF of Deaths (9) different result formats. NPDS Case Log reports now
support a variety of outputs including case line listing, daily
4 Death only 1,2,3 1,146
5 Death only 1,2,3 1,146 and monthly counts, time series charts, and US maps. Case
8 Death only 1,2,3 1,146 Log Counts Reports were added that stratify the results based
9 Death only 1,2,3 1,146 on user defi ned classifi cations. To simplify product selection
11 Death and Death (indirect report) All 1,730
for reports, a new product selection function was added that
12 Death and Death (indirect report) All 1,730
displays products associated with a specifi c AAPCC Generic
17E Death and Death (indirect report) All 1,730
18 Death only 1,2,3 1,366 Code. Finally, a new National Case Log report was added
19A Death and Death (indirect report) All 1,730 that allows Regional Poison Centers to use the power of the
1 19B Death and Death (indirect report) All 1,730 Case Log (Generic Code) report to execute a national case
1
14/ 21 Death and Death (indirect report) 1,2,3 1,366 listing without geographic or case identifi ers.
2/
1 22 Death and Death (indirect report) - All 764 New surveillance functions were added to support infor-
n
4 o Single substance deaths only mation call and animal call volume surveillance. To aid the
9
4. AAPCC Surveillance Team anomaly review, a ‘ Pending ’
6.21 Enhancements were added to the NPDS Fatality module to Status indicator was added for all anomalies to allow users to
1 aid the fatality team in performing their review. The assign-
4. identify anomalies that are in the process of being analyzed.
y 17 ment of the Annual Report ID for the fatality cases included In addition, a new Case Classifi cation parameter was added
b in Table 21 has now been automated. This will allow the
m to the Case Based anomalies to allow users to classify the
o cases in Table 21 to be easily identifi ed when responding to
c anomaly.
ealthcare.use only. Ainng Tn Guharrool uuRpge hproeouvrtit e tqwhuese ysthteieao rnG tshe oner eA rciAocm PCCmoCdeen Msts ai. cnrdo mreesdpeoxn dJso itnot qCuoeds-- eve Tnots p, rao vSidpee ccieanlt ePrrso wjeicthts m roepreo irnt fworams aatidodne odn t pou tbhleic NhePaDltSh
ahal enterprise reporting system. This report provides geocentric
m informor person toMifo incAsrAo amnPdCe drCee xqm uePesmotisbs fienordrs enaxen ® wd g(eMedniietcorrirocima cloe addneexds. TlHehxeeiac lgotrhnoc uasprtae cf ofS nfesrrioisemtss rmepoonrittoinrgin go.f FAoAr PexCaCm pdleefi, ntheed NprPoDduSc rtse pfoorrt rweaasl utitmiliez eedv ebnyt
oF regional poison centers to access national cases related to the
d fr [Internet database]. Greenwood Village, CO: Thomson Gulf of Mexico Oil spill in real-time.
e
d Reuters [Healthcare] Inc.). New Product Codes and AAPCC
oa NPDS aggregate and case detail web services oper-
nl Generic Codes were added to NPDS to address emerging
w ate continuously, allowing external systems or viewers to
o products. In 2010, new generic codes were added for the fol-
D analyze NPDS data in ways not otherwise possible in the
y lowing six product classes:
og NPDS application. The aggregate web service provides
ol
c total call volume, human exposure call volume, or clinical
xi 1. Electronic Cigarettes
To effects counts allowing an external system such as RODS
cal 2. Energy Drinks (Realtime Outbreak and Disease Surveillance, University of
ni 3. Hand sanitizers
Cli 4. Opioids Pittsburgh, Department of Biomedical Informatics) to create
time-series or GIS displays. Unique to NPDS, the aggregate
5. Tetrahydrocannabinol (THC) Pharmaceuticals
case count web service is not only accessible by external
6. Tetrahydrocannabinol (THC) Homologs
computer systems but also directly by system users to create
their own time series without the need for external system
At the time of this report, there were 965 active and 12 obso-
software. Two state health departments utilize the case detail
lete generic codes. The active codes are divided into Non-
web service to analyze data from their PCs. Four state health
Pharmaceutical (541) and Pharmaceutical (424) groups.
departments access the aggregate count web service for data.
These two groups are further divided into Major (67) and
The web services allow NPDS data to be provisioned in a
Minor (167) categories. New products associated with
federated manner where the data is always current in NPDS
these classes were also added by Micromedex. Addition of
and can be readily accessed as needed without the need for
these generic codes provides enhanced report granularity as costly cloning and warehousing.2
refl ected in Table 22. Because the new codes were added
at different times during the year, the numbers in Table 22
may not accurately refl ect all of the cases in these categories, Limitations and Plans
and for completeness certain categories require customized As outlined above, the encounters (exposure reports and infor-
data retrieval until these categories have been in place for a mation questions) which comprise NPDS are collected from
minimum of a full year or more (2011 forward). spontaneous, self-reported calls made to US PCs. Exposures
Copyright © Informa Healthcare USA, Inc. 2011
916 A. C. Bronstein et al.
in NPDS comprise a portion of the total number of incidents per day in January. On average, US PCs received a call about
that occurred. These refl ect the limitations of this type of an actual human exposure every 13.2 sec.
passive reporting system (see DISCLAIMER).
Most of the 390,000 proprietary and non-proprietary
Call Management – Specialized Poison
drugs, chemicals, and biological agents including food poi-
Exposure Emergency Providers
soning agents in the NPDS products data base are classifi ed
by their primary active ingredient into one of 965 AAPCC Most PC operations management, clinical education, and
generic codes. Some multiple ingredient products are coded instruction are directed by Managing Directors (most are
to multiple product generic codes (e.g., acetaminophen with PharmDs and RNs with American Board of Applied Toxi-
hydrocodone). Table 22 and other tables reporting informa- cology [ABAT] board certifi cation). Medical direction is
tion by generic category are organized by this system. Thus provided by Medical Directors who are board-certifi ed phy-
our current review and reporting methods do not necessarily sician medical toxicologists. At some PCs, the Managing and
distinguish between the individual components of a combi- Medical Director positions are held by the same person.
nation product. Calls received at US PCs are managed by healthcare
Nonetheless, the scope and immediacy of these data have professionals who have received specialized training in
much to offer. In particular, the 28-years history offers a toxicology and managing exposure emergencies. These pro-
1 unique opportunity to assess the long term (secular) trends viders include medical and clinical toxicologists, registered
4/1 in exposures and information calls. nurses, doctors of pharmacy, pharmacists, chemists, hazard-
1
12/ There are a number of plans to improve the data system ous materials specialists, and epidemiologists. Specialists in
on and reporting for 2010 and beyond including: Poison Information (SPIs) are primarily registered nurses,
94 PharmDs, and pharmacists. They work under the supervi-
214. • Enhancements to NPDS real-time geographic informa- sion of a Certifi ed Specialist in Poison Information (CSPI).
16. tion system (GIS) with more data display options for SPIs must log a minimum of 2,000 calls over a 12-month
4.
17 appropriate data analyses; period to become eligible to take the CSPI examination
by • Enhancements to case-based surveillance systems; for certifi cation in poison information. Poison Information
om • Continued improvements in data quality edits; Providers (PIPs) are allied healthcare professionals. They
c
ealthcare.use only. • • IsEmpneptcelirefipm cri espnert o rdesepucocutr tra iectync ehpsaasn rcfaoedrmi greemnpt oser;nt sh aanncde smuervnetsil ltaon cseu;p port mafancadtn atwhgoaetr iknn ofuo nnrdmuerarst iintohgne - otsryu pppehe aarvrnmids ialoocnyw osacfc huaoi toCyl S(onPfofIe.n r-Osh foa sntpooixttaeicl )oi scl oatglhlyes
m informahor personal • • N Lsyeesxwtiec maoun t too-b uabpseleotdtae dra rnmeaqleyuesitri esc muoerfrn etntsh ta en edxc puimorrsepunrrote v getrdean sceokrliiunct gi ocnoan;d de cianuc crprriercdouigltrueadmm b sdy e otshifgfeen AreedAd PfobCryC P tCmhe ewiero tirrnkegs apsnetrdcit ciStv PesIt asP nmCda.u rsdCt seb naent etdrr asmi nauersdet
oF
d fr surveillance needs; be reaccredited every 5 years.
de • Review and analysis of NPDS clinical effect coding
a
o
nl terminology.
w
o NPDS – Near Real-time Data Capture
D
y These and other initiatives are under continuous review
g Launched on 12 April 2006, NPDS is the data repository for
colo by the AAPCC Board, NPDS Steering Committee, and all of the US regional PCs. In 2010, all 60 of the 60 US
xi CDC.
o PCs uploaded case data automatically to NPDS through
T
al 17 December 2010. The center count decreased to 59 as of
c
Clini Methods 17 December 2010, to 58 as of 30 December 2010 and to 57
as of 31 December 2010. All centers submitted data in near
Characterization of Participating Poison
real-time making NPDS one of the few operational systems of
Centers and Population Served
its kind. PC staff record calls contemporaneously in 1 of 4 case
Sixty participating centers submitted data to AAPCC through management systems. Each center uploads case data periodi-
17 December 2010, 59 participating centers submitted data cally as it is entered. The time to upload data for all PCs is 19.9
to AAPCC through 30 December 2010, 58 participating cen- [9.7, 58.7] (median [25%, 75%]) minutes creating a real-time
ters submitted data to AAPCC through 31 December 2010, national exposure database and surveillance system.
with the total center count decreasing to 57 for the remain- The web-based NPDS software facilitates detection, analy-
der of 2010. Fifty-seven centers (95%) were accredited by sis, and reporting of NPDS surveillance anomalies. System
AAPCC as of 1 July 2010. The entire population of the 50 software offers a myriad of surveillance uses allowing
states, American Samoa, the District of Columbia, Federated AAPCC, its member centers and public health agencies to
States of Micronesia, Guam, Puerto Rico, and the US Virgin utilize NPDS US exposure data. Users are able to access
Islands was served by the US PC network in 2010.3 ,4 local and regional data for their own areas and view national
The average number of human exposure cases managed aggregate data. The application allows for increased “ drill-
per day by all US PCs was 6,534. Similar to other years, down ” capability and mapping via a geographic information
higher volumes were observed in the warmer months, with system (GIS). Custom surveillance defi nitions are available
a mean of 6,950 cases per day in June compared with 6,305 along with ad hoc reporting tools. Information in the NPDS
Clinical Toxicology vol. 49 no. 10 2011
AAPCC 2010 Annual Report of the NPDS 917
database is dynamic. Each year the database is locked prior defi nitions with a variety of mathematical options and
to extraction of annual report data to prevent inadvertent historical baseline periods from 1 to 11 years. NPDS surveil-
changes and ensure consistent, reproducible reports. The 2010 lance tools include the following:
database was locked on 9 October 2011 at 0930 hr EDT.
• Volume Alerts Surveillance Defi nitions
• Total Call Volume
Annual Report Case Inclusion Criteria • Human Exposure Call Volume
The information in this report refl ects only those cases • Animal Exposure Call Volume
that are not duplicates and classifi ed by the regional PC as • Information Call Volume
CLOSED. A case is closed when the PC has determined • Clinical Effects Volume (signs and symptoms, or
that no further follow-up/recommendations are required or laboratory abnormalities)
no further information is available. Exposure cases are fol- • Case Based Surveillance Defi nitions utilizing various
lowed to obtain the most precise medical outcome possible. NPDS data fi elds linked in Boolean expressions
Depending on the case specifi cs, most calls are “ closed ”  Substance
within the fi rst hours of the initial call. Some calls regard-  Clinical Effects
ing complex hospitalized patients or cases resulting in death  Species
1 may remain open for weeks or months while data continues  Medical Outcome and others
4/1 to be collected. Follow-up calls provide a proven mechanism
1
2/ for monitoring the appropriateness of management recom- Incoming data is monitored continuously and anomalous
1
n mendations, augmenting patient guidelines, and providing signals generate an automated email alert to the AAPCC ’ s
o
94 poison prevention education, enabling continual updates of surveillance team or designated regional PC or public health
4.
1 case information as well as obtaining fi nal/known medical agency. These anomaly alerts are reviewed daily by the
2
16. outcome status to make the data collected as accurate and AAPCC surveillance team and/or the regional PC that cre-
4.
7 complete as possible. ated the surveillance defi nition. When reports of potential
1
by public health signifi cance are detected, additional informa-
m
tion is obtained via the NPDS surveillance correspondence
o
c Statistical Methods
ealthcare.use only. Abyll tthaeb lNesP eDxSc ewpet bT-abbalseesd 3 Bap apnlidc a1t7ioBn w aenrde cgaenn ethrautse db ed irreepcrtoly- srdeyegspitaoermntma lo ePnr Ctps .ht Phoeunnbe l aiaclse h retasap ltpthhreo iipsr srriuaeetssep aefrcretoi bvmre o sruetgaphtoetr ttooirn tglho ecP aaCtlt seh.n etTailohthne
mahnal duced by each center. The fi gures and statistics in Tables 3B of the Health Studies Branch, Division of Environmental
m inforor perso aInnsdt it1u7tBe, wCearrey , cNreCat)e do nu ssiunmg mSAarSy JcMouPn tvse grseinoenr a9t.e0d. 0b (yS AthSe Hmaeznatardl sH aenadlt hH, eCaelnthte Ersf ffeocrt sD, iNseaatsioen Calo nCtreonlt earn dfo Pr rEevnevnirtoionn-
oF
d fr NPDS web-based application. (CDC). This unique near real-time tracking ability is a unique
de feature offered by NPDS and the regional PCs.
a
nlo NPDS Surveillance AAPCC Surveillance Team clinical and medical toxicol-
w
Do As previously noted, all of the active US PCs upload case ogists review surveillance defi nitions on a regular basis to
gy data automatically to NPDS. This unique near real-time fi ne-tune the queries. CDC, as well as State and local health
olo upload is the foundation of the NPDS surveillance system. departments with NPDS access as granted by their respec-
c
oxi This makes possible both spatial and temporal case volume tive regional PCs, also have the ability to create surveillance
al T and case based surveillance. NPDS software allows creation defi nitions for routine surveillance tasks or to respond to
nic of volume and case based defi nitions. Defi nitions can be emerging public health events.
Cli
applied to national, regional, state, or ZIP code coverage
Fatality Case Review and Abstract Selection
areas. Geocentric defi nitions can also be created. This func-
tionality is available not only to the AAPCC surveillance NPDS fatality cases can be recorded as DEATH or DEATH
team, but to every regional PC. PCs also have the ability to (INDIRECT REPORT). Medical outcome of death is by
share NPDS real-time surveillance technology with external direct report. Death (indirect reports) are deaths that the
organizations such as their state and local health departments PC acquired from medical examiners or media, but did not
or other regulatory agencies. Another NPDS feature is the manage nor answer any questions related specifi cally to that
ability to generate system alerts on adverse drug events and death.
other products of public health interest like contaminated Although PCs may report death as an outcome, the death
food or product recalls. NPDS can thus provide real-time may not be the direct result of the exposure. We defi ne
adverse event monitoring and surveillance for resilience exposure-related fatality as a death judged by the AAPCC
response and situational awareness. Fatality Review Team to be at least contributory to the expo-
Surveillance defi nitions can be created to monitor a variety sure. The defi nitions used for the Relative Contribution to
of volume parameters, any desired substance or commercial Fatality (RCF) classifi cation are defi ned in Appendix B and
product in the Micromedex Poisindex products database. the methods to select abstracts for publications is described
The database contains over 390,000 entries. Surveillance in Appendix C. For details of the AAPCC fatality review
defi nitions may be constructed using volume or case based process, see the 2008 annual report.1
Copyright © Informa Healthcare USA, Inc. 2011
918 A. C. Bronstein et al.
Pediatric Fatality Case Review Table 1A. AAPCC Population Served and Reported Exposures
(1983 – 2010)
A focused Pediatric Fatality Review team, comprised of 3
pediatric toxicologists, was assembled this year to evaluate Exposures
cases in patients under 18 years of age. The panel reviewed No. of Population per
the documentation of all such cases, with specifi c focus on participating served (in Human thousand
the conditions behind the poisoning exposure and on fi nd- Year centers millions) exposures population
ing commonality which might inform efforts at prevention.
1983 16 43.1 251,012 5.8
Seventy-one cases were reviewed and found to have a bimodal 1984 47 99.8 730,224 7.3
age distribution. Exposures causing death in children (cid:2) age 1985 56 113.6 900,513 7.9
5 years were mostly coded as “ Unintentional-General ” while 1986 57 132.1 1,098,894 8.3
1987 63 137.5 1,166,940 8.5
those in ages over 12 years were mostly “ Intentional ” . Often
1988 64 155.7 1,368,748 8.8
the Reason Code did not capture the complexities of the case.
1989 70 182.4 1,581,540 8.7
For example, there were few mentions of details such as the
1990 72 191.7 1,713,462 8.9
involvement of law enforcement or child protective services. 1991 73 200.7 1,837,939 9.2
While there were some complete and informative reports, 1992 68 196.7 1,864,188 9.5
in many narratives the circumstances which preceded the 1993 64 181.3 1,751,476 9.7
1994 65 215.9 1,926,438 8.9
1 exposure thought responsible for the death was unclear or
2/14/1 absent. In response to these fi ndings, the pediatric fatality 11999956 6677 221382..53 22,,012535,,098592 99..33
n 1 review team will develop Pediatric Narrative Guidelines for 1997 66 250.1 2,192,088 8.8
4 o the upcoming year, with specifi c attention to the root cause 1998 65 257.5 2,241,082 8.7
4.9 of these cases. As a result, poison centers will be requested 1999 64 260.9 2,201,156 8.4
16.21 to implement guidelines recommending the most in-depth 22000001 6634 227801..63 22,,126687,,294789 88..01
4. “ causality ” investigation possible.
7 2002 64 291.6 2,380,028 8.2
1
y 2003 64 294.7 2,395,582 8.1
b
m 2004 62 293.7 2,438,643 8.3
o Results
c 2005 61 296.4 2,424,180 8.2
ealthcare.use only. Itenr 2s 01in0c, ltuhdei pnagr ti2c,i3p8a4ti,n8g2 5P Ccsl loosgegde dh 3u,m95a2n, 7e7x2p toostaulr een ccoausnes- 222000000678 666111 233900958...465 b 222,,,444089321,,,500344919 888...011
mahnal (Table 1A), 94,823 animal exposures (Table 1B), 1,466,253 2009 60 310.9 b 2,479,355 8.0
m inforor perso ienxfpoorsmuaretiso,n a cnadl ls3 3(T4a balnei m1Cal) ,c 6o,n5fi3 r7m heudm naonn c-eoxnpfi orsmuereds .n oAnn- 2 T0o1ta0l 60 a 313.3b 502,,933854,,388255 7.6
ed froF alodcdkit. iTonhael c4u4m9u claatlilvs ew AeAreP sCtiCll doapteanb aaste tnhoew ti mcoen toafi ndsa tnaebaarslye ab A Ass ooff 11 JJuulyly 2 M01i0d tYheearer UwSer eC 6e0n sPuasr t(i5c0ip Uatninitge dC eSntateterss., American Samoa,
d
oa 51 million human exposure case records (Table 1A). A total District of Columbia, Federated States of Micronesia, Guam, Puerto Rico,
nl and the US Virgin Islands).3,4
w of 13,357,650 information calls have been logged by NPDS
o
D since the year 2001.
y
og Figure 1 shows the human exposures, information calls
ol
c and animal exposures by day since 2001. Second order (qua-
xi
To dratic) least squares regression for 2000 – 2010 has shown a Figure 2 shows that All Drug ID calls decreased dra-
cal statistically signifi cant departure from linearity (declining matically in mid-2009, and again in late-2010 (no regression
Clini rate of calls since mid-2007) for Human Exposure Calls. was fi t to these data). Enforcement Drug ID Calls showed
Information Calls are declining more rapidly than the qua- a declining rate of increase. The most frequent informa-
dratic regression this year, and Animal Exposure Calls have tion call was for Drug ID, comprising 942,614 calls to PCs
likewise been declining since mid-2005. during the year. Of these, 566,543 (60.1%) were identifi ed
A hallmark of PC case management is the use of fol- as drugs with known abuse potential; however, these cases
low-up calls to monitor case progress and medical outcome. were categorized based on the drug ’ s abuse potential without
US PCs made 2,841,477 follow-up calls in 2010. Follow-up knowledge of whether abuse was actually intended.
calls were done in 46.0% of human exposure cases. One While the number of Drug Information calls decreased
follow-up call was made in 22.4% of human exposure cases, 9.4% from 2009 (239,943 calls) to 2010 (217,286), the Drug
and multiple follow-up calls (range 2 – 666) were placed in Information calls as a percentage of all information calls was
23.6% of cases. 14.3% and 14.8%, respectively. Of these, the most common
requests were in regards to therapeutic use and indications,
followed by drug – drug interactions, questions about dosage
Information Calls to Poison Centers
and inquiries of adverse effects. Environmental inquiries
Data from 1,466,253 information calls to PCs in 2010 (Table comprised 1.6% of all information calls. Of these environ-
1C) was transmitted to NPDS, including calls in optional mental inquiries, questions related to cleanup of mercury
reporting categories such as prevention/safety/education (thermometers and other) remained the most common fol-
(31,656), administrative (23,546) and caller referral (65,652). lowed by questions involving pesticides.
Clinical Toxicology vol. 49 no. 10 2011
AAPCC 2010 Annual Report of the NPDS 919
Human Exposures = -150366 + 78.3*Year - 20.4*Year^2
10000
Information Calls = -515029 + 259*Year - 25.84*Year^2
ay 8000 Animal Exposures = 14.3 + 0.180*Year - 4.14*Year^2
D
er
P
s 6000
er
nt
u
co 4000
n
E
2000
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
Fig. 1. Human Exposure Calls, Information Calls and Animal Exposure Calls by Day since 1 January 2000.
1
1
4/ Black lines show least-squares second order regression – both linear and second order (quadratic) terms were statistically signifi cant for each of the 3 regressions.
2/1 (See colour version of this fi gure online).
1
n
o
4 Of all the information calls, poison information com- Table 1C. Distribution of Information Calls
9
4. prised 4.8% of the requests with inquiries involving general
21 % of
6. toxicity the most common followed by questions involving
1 Info.
4. food preparation practices, plant toxicity, and safe use of
7 Information call type N calls
1
y household products.
b
m Drug identifi cation
co Public inquiry: Drug sometimes 462,128 31.52
ealthcare.use only. E Fixgpuorseu 3r es hCoawllss ato g Praopishoicn sCuemnmtearrsy and analyses of Health Pubibnelv iaocb livunesqdeu diinry a: bDursueg not known to 192,972 13.16
mahnal Care Facility (HCF) Exposure and HCF Information calls. Public inquiry: Unknown abuse 5,416 0.37
om inforFor perso HuIneCfdoF rt moE xaitpniocorsneu arCseea C llaastl lhasa dssit deb anedeoynt drdaeetpeca)lr itnw firnhogilm es litinhnceee a rraeitateyr l (yoc fo 2Hn0t0Cin5F-. PHuCpboPlit cein niqtniuqailuriyr:y D: Urunga bsolem teot iimdeenst ify 866,,821091 05..4878
d fr This linearly increasing use of the PCs for the more seri- involved in abuse
e
d HCP inquiry: Drug not known to 12,317 0.84
a ous exposures (HCF calls) is important in the face of the
ownlo declining growth of all exposure and information calls. HCbeP ainbuqsueirdy: Unknown abuse 458 0.03
D The 2 May 2006, exposure data spike on the fi gure was
y potential
og the result of 602 children in a Midwest school reporting a HCP inquiry: Unable to identify 5,056 0.34
col noxious odor which caused anxiety, but resolved without Law Enf. Inquiry: Drug 97,596 6.66
oxi sequelae. sometimes involved in abuse
T
al Tables 22A (Nonpharmaceuticals) and 22B (Pharma- Law Enf. Inquiry: Drug not known 51,007 3.48
Clinic ceuticals) provide summary demographic data on patient Latwo bEen af.b Iunsqeudiry: Unknown abuse 1,726 0.12
age, reason for exposure, medical outcome, and use of
potential
a health care facility for all 2,384,825 human exposure Law Enf. Inquiry: Unable to 14,121 0.96
cases, presented by substance categories. identify
Other drug ID 6,797 0.46
Subtotal 942,614 64.29
Table 1B. Non-Human Exposures by Animal Type Drug information
Adverse effects (no known 13,893 0.95
Animal N % exposure)
Brand/generic name clarifi cations 3,710 0.25
Dog 85,804 90.49 Calculations 213 0.01
Cat 7,936 8.37 Compatibility of parenteral 309 0.02
Horse 259 0.27 medications
Bird 238 0.25 Compounding 617 0.04
Rodent/lagomorph 185 0.20 Contraindications 1,824 0.12
Cow 70 0.07 Dietary supplement, herbal, and 792 0.05
Sheep/goat 64 0.07 homeopathic
Aquatic 30 0.03 Dosage 13,506 0.92
Other 237 0.25 Dosage form/formulation 2,865 0.20
Total 94,823 100.00
(Continued)
Copyright © Informa Healthcare USA, Inc. 2011