Part I
Overview



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Forging a Poison Prevention and Control System Part I Overview

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Forging a Poison Prevention and Control System 1 Introduction “Alle Ding sind Gift und nichts ohne Gift; alein die Dosis macht das ein Ding kein Gift ist” “All things are poison and not without poison; only the dose makes a thing not a poison” Paracelsus (1493–1541) BACKGROUND The field of poison prevention provides some of the most celebrated examples of successful public health interventions, yet paradoxically, the poison control “system” today is little more than a network of poison control centers that is poorly integrated into the larger spheres of public health or injury prevention. Reviews of the history of effective injury prevention strategies frequently highlight the introduction of the “baby aspirin” poisoning legislation in 1966 and the Poison Prevention Packaging Act in 1970. These legislative and regulatory successes were among the first achievements of the modern consumer movement and were consolidated under the jurisdiction of the new Consumer Product Safety Commission in 1973. The introduction of packages containing less than a toxic dose and childproof safety closures on hazardous substances heralded the so-called “passive” methods to prevent injuries, measures requiring little direct behavioral input from the potential victim.

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Forging a Poison Prevention and Control System The establishment of the first poison control center, which preceded the legislative actions by some years, represented an innovation in pediatric health care delivery, one that was immediately hailed and replicated across the nation. Poison control center telephone numbers were promoted by pediatricians and adorned family refrigerator doors. A new cadre of highly trained poison information specialists and clinical toxicologists evolved to help staff these centers. The number of phone calls—currently more than 2 million exposure calls annually—attests to the need for and popularity of these services. Despite these early successes in both the implementation of effective poison control legislation and the development of this new model of poison treatment service, the evolution of the poison control network has been chaotic and uneven. The early growth of poison control services was encouraged and supported by the Emergency Medical Services Systems Act of 1973 (Pub. L. No. 93–154), but little federal funding was available to plan or promote this growth in the 1970s. Ultimately, more than 600 sites in the United States identified themselves as poison control centers. They varied from little more than a designated telephone in small community hospitals with no dedicated staff to centers in academic medical institutions with 24-hour dedicated staff and nationally recognized medical and clinical toxicologist1 backup. No federal public health agency took responsibility for the oversight of this patchwork poison control network, and no systematic sources of governmental funding emerged to support these heavily utilized health care services. Poison control centers remained generally peripheral to the expansion of the injury control system during the 1980s and 1990s. Little epidemiological research emerged from such centers to inform the policy and public health practice communities of the magnitude of the poisoning problem or of its place in the greater domain of injury prevention. Some individual poison control centers played a role in injury control, but most struggled financially to sustain the staff and infrastructure to answer phone calls and provide appropriate follow-up. Successful poison control centers supported their operations through ad hoc funding arrangements, in some cases receiving funding from state maternal and child health and emergency medical services agencies, by providing service in occupa- 1   The term toxicologist is a general description of an individual dealing with any aspect of acute or chronic poisonings, and it does not have a specific definition or implication with regard to training or job description. For example, this term may be used to describe individuals whose activities range from molecular biology to epidemiology, as long as they deal in some way with the toxic effects of chemicals. The term clinical toxicologist implies a more clinical orientation, but likewise has no specific definition or implications. Medical toxicologists are physicians with specific training and board certification in the subspecialty of medical toxicology, which focuses on the care of poisoned patients.

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Forging a Poison Prevention and Control System tional medicine settings, and through contractual agreements with the pharmaceutical and other chemical companies. Ultimately, the vast majority of centers closed, leaving the current 63 to cover the U.S. population. Furthermore, the poison control centers were not involved with or incorporated into the development of the emergency medical services for children system. The 1999 Institute of Medicine (IOM) report, Reducing the Burden of Injury: Advancing Prevention and Treatment, barely mentions poison control; nor does this issue feature prominently in Healthy People 2000 or 2010 (http://www.healthypeople.gov). Onto this background of a small, innovative field struggling to survive, four important developments emerged in the past 10 years: First, the American Association of Poison Control Centers (AAPCC), although founded in 1958, emerged as the developer of a critical poison exposure data collection system, the certifier of poison control centers and their key personnel, and the principal advocate for federal legislation and funding. Second, two federal agencies of the U.S. Department of Health and Human Services—the Health Resources and Services Administration/ Maternal and Child Health Bureau (HRSA/MCHB) and the Centers for Disease Control and Prevention (CDC)—entered the poison control center picture. For the first time, federal legislation (Poison Control Center Enhancement and Awareness Act of 2000 [Pub. L. No. 106–174]) authorized substantial funding for a variety of poison control services, including education, medical toxicology, enhanced data collection, and a national toll-free number. These federal agencies began examining the functioning of the poison control network and the place of poison control centers in public health. Third, advances in telecommunication made it possible to answer telephone calls from anywhere in the country and to triage calls to appropriate centers. A national “800” telephone number created a single point of contact for consumers. In addition, a real-time, electronic submission of poison exposure data enabled the rapid assessment of toxic exposures handled by poison control centers across the United States. Fourth, the national program of homeland security and the imperative of preparing the public health system to address the risks of biological and chemical terrorism provided new opportunities for poison prevention and surveillance. The availability of the Toxic Exposure Surveillance System (TESS) data propelled the poison control centers into a potentially crucial position in all-hazards/public health preparedness. The anthrax attack demonstrated how a concerned public looked to poison control centers for information and advice (see Appendix 5-A for description).

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Forging a Poison Prevention and Control System CHARGE TO THE IOM COMMITTEE HRSA/MCHB asked the IOM to convene the Committee on Poison Prevention and Control to assist it in developing a more systematic approach to understanding, stabilizing, and providing long-term support for poison prevention and control services. Specifically, HRSA/MCHB charged the Committee to consider the future of poison prevention and control services in the United States by reviewing the past and current approaches to the provision of these services in terms of: The scope of services provided, including consumer telephone consultation, technical assistance and/or hospital consultation for the care of patients with life-threatening poisonings, and education of the public and professionals; The coordination of poison control centers with other public health, emergency medical, and other emergency services; The strengths and weaknesses of various organizational structures for poison control centers and services, including a consideration of personnel needs; Approaches to providing the financial resources for poison prevention and control services; Methods for assuring consistent, high-quality services, including the certification of centers and methods of evaluation; and Current and future data systems and surveillance needs. Furthermore, the Committee was asked to consider these questions in light of future demographic and population trends, and in the context of the threats of biological and chemical terrorism. In order to respond fully and specifically to the charge, the Committee adopted the language used by HRSA, that is, to consider the “future of poison prevention and control services” and to develop a “systematic” approach. We believe that HRSA chose this language carefully, asking the Committee to do more than review the current poison control centers in isolation. Therefore, the Committee examined the role of poison control services within the context of the larger public health system, the injury prevention and control field, and the fields of general medical care and medical and clinical toxicology. As part of this approach, the Committee further examined how poison control centers function (e.g., respond to the public and health care professions regarding poisoning exposures, provide toxicosurveillance, potentially detect bioterrorism, train medical and clinical toxicologists) in light of the functions performed by other health care agencies and governmental organizations at federal, state, and local levels.

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Forging a Poison Prevention and Control System POISONING: A MATTER OF DEFINITION This chapter begins with a quote from Paracelsus: “All things are poison…only the dose makes a thing not a poison.” This statement goes to the heart of a definitional dilemma that faced the Committee throughout its work. As discussed more completely in Chapter 3, there is no single agreed-upon definition of a “poisoning.” Each agency that collects data or provides services in this arena has evolved its own definitional boundaries of the poisoning problem. The definition of a poisoning and its place among other medical diagnoses vary from the 9th to the 10th revisions of the International Classification of Diseases, which drives data collection at several levels of federal and state government. The poison control centers have their own operational definition of what constitutes an “exposure” to a poisonous substance. Various authorities and authors may decide to include or exclude from the operational definition such important components as intentionally self-inflicted poisoning (as in the act of suicide), overdoses and intoxications from alcohol and illicit drugs, envenomation by insects, illness caused by toxic infectious agents, and ingestions of the right prescription medicine taken at the wrong dose, among others. The implication of these inconsistent definitions is profound for the measurement of the magnitude of poisonings and for the development of public policy and practice in this area. The Committee adopted an operational definition of poisoning that could be used to analyze the available datasets in order to better understand the problem. This definition subsumes “damaging physiological effects of ingestion, inhalation, or other exposure to a range of pharmaceuticals, illicit drugs, and chemicals, including pesticides, heavy metals, gases/vapors, and common household substances, such as bleach and ammonia” (Centers for Disease Control and Prevention, 2004, p. 233). Definitional issues are discussed further in the following sections and in more detail in Chapter 3. MAGNITUDE OF POISONINGS: A PUBLIC HEALTH PROBLEM The Committee discovered that estimating the magnitude and cost of poisoning as a public health problem is more complex than generally appreciated, requiring special analyses of available mortality, morbidity, and cost data from separate sources. While more detailed analyses of both the epidemiology of poisoning and the costs and benefits of poison control will be presented in later chapters, we focus initially on three important points: first, that poisoning is a larger and more important public health problem than has generally been recognized; second, that poisonings generate a high cost to the United States; and third, that the population at risk of poisoning is broader than that of young children.

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Forging a Poison Prevention and Control System Poisoning: The Second Leading Cause of Injury-Related Death in the United States The Committee estimates that in 2001 (the most recent year for which data from all sources were available), there were 30,800 poisoning-related deaths in the United States (based on published figures and specially provided estimates from Lois Fingerhut at the National Center for Health Statistics, 2003). This estimate makes poisoning the second leading cause of injury-related death in the United States, behind motor vehicle deaths (N = 42,443) and ahead of gun-related deaths (N = 29,573). Our estimate is higher than that usually reported because it combines (1) the number of deaths in which poisoning is the reported underlying cause, along with (2) deaths in which alcohol or illicit drugs of abuse are the reported underlying cause. The Committee believes that including the alcohol and illicit drug deaths in its estimate is justified because these poisonings come to the attention of the poison control centers and because the revisions of the coding systems seem to be moving toward the inclusion of these cases. Poisoning Morbidity As measures of morbidity, the Committee examined poison-related hospitalizations and overall exposures. Again, each of these estimates has its own unique definitional limitations, but the numbers presented in Table 1-1 are a way of showing the order of magnitude of poisoning as a cause of morbidity and health care system use. In 2001, there were 282,012 hospitalizations, as reported through the National Hospital Discharge Data Set, and more than 2.3 million human poison exposures (includes both actual and suspected exposures), as reported to TESS (Watson et al., 2003) by the poison control centers. It should be pointed out that TESS human exposure reports include both actual and suspected exposures to poisonous substances of all types. If anything, these are likely to be underestimates of true death and hospitalization numbers. TABLE 1-1 Summary of Poisoning Mortality and Morbidity (2001) Level of Poisoning Severity Number of Deaths Poison-related deaths 30,800 Underlying cause (24,173) Alcohol and drugs (6,627) Number of poison-related discharges from short-stay hospitals 282,012 Human exposure calls to poison control centers 2,267,979

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Forging a Poison Prevention and Control System Cost of Poisoning The annual cost of poisoning, not including costs related to alcohol deaths, to the United States (based on lifetime cost of injury) was estimated in 1989 to be $8.5 billion (Rice et al., 1989). A major definitional limitation of this study was that it excluded costs related to poisoning from alcohol and other illicit drugs. Unfortunately, the Committee found no more recently published data. Adjusting the cost estimates from the Rice study to 2003 dollars using the Consumer Price Index provides an estimate of $12.6 billion for the current cost of poisoning. Population at Risk Not only have the magnitude and cost of the poisoning problem been underappreciated, but the diverse nature of poisonings and the populations at risk have changed over time. While poisoning was initially viewed as a problem of young children, it now emerges as a concern across the entire lifespan. Half of all poison exposures reported to TESS occur among children 5 years of age; however, only 8 percent of the moderate to major effects from poisonings occur among those in the 5 years and under age group. Approximately 71 percent of moderate and major exposures occur in those over 19 years of age. Unintentional death from exposure to hazardous household substances occurs primarily among children and youth, the group that also has the highest level of exposure to poisonous substances. However, suicide by poison and alcohol and illicit drug-related poison deaths occur in older adolescent and young adult populations (approximately 7.6 percent of the poison exposures reported to TESS are suspected suicides; another 3.5 percent are from intentional substance misuse or abuse). Death in the workplace from exposure to hazardous substances occurs primarily among working adults. Pesticide deaths are likely to be concentrated in rural farm populations, including immigrant and illegal laborers. Finally, the elderly are at risk of taking the wrong medications or the right medication at the wrong dose. Approximately 8 percent of poisoning exposures reported to TESS are from individuals over 59 years of age. In addition, elderly persons may be the source of medications that inadvertently poison young children. This changing pattern of poisoning in the U.S. population has important implications for the provision of prevention and control services. Poison control centers were developed to respond primarily to parental concerns about the exposure of their young children to potential poisons and rely on telephone communication. Increasingly, these centers have become involved with the additional situations described above—suicide

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Forging a Poison Prevention and Control System attempts, alcohol intoxications, medication errors, hazards evaluations—that arise from requests from emergency medical services and emergency department personnel, police and fire officials, and homeland security staff. A future system for poison prevention and control may need to be more appropriately designed and organized to respond to this variety of demands. THE COMMITTEE’S APPROACH TO THE PROBLEM Early in its deliberations, the Committee realized that in order to address its charge, it must step back from a focus on the poison control centers alone and reexamine the overall context for preventing and treating poisoning. Reviewing the history of poison prevention in the United States reminded us that, in the past, a broad array of societal strategies, including safe product packaging and consumer legislation, had been used to reduce the risks posed by potentially hazardous substances. Adopting such a broad analysis led us to view poison control centers as part of a public health system intended to improve the health of communities and populations. The argument for a broad public health approach to poisoning begins with the recognition that the United States has set specific year 2010 objectives (Healthy People 2010) for reduction of nonfatal poisonings to no more than 292 per 100,000 population, from the baseline of 349 in 1997, and deaths caused by poisoning to 1.5 per 100,000, from 6.8 in 1997. These ambitious objectives cannot be achieved by the poison control center network alone. There is no evidence that these centers, despite their critical role in poison control management, have reduced the incidence of poisoning in the population. There is good evidence, however, that hazardous substance packaging and regulation have had a primary preventive impact on poisoning (Rodgers, 1996). Furthermore, the body of evidence from the broader field of injury control indicates that reducing the burden of injury in the population (Bonnie et al., 1999) requires an integrated strategy of active behavioral, passive regulatory and engineering, and medical management strategies. Drawing on this broad perspective leads us to propose in Chapter 2 the creation of a Poison Prevention and Control System. Currently there is no comprehensive system of poison prevention and control. Although poison control centers operate on a common set of certification standards, they form at best a loosely organized network. Each center has grown up in its own culture, has created its own organization and procedures, and cultivates its own mixture of funding sources. The absence of a “system” has led, in part, to the uneven and unstable development of the field. The current poison control center network needs

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Forging a Poison Prevention and Control System to be integrated into a larger system, just as burn centers operate in a broader context. Based on its own record of hearings, the Committee came to recognize that its very formation and charge created a high level of anxiety in the poison control center community. It is not surprising that a field that has struggled for survival, and that only recently has had national policy successes in obtaining federal legislation and funding, would view the Committee’s charge with apprehension. Therefore, the Committee committed itself to an analysis that would provide the strongest basis for a Poison Prevention and Control System that could be sustained and well integrated into the health care system. This report will begin with a summary of the future Poison Prevention and Control System as envisioned by the Committee (Chapter 2). That system encompasses, but is not restricted to, the role and position of the poison control centers. Rather, our proposal is based on, first, an analysis of the broad public health functions that underlie all aspects of poison control (e.g., primary prevention through consumer product regulation and public education and secondary prevention through telephone-based poison consultation); second, an analysis of the core functions of a poison prevention and control system and, within these, the core functions of poison control centers; and third, a proposal for a national approach to the organization, funding, and accountability for such a system. The Committee recognizes that this is an ambitious task. THE COMMITTEE’S METHODS The Committee met six times between February 2003 and January 2004. These meetings were used to plan our work and gather firsthand information on the poison control system from key informants and from a site visit to the Rocky Mountain Poison and Drug Center, Denver, Colorado (see Appendix A for the list of contributors). At its first three meetings, the Committee received both solicited and unsolicited opinions and information from representatives of professional organizations and poison control centers. At our second meeting, we heard testimony from the directors of four poison control centers (Rocky Mountain Poison and Drug Center, California Poison Control System, DeVos Children’s Hospital Regional Poison Center, and Middle Tennessee Poison Center) representing the range of large and small centers located in a variety of organizational settings. In addition, visits by one or more Committee members and staff were made to the National Capital Poison Control Center and the Maryland Poison Control Center. Early in the process, the Committee recognized that the literature on poison control centers and the poison control system could not provide

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Forging a Poison Prevention and Control System the evidentiary base sufficient to fully answer its charge. As a result, the methods used by the Committee were different than those generally used by IOM committees. Rather than relying solely on limited peer-reviewed publications, we focused our efforts on analyses of existing datasets and, where necessary, on primary data collection. To investigate the organizational and financing aspects of poison control centers, the Committee made use of historical reports, including the work by Zuvekas et al. (1997) that provided an excellent analytical framework. Unfortunately, these data are of limited value because they are based on only six centers. Secondary analyses of the administrative data collected annually by AAPCC were used to examine the range of programmatic indicators and costs from all member poison control centers. We wish to thank AAPCC for its cooperation in providing data from the 2000 and 2001 surveys. Unfortunately, data from the 2002 survey were not available until after the Committee had completed its deliberations. Based on the analysis of these data, the Committee carried out a qualitative survey of 10 poison control centers to better understand the relationship among various organizational arrangements and effective and efficient service provision. Survey interviews were conducted by telephone with poison control center directors and their staff. These centers were a stratified, nonprobability sample based on cost per human exposure call handled in 2001, population served, and penetrance. To investigate the epidemiology of poisoning, the Committee recruited the help of Lois Fingerhut at the National Center for Health Statistics. Ms. Fingerhut provided special analyses of poisoning data from the national death statistics for the use of the Committee. In addition, we commissioned Miriam Cisternas to prepare a paper on the epidemiology of poisoning, contrasting and comparing the data from multiple public use data sources. This paper forms the basis for much of the analysis presented in Chapter 3. Another source of data on the epidemiology of poisoning was provided by Monique Sheppard at the third Committee meeting. She reported on the integration of poison data from multiple sources based on an analysis of data from eight northeastern states. To understand the goals and related programs of the federal agencies, the Committee interviewed representatives from the Consumer Product Safety Commission, U.S. Food and Drug Administration, U.S. Department of Agriculture, Health Resources and Services Administration/Maternal and Child Health Bureau, and Centers for Disease Control and Prevention. A subcommittee spent a day in Atlanta being briefed by CDC staff from the National Center for Injury Prevention and Control, National Center for Environmental Health, Agency for Toxic Substances and Disease Registry, National Institute for Occupational Safety and Health, and Office of Terrorism Preparedness and Emergency Response. Federal

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Forging a Poison Prevention and Control System contracts and program guidance materials were reviewed. The Committee also drew upon two membership organizations of state agency directors, the Association of Maternal and Child Health Programs and the State and Territorial Injury Prevention Directors Association, for information about the relationship of state agencies to poison control. These organizations conducted voluntary surveys of their member state organizations and provided us the information. Finally, the state plans for the National Bioterrorism Hospital Preparedness Program were reviewed for information on poison control center involvement. OVERVIEW OF REPORT CHAPTERS This report is presented in three parts. Part I begins with this introductory chapter followed by Chapter 2, which provides an overview of the Committee’s proposal for a future Poison Prevention and Control System; a system does not exist at the moment and will need to be created. In Part II, we review the historical development of the poison control network, the current status of poisoning as a public health problem, and the principal functional elements of the system. Chapters 3 through 9 describe the evidence and the analyses we used in reaching our conclusions and recommendations. Chapter 3 presents data estimating the magnitude of poisoning in the United States. Chapter 4 provides a historical context for the development and growth of poison control services through 2001. Chapters 5 through 9 examine the current status of poison control centers in terms of functions (including core services), personnel, quality assurance, organization, cost, funding, data and surveillance, prevention and public education, and linkages to federal, state, and local agencies. Part III summarizes the argument for a new Poison Prevention and Control System by focusing on the Committee’s conclusions and recommendations. In Chapter 10, the concluding chapter, we link our analysis to our conception for the future system.