9
A Public Health System for Poison Prevention and Control

The mission of public health is to “fulfill society’s interest in assuring conditions in which people can be healthy” (Institute of Medicine, 1988, p. 17). Public health entities at the federal, state, and local levels of government are in place to assist with prevention of disease and promotion of health. The recent Committee on Assuring the Health of the Public in the 21st Century (Institute of Medicine, 2002a) focused attention on the collaborative efforts among potential system partners (e.g., private health care, academia, business) needed to achieve the vision of “healthy people in healthy communities.” A strong public health system needs to be in place to support the goal of a consistent, comprehensive, and community-based Poison Prevention and Control System.

An approach to addressing the health care needs of the population is to set goals and objectives for the nation. One set of goals for the Poison Prevention and Control System is from Healthy People 2010, which set two target objectives for the field of poisoning (http://www.healthypeople.gov):

Objective 15-7: Reduce nonfatal poisonings to no more than 292 per 100,000 population (based on emergency department visits) (baseline was 349 in 1997)

(http://www.healthypeople.gov/document/html/objectives/15-07.htm)

Objective 15-8: Reduce deaths caused by poisonings to 1.5 per 100,000 population (baseline was 6.8 per 100,000 in 1997)

(http://www.healthypeople.gov/document/html/objectives/15-08.htm)



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Forging a Poison Prevention and Control System 9 A Public Health System for Poison Prevention and Control The mission of public health is to “fulfill society’s interest in assuring conditions in which people can be healthy” (Institute of Medicine, 1988, p. 17). Public health entities at the federal, state, and local levels of government are in place to assist with prevention of disease and promotion of health. The recent Committee on Assuring the Health of the Public in the 21st Century (Institute of Medicine, 2002a) focused attention on the collaborative efforts among potential system partners (e.g., private health care, academia, business) needed to achieve the vision of “healthy people in healthy communities.” A strong public health system needs to be in place to support the goal of a consistent, comprehensive, and community-based Poison Prevention and Control System. An approach to addressing the health care needs of the population is to set goals and objectives for the nation. One set of goals for the Poison Prevention and Control System is from Healthy People 2010, which set two target objectives for the field of poisoning (http://www.healthypeople.gov): Objective 15-7: Reduce nonfatal poisonings to no more than 292 per 100,000 population (based on emergency department visits) (baseline was 349 in 1997) (http://www.healthypeople.gov/document/html/objectives/15-07.htm) Objective 15-8: Reduce deaths caused by poisonings to 1.5 per 100,000 population (baseline was 6.8 per 100,000 in 1997) (http://www.healthypeople.gov/document/html/objectives/15-08.htm)

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Forging a Poison Prevention and Control System As noted in Chapter 3, these national objectives are very ambitious and may even be based on poor estimates of true incidence. Clearly, the United States has a longer way to go in reaching its 2010 objectives than originally anticipated. The Committee’s estimate of 8.5 fatal poisonings per 100,000 population (Chapter 3) is far above the national 2010 objective of 1.5, and even higher than the 1997 estimate of 6.8 used as a baseline. Furthermore, our estimate of nonfatal poisonings of 530 per 100,000 population in 2001 (Chapter 3) is nearly twice the national 2010 objective of 292 and again even higher than the 1997 baseline estimate of 349 nonfatal poisonings per 100,000. These findings suggest that national efforts to reduce poisonings and fatalities must be more strongly linked to the nation’s overall agenda for health promotion and disease prevention. In this chapter we develop the argument for how incorporating the Poison Prevention and Control System into the broader public health system will accomplish this health improvement. CORE PUBLIC HEALTH FUNCTIONS Since the publication of the 1988 Institute of Medicine (IOM) report, The Future of Public Health, the public health system has addressed the charge of “disarray” in the field by focusing scientific and technical knowledge into three core functions needed to improve the health of the public: assessment (e.g., monitoring health status of a population, surveillance to detect disease outbreaks), policy development (e.g., development of partners, implementation of legislation), and assurance (e.g., education of the public and providers, standards and regulations to promote quality services, provision of direct health care services). These three core functions are helpful in describing the components of an integrated Poison Prevention and Control System at the federal, state, and local levels in the United States as they relate to the public health system. Assessment Data collection and analysis on a populationwide basis serves to monitor health status in order to identify and plan solutions for community health problems; characterize and investigate health problems and health hazards in the community; evaluate effectiveness, accessibility, and quality of personal and population-based health services; and carry out research for new insights and innovative solutions to health problems and conditions. According to the Centers for Disease Control and Prevention’s (CDC’s) Updated Guidelines for Evaluating Public Health Surveillance Systems (2001b, p. 2), “public health surveillance is the ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a

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Forging a Poison Prevention and Control System health-related event for use in public health action to reduce morbidity and mortality and to improve health. Data disseminated by a public health surveillance system can be used for immediate public health action, program planning and evaluation, and formulating research hypotheses.” The importance of poisoning data tracking and surveillance is discussed in detail in Chapter 7. Policy Development The development and implementation of policies and plans that support individual and community health efforts are essential components of public health practice. Sound health policy development requires a combination of scientific guidance and analyses of existing policies, resources, research, and evaluation. Policy development and implementation may be expressed as legislation, regulation, executive orders, or policy. Processes for improving health in the community, including the use of performance measures to track progress on solving the health problem, are outlined in the IOM report, Improving Health in the Community (Durch et al., 1997). Policy development is an important component of assuring a comprehensive Poison Prevention and Control System in every community in the United States. Data quantifying the incidence and prevalence of poisonings, along with evaluation and research findings about prevention strategies, are useful at all levels of government public health to implement policies to protect the public. Development of evidence-based policies best occurs through an informed process that includes input from a broad-based spectrum of disciplines, professional backgrounds, interest groups, community stakeholders, consumers, and others. A commitment by state and federal public health agencies to provide resources to assure a comprehensive poison control system of equal quality and accessibility in every jurisdiction is an example of a policy designed to decrease poisonings and improve outcomes of those poisoned. Assurance It is important to assure the public that services necessary to achieve the best health outcomes and quality of life are provided, either by encouraging action by other private or public entities, by requiring such action through regulation or legislation, or by public health agencies providing the services directly either with staff or through contracts with providers (Institute of Medicine, 1988). Strategies related to assurance within a poisoning prevention and control system may include (1) education of the public about poisonings, including how to prevent them as well as what to do if one occurs; (2) edu-

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Forging a Poison Prevention and Control System cation of health providers, including first responders, about poisonings; (3) training of health professionals with expertise in toxicology; (4) development and implementation of clinical standards and protocols for responding to individuals who are poisoned; (5) implementation of standards for poison control centers to assure consistent seamless coverage and responses in all communities; and (6) provision of resources for all components of the Poison Prevention and Control System. It is important that data systems be established to track the delivery of services and implementation of standards and policies so that quality improvement mechanisms are in place at all levels of performance within the system. Using the model outlined in the IOM report (Durch et al., 1997) for improving health in the community, a set of performance indicators for poison prevention and control might be developed and implemented in every community in the country. This “shared accountability model” for the health of the community would designate who, either alone or together with another stakeholder (e.g., public health department, poison control center, law enforcement, hospital, provider), is responsible for various outcomes within the system. For example, state health departments have an infrastructure and experience with primary prevention and health education activities across the lifespan; they also have one or more individuals with training in health education and community prevention. These activities are funded with federal dollars through programs such as the Maternal and Child Health Block Grant, Substance Abuse Block Grant, and Women, Infant, and Children’s Nutrition Service. Thus, the state is a good candidate for taking the lead in prevention and health education regarding poisonings. Essential Services for Public Health Related to Poisoning Prevention and Control The three core public health functions previously mentioned have been expanded into 10 essential services by the major stakeholder groups in public health. The document, The Essential Services of Public Health (http://www.apha.org/ppp/science/10ES.htm), outlines the practices needed to discharge these obligations for the entire population in a community. These roles are generally much broader than the provision of direct clinical services and they are used frequently today to assess the capability of local and state public health agencies. For example, they are currently used to assess local and state health capacity to be prepared to respond to “all disasters,” including bioterrorism and chemical terrorism. Table 9-1 shows the relationship between the essential services and the core public health functions and provides a brief description of each service as it relates to poison prevention and control.

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Forging a Poison Prevention and Control System To best achieve the goals and function as a system, federal, state, and local agencies ideally would perform in a unified fashion so that all of the essential services related to poison prevention and control are performed or assured for every community across the nation. Sharing and linking of relevant data addressing poisoning exposures, therapeutic interventions, and outcomes among providers, institutions, and poison control centers will be essential to advance these goals. The remainder of this chapter will review what capacity and activities currently exist within federal, state, and local agencies related to the system functions needed to meet the Healthy People 2010 goals for poisoning. POISON CONTROL SERVICES IN THE CURRENT PUBLIC HEALTH INFRASTRUCTURE Turnock has described public health infrastructure as the “nerve center of public health” (Centers for Disease Control and Prevention, 1998). Healthy People 2010 includes objectives for the nation regarding public health infrastructure in several areas: data and information systems, skilled workforce, effective public health organizations, resources, and prevention research. Because of the importance of public health’s role in national security and preparedness for all hazards, there is increased interest and attention on building an effective and sustainable public health infrastructure (Centers for Disease Control and Prevention, 2001c). At present, the accountability for the establishment and maintenance of a population-based Poison Prevention and Control System is diffuse at all levels of governmental public health. Although there are a variety of interested programs and components of public health agencies involved in various aspects of poison prevention and control, some of which interact with the poison control centers, there is insufficient clarity in the roles of each entity in the maintenance of a system across any level of geography. For example, at a local and/or state public health level, it is not unusual for the following programs within a health department to have an interface with the poison control centers and larger Poison Prevention and Control System: emergency medical services, the injury prevention and control program, maternal and child health program, occupational health program, substance abuse program, health statistics, epidemiology, environmental health, emergency preparedness, and others. In addition, there are activities related to poisonings in agencies outside of the usual public health authority; these include the Environmental Protection Agency, the medical examiner’s office, the mental health agency, and the Board of Pharmacy. Each of these programs at the local and/or state level(s) has an associated link(s) to a federal agency that mirrors the state. The complexity

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Forging a Poison Prevention and Control System TABLE 9-1 Core Functions and Essential Services of Public Health as Applied to Poison Prevention and Control Services Core Functions 10 Essential Services Assessment Monitor health status to identify community problems. Diagnose and investigate health problems and the health hazards in the community. Evaluate the effectiveness, accessibility, and quality of personal and population-based health services. Collection, assembly, analysis, and distribution of information on the community’s health Policy development Inform, educate, and empower people about health issues. Mobilize community partnerships to identify and solve health problems. Develop policies and plans that support individual and community health efforts. Development of comprehensive policies based on scientific knowledge and decision making Assurance   Assure a competent public health and personal health care workforce. Enforce laws and regulations that protect health and ensure safety. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Determination of needed personal and communitywide health services, and provision of these services by encouraging action by others, by requiring action by others, or by direct provision Assessment, policy development, and assurance Research for new insights andinnovative solutions to health problems SOURCE: Adapted from the IOM report, The Future of Public Health (1988). and variety of agencies involved with activities related to poisoning is greater at the federal level. Currently there is no single state or federal plan or authority (e.g., legislative, regulatory) that gives one entity accountability for all poison prevention and control activities. Local and State Health Department Involvement with Poison Prevention and Control Activities There is no single point of accountability for poison prevention and control activities at most local or state health departments. The few tar-

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Forging a Poison Prevention and Control System Examples as Applied to Poison Prevention and Control Services Monitor population frequency of poisonings across the lifespan. Assess outcomes. Assess factors contributing to poisonings. Develop policies and services for primary and secondary prevention. Evaluate public education activities related to poisonings. Continuously review and evaluate poison control center functions and their efficiency and effectiveness. Ensure the availability and accessibility of poison control information to the entire public. Assess and enhance the public’s knowledge about poison impact, prevention, and control. Establish effective communication with community members regarding poisonings. Apply population-based data to policy development for poison prevention and control. Create and maintain a workforce that is competent in poison prevention and control. Educate health professionals on subjects related to poisonings. Develop laws, statutes, and regulations that provide for optimal use of poison control centers and protect individuals in the workplace. Create provisions for high-quality, culturally competent poison control center services. Ensure linkages among all parts of the public health and medical systems with poison control centers. Identify best practices for poison control centers. Contribute to the evidence base for poison prevention and control through the funding and generation of new knowledge. geted poison prevention activities that exist are located in the injury prevention and control program and/or the maternal and child health program. Data and surveillance are usually located in the health statistics and information unit with links to the state epidemiologist, the medical examiner, and the agency that collects hospital discharge data. Other programs within public health departments that may be involved with poison prevention and control activities are emergency medical services, maternal and child health, health education and promotion, emergency preparedness, substance abuse services, environmental health, occupational health, and the medical director. The following is a more in-depth

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Forging a Poison Prevention and Control System discussion of specific roles of several state health department programs in relation to poison prevention and control, including links to the state poison control center(s). Maternal and Child Health Linkages To understand the current linkages between poison control centers and various programs within state health departments, an informal survey of activities or linkages with the state Title V agencies was conducted in 2003 by the Association of Maternal and Child Health Programs. Twenty-nine states and territories responded. Eleven additional states included information on poison prevention and control in their applications for 2003 or 2004 funding. All but 4 of the 40 indicated some degree of involvement with poison control centers, such as participation in advisory groups and partnering on health education and data reviews. Since the early 1990s, states have provided the federal Maternal and Child Health Bureau (MCHB) with up to 10 state-selected performance measures, often related to Healthy People 2000 or Healthy People 2010, established every 5 years as part of a mandated needs assessment and updated or revised as part of their annual plans. None of the reporting states and territories described a poison-specific performance measure, although many noted that poisonings were included in other measures such as hospitalizations or child deaths. Several noted that home visiting projects for new parents included information on poisoning prevention in early childhood. Based on information from questionnaires and annual applications, three-fourths (30 of 40) of the states have working relationships between Title V and poison control centers. Examples include Healthy Child Care America initiatives, serving on injury prevention advisory groups such as SAFE KIDS, special projects including mercury thermometer removal from home or schools, and lead poisoning prevention. A few states reported specific agreements to share data or data analyses, participate on each other’s advisory committees, collaborate on trainings, and so forth. Nearly half (19 of 40) reported funding information and 6 more specified there was no health department or state allocation to poison control centers. However, nearly a third (15 of 40) skipped the item or reported they lacked information regarding such allocations. Although specific detail was lacking from 7 of the 19 reporting states, the Title V block grant was noted to support programs in 3, bioterrorism programs in 4, and state appropriations in 8; 3 states reported that more than one of these sources supported poison control centers.

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Forging a Poison Prevention and Control System Injury Prevention and Control Linkages The State and Territorial Injury Prevention Directors Association sent a similar survey to its members in 2003 to better understand (1) the activities related to poison prevention and control that occur within their departments and (2) the relationship of the injury prevention and control programs in state public health departments to the poison control centers covering their state. Unlike the maternal and child health program, which receives a block grant for activities, there is no regular state or federal funding stream for injury prevention and control activities in states. Because of its importance in public health, every state does have a named director for these activities, regardless of the size of the program. Of the 12 states that responded, all reported that the state’s injury prevention and control activities include issues of poisoning for children, youth, and families. Little attention is directed to older adults and senior citizens. Eleven programs include education about poisonings in the materials, resources, and activities of the other injury and prevention activities in their program; two described a special focus on poisoning, such as participation in Poison Prevention Week. Two states (Georgia and Oregon) mentioned a strong link of the state program to the SAFE KIDS Coalition. Eleven of the 12 reporting states have done analyses and/or published reports on state and local data related to poisonings. Of those with reports, most were published on an annual or biannual basis. All reports included data from deaths and hospital discharge; a few included emergency department and poison control center data. Nine stated they used the data from the poison control center, usually in the format published in an annual report. Although data from standard reports were accessible, several respondents noted that it was difficult to obtain data for specific requests and purposes from their poison control center. One example of collaboration in sharing data for public health planning and follow-up is that between the poison control centers in Michigan and the Michigan Department of Community Health. Michigan’s epidemiology unit works closely with the local poison control centers to assure reporting of occupational disease under the public health code. In addition, the Michigan poison control centers provide almost “real time” (electronically) all occupational pesticide exposure calls to the Michigan pesticide surveillance system and identify data daily for syndromic surveillance for the Emergency Preparedness Program. All these states reported that they had an ongoing relationship/partnership with the poison control centers in their state. Seven of the 12 states reported they served on the advisory committee for the center and 6 said they participated in using data on poisonings. Five said they participated in press releases with the poison control center; for example, Massachusetts

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Forging a Poison Prevention and Control System participated with the poison control center in a major event on inhalant use and young teens. Five of the states (Colorado, Indiana, Massachusetts, Michigan, and New Jersey) had a contractual relationship with the poison control centers and managed the use of state/federal funds for poison control center services. For example, in Colorado the state general funds specified for the poison control center are managed by the Emergency Medical/Trauma Services Unit. Massachusetts uses Title V Maternal and Child Health Block Grant Funds to jointly purchase services with Rhode Island; the contract is managed by the Injury Prevention and Control Division. States responding to the Injury Prevention and Control questionnaire included four that had not provided information through the Maternal and Child Health (MCH) questionnaire or in their state MCH block grant materials. Nearly all show at least some degree of involvement with their state or regional poison control center (40 of 44); three-fourths (33 of 44) have established working relationships between their centers and state public health. Although the degree of health department involvement with the state or regional poison control center is common, the form and extent of involvement is variable and commonly linked to the extent of center financial support. Emergency Preparedness and Response Poison control centers can play an important role in all-hazards preparedness and response. They are considered to be a vital part of the continuum of necessary emergency services needed for all Americans facing the threat of bioterrorism and can serve as part of the nation’s surveillance and first response system (http://www.hhs.gov/budget/hrsa_bioterror.html [statement by Duke]). The challenges of preparing for and responding to an act of terrorism are significant, and may include identifying, responding to, and recovering from acts of terrorism and other public health emergencies (Levy and Sidel, 2003). Cooperation among public health officials, emergency managers, first responders, and health care providers is a top priority, and the role each plays in responding to an emergency is essential to effectively respond to a crisis, minimize loss of life, and control the spread of disease and chaos. In the face of new and emerging threats, more effort is needed to strengthen the health care system’s ability to detect and respond to such public health emergencies. The full spectrum of health care providers, including poison control centers, have potential roles in preparing for and responding to the possibility of bioterrorism or other public health emergencies.1 1   In this context, the terms bioterrorism and other public health emergencies includes other forms of terrorism, such as use of chemical agents against the public.

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Forging a Poison Prevention and Control System Present-day planning for possible acts of terrorism are strengthening the public health infrastructure and, to some degree, improving poison control centers’ ability to respond to natural disasters, chemical releases, disease outbreaks, and other public health emergencies. Based on funding priorities of the federal government since September 2001, regional and perhaps national emergency planning and response promise to become an important component of poison control center services, although there is a need to also consider the implications for long-term support for the centers to provide this service. An Institute of Medicine and National Research Council (1999) report on chemical and biological terrorism indicated that in most plausible chemical terrorism scenarios, the rapid onset of toxic effects would lead to highly localized collections of victims within minutes or hours: A network of regional poison control centers is well established, however, and, if its personnel were educated about military chemical weapons, would be well suited for surveillance. Poison control centers are also obvious candidates to serve as regional data and resource coordinating centers in incidents involving multiple sites or large numbers of patients (p. 7). This report also cited “a glaring need” to strengthen disease surveillance to prepare for the threat of bioterrorism and address emerging pathogens (p. 74). Better preparation of the nation’s clinicians for the roles they will play in responding to a bioterrorist attack is also necessary. The 2001 Presidential Task Force on Citizen Preparedness in the War on Terrorism recommended that poison control centers be used as a source of public information and public education regarding potential biological, chemical, and nuclear domestic terrorism (Pub. L. No. 106–174). An Agency for Healthcare Research and Quality Evidence Review (http://www.ahrq.gov/clinic/tp/biotrp.htm) indicated that the lack of strong evidence on how to train clinicians for public health events represents an important gap in bioterrorism preparedness. The information that public health officials need for preparation for and response to a bioterrorism event can be considered in relation to the decisions they must make: the interpretation of surveillance data; the investigation of outbreaks; the institution of epidemiologic control measures; and the issuance of surveillance alerts. Communication decisions relate to the specific information that needs to be conveyed to other public health officials, clinicians, the media, and other decision makers. The Health Resources and Services Administration (HRSA) (2004) has indicated that poison control centers can serve as part of the nation’s surveillance and first response system. For example, during the anthrax incident that took place in Florida, the Florida Poison Control Center was

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Forging a Poison Prevention and Control System chemical or biological—in the workplace (http://www.cdc.gov/niosh/homepage.html). Agency for Toxic Substances and Disease Registry The Agency for Toxic Substances and Disease Registry (ATSDR) serves the public by providing health information to prevent harmful exposures and diseases related to toxic substances. ATSDR offers public health assessments of waste sites, health consultations regarding specific hazardous substances’ health surveillance and registries, responses to emergency releases of hazardous substances, applied research, information development and dissemination, and education and training concerning hazardous substances. ATSDR has a hazardous substance research and health effects database called HazDat. HazDat is the scientific and administrative database developed to provide access to information on the release of hazardous substances from Superfund sites or from emergency events and on the effects of hazardous substances on the health of human populations. HazDat contains information such as community health concerns, ATSDR public health threat categorizations, ATSDR recommendations, exposure routes, and physical hazards at the site/event. The agency is currently being integrated with CDC’s National Center for Environmental Health (http://www.atsdr.cdc.gov). Health Resources and Services Administration The Health Resources and Services Administration assures the availability of quality health care to low-income, uninsured, isolated, vulnerable, and special needs populations. HRSA’s goal is for Americans to have 100 percent access to health care without any disparities. HRSA has a consumer education program that provides health-related information for families to live healthier lives. This program includes contact information for poison control. Furthermore, HRSA has awarded funds to support the work of poison control centers as well as bioterrorism aid for states. HRSA’s Maternal and Child Health Bureau promotes and improves the health of mothers and children by working in partnership with states, communities, public–private partners, and families. MCHB administers seven programs, one of which is the Poison Control Centers Program (developed as a result of the Poison Control Center Enhancement and Awareness Act), jointly administered with CDC. MCHB and CDC have created a nationwide toll-free telephone number system, a nationwide

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Forging a Poison Prevention and Control System media educational campaign, and a grant program to develop and improve infrastructure elements of the regional poison control centers (http://www.hrsa.gov). Substance Abuse and Mental Health Services Administration The Substance Abuse and Mental Health Services Administration (SAMHSA) is the nation’s health care delivery system to provide substance abuse prevention, addiction treatment, and mental health services for people at risk for or experiencing substance abuse or mental illnesses. SAMHSA builds partnerships with states, communities, and private organizations to address the needs of individuals with substance abuse and mental illnesses and to identify and respond to the community risk factors that contribute to these illnesses. SAMHSA’s programs support the adoption and adaptation, as well as the evaluation, of evidence-based, high-quality diagnostic, treatment, and prevention service practices. Under its block grant program, SAMHSA encourages the states and territories to address state and local substance abuse and mental health needs by supporting implementation and maintenance of specific service programs and assesses and reports on progress, needs, and ongoing activities. SAMHSA’s data collection and analysis activities—including the National Survey of Drug Use and Health and other data—gather, aggregate, assess, and report on trends related to mental health services addiction treatment and substance abuse prevention. The agency houses three substance abuse and mental health service-and prevention-related centers—Center for Mental Health Services, Center for Substance Abuse Prevention, and Center for Substance Abuse Treatment. SAMHSA also includes the Office of Applied Studies, the data collection and analysis hub for SAMHSA, and several other staff offices (http://www.samhsa.gov). Food and Drug Administration The U.S. Food and Drug Administration (FDA) promotes and protects public health by helping safe and effective products reach the market in a timely manner and monitoring products for continued safety after they are in use. The FDA ensures that the nation’s food is free of chemicals or other harmful substances. The FDA also monitors dietary supplements, medical products, and biologics, and protects the public from unnecessary exposure to radiation from electronic products. FDA research provides the scientific basis for its regulatory decisions, evaluates new products, develops test methods, and provides support for product moni-

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Forging a Poison Prevention and Control System toring. The FDA offers information on protecting children from poisons in their homes, including medicines, cleaning products, and houseplants. Center for Biologics Evaluation and Research The FDA’s Center for Biologics Evaluation and Research (CBER) advances public health through innovative regulations that ensure the safety, effectiveness, and timely delivery to patients of biological and related products. CBER is also responsible for an adequate and safe supply of allergenic materials and antitoxins and for the safety and efficacy of biological therapeutics. CBER plays an important role in the President’s Initiative on Countering Bioterrorism, including ensuring the expeditious development and licensing of products to diagnose, treat, or prevent outbreaks from exposure to the pathogens that have been identified as bioterrorist agents (http://www.fda.gov). Centers for Medicare and Medicaid Services The Centers for Medicare and Medicaid Services (CMS) ensures health care security for beneficiaries, improving quality and efficiency in an evolving health care system. CMS runs Medicare, the nation’s largest health insurance program, which covers nearly 40 million Americans. Medicare provides care to people age 65 or older, some people with disabilities under age 65, and people with permanent kidney failure requiring dialysis or a transplant. CMS also runs Medicaid, a health insurance program for certain low-income people that is funded and administered through a state–federal partnership. There are broad federal requirements for Medicaid, but states have a wide degree of flexibility to design their program. CMS runs the State Children’s Health Insurance Program, which became available on October 1, 1997, and helps states expand health care coverage to more than 5 million of the nation’s uninsured children. CMS provides information on how to guard young children against poisons (http://www.cms.gov). Agency for Healthcare Research and Quality The Agency for Healthcare Research and Quality (AHRQ) is the health services research arm of DHHS, complementing the biomedical research mission of its sister agency, the National Institutes of Health. AHRQ specializes in research on quality improvement and patient safety, outcomes and effectiveness of care, clinical practice and technology assessment, health care organization and delivery systems, primary care and preven-

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Forging a Poison Prevention and Control System tive systems, and health care costs and sources of payment. AHRQ has been studying and improving links between the clinical care delivery system and the public health infrastructure to improve the nation’s capacity to respond to bioterrorism (http://www.ahrq.gov). National Institutes of Health The National Institutes of Health (NIH) is one of the world’s foremost medical research centers. NIH’s goals are to foster innovative research to advance the nation’s capacity to protect and improve health significantly; develop, maintain, and renew resources that will ensure the nation’s capability to prevent disease; expand the knowledge base in medical and associated sciences to enhance the nation’s economic well-being to ensure a high public investment in research; and exemplify and promote the highest level of scientific integrity, public accountability, and social responsibility in the conduct of science (http://www.nih.gov). National Institute on Alcohol Abuse and Alcoholism The National Institute on Alcohol Abuse and Alcoholism (NIAAA) supports and conducts biomedical and behavioral research on the causes, consequences, treatment, and prevention of alcoholism and alcohol-related problems. NIAAA aims its research at determining the causes of alcoholism, discovering how alcohol damages the organs of the body, and developing prevention and treatment strategies in the nation’s health care system (http://www.niaaa.nih.gov). National Institute on Drug Abuse The National Institute on Drug Abuse (NIDA) is a national leader for research on drug abuse and addiction. NIDA supports a comprehensive research program that focuses on the biological, social, behavioral, and neuroscientific bases of drug abuse as well as its causes, prevention, and treatment. NIDA also supports research and research training on specific biomedical and behavioral effects of drugs of abuse on the body and brain; the causes and consequences of drug abuse, including morbidity and mortality in selected populations; the relationship of drug abuse to the acquisition, transmission, and clinical course of HIV/AIDS, tuberculosis, and other diseases; and the development of effective prevention and intervention strategies (http://www.nida.nih.gov).

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Forging a Poison Prevention and Control System National Institute of Environmental Health Sciences The National Institute of Environmental Health Sciences (NIEHS) aims to reduce environment-related illnesses by understanding each component in their development and how they are interrelated. With the National Toxicology Program headquartered at NIEHS, research is conducted to help eliminate, reduce, or control many hazards, such as lead, mercury, asbestos, many industrial chemicals, food dyes, and agricultural chemicals. NIEHS also funds basic and applied research on health effects of human exposure to potentially toxic or harmful environmental agents (http://www.niehs.nih.gov). National Institute of Child Health and Human Development The National Institute of Child Health and Human Development conducts and supports research to advance knowledge of pregnancy, fetal development, and birth for developing strategies that prevent maternal, infant, and childhood mortality and morbidity; identify and promote the prerequisites of optimal physical, mental, and behavioral growth and development through infancy, childhood, and adolescence; and contribute to the prevention and amelioration of mental retardation and developmental disabilities (http://www.nichd.nih.gov). U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT The U.S. Department of Housing and Urban Development (HUD) works to increase homeownership, support community development, and increase access to affordable housing free from discrimination. The Office of Healthy Homes and Lead Hazard Control (HHLHC), a HUD program, brings together health and housing professionals in a concerted effort to eliminate lead-based paint hazards in U.S. privately owned and low-income housing. HHLHC develops lead-based paint regulations, guidelines, and policies; provides technical assistance; conducts demonstrations, studies, and standards development; and maintains a community outreach program focused on disseminating program information. HUD’s Healthy Homes Initiative (HHI), run by HHLHC, protects children and their families from housing-related health and safety hazards, such as lead hazard control. HHI is a nationwide effort, and is assisted by a panel of nationally recognized experts from the private sector and federal, state, and local governments. Eligible HHI activities may include evaluating the effectiveness of hazard interventions, developing and delivering public education programs, and developing low-cost methods for hazard assessment and intervention (http://www.hud.gov).

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Forging a Poison Prevention and Control System U.S. DEPARTMENT OF AGRICULTURE The U.S. Department of Agriculture (USDA) provides leadership on food, agriculture, natural resources, and related issues based on sound public policy, the best available science, and efficient management. USDA is responsible for the safety of meat, poultry, and egg products. It leads research in topics from human nutrition to new crop technologies that allows farmers to grow more food and fiber using less water and pesticides, brings safe drinking water to rural America, leads the federal anti-hunger effort, helps ensure open markets for U.S. agricultural products, and provides food aid to needy people overseas, as well as other tasks that help U.S. farmers, ranchers, and lands (http://www.usda.gov). Food Safety and Inspection Service The Food Safety and Inspection Service (FSIS) protects consumers by ensuring that meat, poultry, and egg products are safe, wholesome, and accurately labeled. FSIS regulates meat, poultry, and eggs sold in interstate commerce and reinspects imported products to ensure that they meet U.S. safety standards. FSIS sets requirements for labels and certain slaughter and processing activities. FSIS also tests for microbiological, chemical, and other types of contamination and conducts epidemiological investigations in cooperation with CDC based on reports of foodborne health hazards and disease outbreaks (http://www.fsis.usda.gov). Office of Public Health and Science The Office of Public Health and Science (OPHS) provides scientific analysis, data, and recommendations on all matters involving public health and science that are of concern to the FSIS. OPHS assures scientifically sound food safety programs and policies to reduce or eliminate foodborne illness. OPHS experts monitor and analyze production processes; identify and evaluate potential foodborne hazards; determine estimates of risk to human health; respond to recognized, emerging, or potential threats to the food supply; investigate the origin of hazards; coordinate the recall of products when necessary; and provide emergency preparedness for foodborne problems (http://www.fsis.usda.gov/OPHS/ophshome.htm). Agricultural Marketing Service The Agricultural Marketing Service (AMS) administers programs that facilitate the fair, efficient marketing of U.S. agricultural products, including food, fiber, and specialty crops. One AMS program, the Science and

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Forging a Poison Prevention and Control System Technology Program, collects and analyzes data about pesticide residue levels in agricultural commodities. It administers the Pesticide Record-keeping Program, which requires all certified private applicators of federal restricted-use pesticides to maintain records of all applications. The records will be put into a database to help analyze agricultural pesticide use (http://www.ams.usda.gov). U.S. DEPARTMENT OF HOMELAND SECURITY The U.S. Department of Homeland Security (DHS) develops and coordinates the implementation of a comprehensive national strategy to secure the United States from terrorist threats or attacks. Working with executive departments and agencies, state and local governments, and private entities, DHS ensures an adequate strategy for detecting, preparing for, protecting against, responding to, and recovering from terrorist threats or attacks within the United States. DHS coordinates the development of monitoring protocols and equipment use for detecting the release of biological, chemical, and radiological hazards; prevention of unauthorized access to, development of, and unlawful importation of chemical, biological, radiological, nuclear, or other related materials; and containment and removal of biological, chemical, radiological, or other hazardous materials in the event of a terrorist threat or attack involving such hazards (http://www.dhs.gov/dhspublic). U.S. DEPARTMENT OF LABOR The U.S. Department of Labor (DOL) fosters and promotes the welfare of job seekers, wage earners, and retirees of the United States by improving working conditions, advancing employment opportunities, protecting retirement and health care benefits, helping employers find workers, and tracking changes in employment, prices, and other national economic measurements. DOL administers a variety of federal labor laws, including those that guarantee workers’ rights to a safe and healthful working environment (http://www.dol.gov). Occupational Safety and Health Administration The Occupational Safety and Health Administration (OSHA) programs are designed to save lives, prevent injuries, and protect the health of U.S. workers, in partnership with more than 100 million working men and women and their 6.5 million employers. OSHA protects workers with its strong enforcement program and prevents on-the-job injuries and illness through outreach, education, and compliance assistance.

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Forging a Poison Prevention and Control System OSHA has several cooperative programs, such as the Alliance Program, which allows trade or professional organizations, businesses, labor organizations, educational institutions, and government agencies that share an interest in workplace safety and health to collaborate with the administration to prevent injuries and illnesses in the workplace. The Strategic Partnership Program targets strategic areas and includes partnerships that target specific hazards in specific geographic areas. Voluntary Protection Program worksites have achieved exemplary occupational safety and health (http://www.osha.gov). Mine Safety and Health Administration The Mine Safety and Health Administration (MSHA) enforces compliance with mandatory safety and health standards to end fatal accidents, reduce the frequency and severity of nonfatal accidents, minimize health hazards, and promote improved safety and health conditions in U.S. mines. MSHA’s programs include Coal Mine Safety and Health, which is responsible for enforcing the Mine Act at all coal mines. The Act addresses activities such as site inspections, investigations of fatal and serious accidents and complaints of hazardous conditions reported by miners, and development of improved safety and health standards. Metal and Nonmetal Safety and Health enforces the Mine Act at all metal and nonmetal mining operations in the United States. The Directorate of Educational Policy and Development implements MSHA’s education and training programs, which are designed to promote safety and health in the U.S. mining industry. Finally, the Directorate of Technical Support provides expertise to assist MSHA, the states, and the mining industry in the resolution of safety and health issues. Technical Support conducts field investigations, studies, and analyses. Equipment and materials used in mines are also evaluated and approved by the directorate. Emergency response capabilities in mines, including onsite analysis and decision-making assistance for crisis management, are also evaluated (http://www.msha.gov). Bureau of Labor Statistics The Bureau of Labor Statistics is the principal fact-finding agency for the federal government for economics and statistics, producing impartial, timely, and accurate data about the social and economic conditions of the United States, its workers, workplaces, and the workers’ families (http://www.bls.gov).

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Forging a Poison Prevention and Control System U.S. DEPARTMENT OF JUSTICE The U.S. Department of Justice (DOJ) enforces the law and defends the interests of the United States according to the law; provides federal leadership in preventing and controlling crime; seeks just punishment for those guilty of unlawful behavior; administers and enforces the nation’s immigration laws fairly and effectively; promotes fair and impartial administration of justice for all U.S. citizens; and protects the United States from the threat of terrorism (http://www.usdoj.gov). National Drug Intelligence Center The National Drug Intelligence Center (NDIC) is both a component of DOJ and a member of the intelligence community. It is the center for strategic counterdrug intelligence. NDIC assists national policy makers and law enforcement with strategic domestic drug intelligence; supports the intelligence community counterdrug efforts; and produces national, regional, and state drug threat assessments. Among the many products produced by NDIC, The National Drug Threat Assessment is an annual report that provides information such as the current primary drug threat to the nation, fluctuations in consumption levels, and the effects of particular drugs on abusers and society as a whole (http://usdoj.gov/ndic). Drug Enforcement Administration The Drug Enforcement Administration enforces controlled substance laws and regulations of the United States by investigating and preparing for the prosecution of major violators of controlled substance laws at interstate and international levels; investigating and preparing for the prosecution of criminals and drug gangs that perpetrate violence and terrorism; managing a national drug intelligence program in cooperation with federal, state, local, and foreign officials; and other activities (http://www.dea.gov). Environment and Natural Resources Division DOJ’s Environment and Natural Resources Division (ENRD) enforces federal civil and criminal environmental laws and defends environmental challenges to government programs and activities, representing the United States in matters concerning the stewardship of the nation’s natural resources and public lands. The Environmental Crimes Section is responsible for prosecuting individuals and corporations for violating laws that protect the environment, such as those that compel clean-up of hazardous waste sites (http://www.usdoj.gov/enrd).

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Forging a Poison Prevention and Control System U.S. CONSUMER PRODUCT SAFETY COMMISSION The U.S. Consumer Product Safety Commission (CPSC) protects the public from unreasonable risks of serious injury or death from certain types of consumer products under the agency’s jurisdiction, such as toys, cribs, power tools, cigarette lighters, and household chemicals. CPSC is committed to protecting consumers and families from products that pose an electrical, chemical, or mechanical hazard, or can injure children. CPSC has a hotline to report a dangerous product or a product-related injury and a Poison Lookout Checklist (http://www.cpsc.gov). U.S. ENVIRONMENTAL PROTECTION AGENCY The U.S. Environmental Protection Agency (EPA) works to protect human health and to safeguard the natural environment. EPA is one of the nation’s leaders in environmental science, research, education, and assessment efforts, addressing emerging environmental issues and advancing the science and technology of risk assessment and management. Many of the substances regulated by EPA are poisonous to both humans and the environment. Some of the most common cases of human poisoning are from pesticides, lead, and mercury. EPA provides information to help prevent poisoning from these substances and other poisons in the home. EPA also has information on topics such as chemical and radiation accidents, accident preparedness and prevention, emergency preparedness and response, a radiological emergency response team, and the Toxics Release Inventory (TRI) (http://www.epa.gov). OFFICE OF NATIONAL DRUG CONTROL POLICY The Office of National Drug Control Policy (ONDCP) establishes the policies, priorities, and objectives for the U.S. drug control program. The director of ONDCP produces the National Drug Control Strategy to reduce illicit drug use and the manufacturing and trafficking of drugs, drug-related crime and violence, and drug-related health consequences. For fiscal year 2004, the National Drug Control Strategy proposes three core priorities: (1) stopping drug use before it starts, (2) healing America’s drug users, and (3) disrupting the illicit drug market (http://www.whitehousedrugpolicy.gov).

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