cases is obtained. This estimate of annual incidence of poisoning is nearly twice as high as that estimated by the NHIS data and more than 60 percent higher than that based on TESS data alone.

Patients who receive inpatient care for poisoning are almost always admitted to a hospital through the emergency department, physician/ clinic referral, or via transfer from another institution. Thus, NHDS data should not add to the overall estimate of poisoning episodes. This source yields an estimate of 282,012 annual episodes, which is consistent with the discharge status of hospital admission for 265,714 visits provided by the disposition information from the NHAMCS outpatient data and emergency department files combined, and with the assumption already discussed. This estimate excludes any contribution to the hospitalization total from NAMCS, for which hospitalization was noted for two sample observations only (1.9 percent, unweighted). Even if an additional 30,000 hospitalizations were added from this source, the combined NAMCS/ NHAMCS estimate would remain similar (and would be even closer) to the NHDS figure.

Estimates of fatal poisonings range from 1,074 for TESS data to 24,173 for the NCHS analysis of death certificate data for 2001 (climbing to 30,800 when alcohol behavioral disorder coded deaths are included). Death certificate data are generally considered the most reliable source for such data as they also include out-of-hospital deaths (see Chapter 7 for a detailed discussion of the strengths and limitations of death certificate data). It is noteworthy that only one in four in-hospital deaths (based on NHDS) appear to be reported through TESS, compared with a 1:5 ratio of TESS to NAMCS/NHAMCS for poisoning cases receiving direct health care. This suggests that case severity alone does not drive poison control center case consultation as reflected in TESS reporting (also discussed in Chapter 7).

It is important to acknowledge that varying approaches to case definition and coding inclusion may impact the estimates cited above. For example, the inclusion of envenomations of various kinds may have led to inflated survey-based estimates, particularly for nonhospitalized poisoning events. The category of bites/sting is also included in TESS estimates, accounting for 85,713 cases (3.8 percent of the total) in that system in 2001. TESS totals also include adverse drug reactions (35,634; 1.6 percent) and “food poisoning” (41,319; 1.8 percent), categories that were excluded from the other analyses. The inclusion of 6,627 alcohol behavioral abuse coded deaths in the NCHS analysis should also be viewed in the context of TESS reporting, which in the same year reported only 15 ethanol deaths, only 5 of which were not combined with another co-ingestion.

It is also important to acknowledge that these estimates are based on selected major national surveys and databases. We did not attempt to derive estimates from a wider range of possible surveillance data sources,

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