4
Historical Context of Poison Control

At the beginning of the 20th century, there was no modern specialty of toxicology, no poison control centers, no oversight of pharmaceutical manufacturing or drug labeling, and little knowledge regarding the treatment of poisonings in the United States. Household and occupational toxic hazards were poorly understood. As public health concepts were in their formative stages, surveillance of toxic exposures and the morbidity and mortality associated with these exposures were virtually unknown. Similarly, emergency response personnel and systems of emergency care that could respond to poisonings in the home or workplace were virtually nonexistent.

This chapter summarizes some of the key historical determinants of poison control and management as a modern health care service. Through a review of these developments, we can better understand the origin of our current “system” of poison control and management. Understanding this history can enhance efforts to advance this vital health care service by identifying potential barriers to the evolution of an optimal poison control and management system.

BRIEF OVERVIEW

Issues of misbranding, mislabeling, and adulteration of food and drugs concerned those who were involved in public health as well as health care providers and led to the founding of the United States Pharmacopeia (1820), the American Medical Association (1847), the American



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Forging a Poison Prevention and Control System 4 Historical Context of Poison Control At the beginning of the 20th century, there was no modern specialty of toxicology, no poison control centers, no oversight of pharmaceutical manufacturing or drug labeling, and little knowledge regarding the treatment of poisonings in the United States. Household and occupational toxic hazards were poorly understood. As public health concepts were in their formative stages, surveillance of toxic exposures and the morbidity and mortality associated with these exposures were virtually unknown. Similarly, emergency response personnel and systems of emergency care that could respond to poisonings in the home or workplace were virtually nonexistent. This chapter summarizes some of the key historical determinants of poison control and management as a modern health care service. Through a review of these developments, we can better understand the origin of our current “system” of poison control and management. Understanding this history can enhance efforts to advance this vital health care service by identifying potential barriers to the evolution of an optimal poison control and management system. BRIEF OVERVIEW Issues of misbranding, mislabeling, and adulteration of food and drugs concerned those who were involved in public health as well as health care providers and led to the founding of the United States Pharmacopeia (1820), the American Medical Association (1847), the American

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Forging a Poison Prevention and Control System Pharmacists Association (1852), and other organizations. Concerns about food and drug safety, beginning in the 19th century, provided the impetus for the first human clinical food additive trials to demonstrate safety and efficacy in December 1902 (Hurt, 1985). These efforts led to the Pure Food and Drug Act of 1906 (Lewis, 2002). This legislation (“Wiley Act”) created the Food, Drug, and Insecticide Administration, which in 1930 became the Food and Drug Administration (FDA). The Act required approval for foods and drugs meant for human consumption. Subsequently, the federal government passed a number of laws, created regulations, and proposed other controls and management of poisoning. These efforts are summarized in Box 4-1. In the 1930s, childhood poisoning was recognized as a significant component of pediatric practice and patient morbidity. Unfortunately, little information existed regarding the toxicity of household products and management recommendations. Jay Arena, M.D., a pediatrician at Duke University, began to systematically collect information regarding toxic hazards in the early 1930s and provided advice to physicians on poisoning cases in the surrounding area. He provided one of the first reports on the hazards of household products to children (Martin and Arena, 1939). Louis Gdalman, R.Ph., a pharmacist in Chicago, collected information during World War II. He developed a toxicological information system using index cards and eventually converted to microfiche. This system eventually covered more than 9,000 commercial and consumer products. Moreover, Gdalman established the precursor to the modern poison control center by personally taking telephone calls 24 hours per day (Botticelli and Pierpaoli, 1992; Burda and Burda, 1997). Although recognized as a growing problem during this period, the magnitude of childhood poisoning was not appreciated until a 1949–1950 epidemiological study focusing on children under 5 years of age reported a significant number of poisoning deaths (Bain, 1954). In 1950, the American Academy of Pediatrics (AAP), which was founded in 1930, established its Accident Prevention Committee, chaired by George M. Wheatley, M.D. That committee surveyed the 3,000 members of AAP and found that 49 percent of reported “accidents” treated by AAP members involved poisoning (Wheatley, 1953). In 1953, Edward Press, M.D., and Gdalman developed the first formal poison control center in Chicago. Their center provided professional telephone advice and included a standard data collection form (Botticelli and Pierpaoli, 1992; Burda and Burda, 1997). These centers rapidly developed, with as many as 265 by 1958 and 661 by 1978 (Scherz and Robertson, 1978). Provision of timely information to physicians regarding drugs and the toxicity of other agents was the driving force for poison control center

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Forging a Poison Prevention and Control System BOX 4-1 Key Legislative and Regulatory Activities Related to Poison Prevention and Management 1906 Pure Food and Drug Act (“Wiley Act”) Created the pre-FDA (Food, Drug, and Insecticide Administration). Required federal approval for sale of all foods and drugs meant for human consumption. Most patent medicines, after testing, were no longer approved for human consumption. 1927 The Caustic Poison Act Required labels to warn parents and protect children from lye (e.g., soap making) and 10 other caustic chemicals. 1930 Food, Drug, and Insecticide Administration becomes the Food and Drug Administration (FDA). 1938 Food, Drug, and Cosmetic Act Requires demonstration of new drug safety of non-narcotic prescription drugs. 1951 FDA defines and restricts further drugs to prescription. 1957 National Clearinghouse for Poison Control Centers (NCHPCC) established in FDA Mandate for poison control centers to collect data and provide to FDA. Used 1/3-page carbon-copy data forms. Provided 5" by 8" drug information cards. Published a bulletin on drug overdose management. Published The Clinical Toxicology of Commercial Products. 1961 Poison Prevention Week established by Pub. L. No. 87–319 (75 Stat. 681). Third week in March designated as National Poison Prevention Week. 1966 Child Protection Act Bans toys and other articles so hazardous that warning labels cannot be written. 1966 “Baby” aspirin packaging regulation limited to 36 tablets of 81 mg to protect children. 1970 FDA requires first patient package insert (oral contraceptives). 1970 Poison Prevention Packaging Act (FDA responsibility until 1973) Establishes Consumer Product Safety Commission (CPSC). 1972 FDA releases report on over-the-counter drugs. Reviews safety, effectiveness, and appropriate labeling. 1973 Emergency Medical Services Systems Act of 1973 (Pub. L. No. 93–154), Department of Health and Human Services Develops regional trauma centers, burn centers, and others, and establishes poison control centers as one of seven priorities. Funds some new poison control centers for 3 years. 1982 CPSC provides tamper-resistant packaging regulations. 1987 NCHPCC program terminated. 1995 FDA adopted “hierarchic” imprint coding of medications. Imprinting used alphanumeric codes and logos Imprinting yields. ~43 percent accuracy rate of unknown tablet and capsule identification. 1997 FDA Modernization Act. 1997 FDA passes iron medication regulations. Requires unit-dose packaging for products with 30 mg or more per dosage unit. 2000 Poison Control Center Enhancement and Awareness Act 106–174 (February 25, 2000) intended to stabilize poison control center funding. 2002 Homeland Security Act of 2002 (Sec. 505).

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Forging a Poison Prevention and Control System operations. These early leaders also recognized that effective telephone triage could avert unneeded medical visits or lead to early treatment at home. Hence, centers soon began to provide advice directly to laypersons and nonphysician care providers. This feature distinguishes poison control centers in the United States from similar centers in other countries, where the task of giving advice remains largely restricted to physicians. In 1957, the Surgeon General established the National Clearinghouse for Poison Control Centers (NCHPCC) within the FDA. At the time, the FDA and the U.S. Department of Agriculture represented the only federal agencies related to consumers with jurisdiction over drugs and chemicals. Product ingredient information was provided and poison exposures were tracked through NCHPCC. Funding was also provided to develop the text Clinical Toxicology of Commercial Products, authored by Robert Gosselin, M.D., Harold Hodge, M.D., and Marion Gleason at the University of Rochester. At the 1958 AAP annual meeting, the American Association of Poison Control Centers (AAPCC) was founded (Mofenson, 1975) (see Box 4-2 for the AAPCC statement of objectives). AAPCC continues to serve as the voluntary association for poison control centers. As the lead professional organization regarding poison control and management, AAPCC—along with other toxicology groups—continues to host medical toxicology scientific presentations and continuing education sessions at its annual meeting in combination with several other societies. In 1968, both the American Academy of Clinical Toxicology and the American College of Emergency Physicians were founded. One impact of both organizations was to take the focus of poisoning beyond pediatric exposures. The American Board of Medical Toxicology gave its first examination for physician toxicologists in 1974 and fellowship training programs were instituted at about the same time. Emergency medicine was recognized as a specialty in the BOX 4-2 Statement of Objectives of the American Association of Poison Control Centers To provide a forum for poison centers and interested individuals to promote the reduction of morbidity and mortality from poisonings through public and professional education and scientific research. To set voluntary standards for poison center operations. SOURCE: http://www.aapcc.org//aapcc.htm.

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Forging a Poison Prevention and Control System United States in 1979 when it received conjoint status from the American Board of Medical Specialists (ABMS) and became a primary specialty 10 years later. Medical toxicology began administering examinations in 1974 and was recognized by the ABMS as a certificate of added qualification in 1994. Although AAP has remained active in the area of poisonings with its Section on Injury and Poison Prevention, founded in 1990, the organization no longer sponsors AAPCC meetings. During the late 1970s, systems of emergency care were developed following passage of the Emergency Medical Services (EMS) Systems Act of 1973 (Pub. L. No. 93–154). The application of technology and centralized public service (communication) access points produced the opportunity for integration of poison control centers within EMS systems. Concurrent steps to enhance home safety (e.g., product labeling, smaller quantities of over-the-counter medications per package, prescription drug safety caps, childproof cabinet locks) coincided with a shift in awareness of mortality risk to include adult poisoning as a major emphasis of care. Given a growing emphasis on adult poisoning management and poisoning response with EMS services, an increasing number of leaders in medical toxicology, including the poison control center medical directors, began to come from a background in emergency medicine followed by a fellowship in clinical toxicology (see Chapter 5). Professional activities by medical toxicologists, pharmacists, and nurses also have grown dramatically in both the management and operation of poison control centers. Centers no longer use clerical personnel or sanitarians to manage exposures. Certain aspects of poisoning prevention in the past 30 years have been independent of poison control center clinical functions. For example, the introduction by the FDA of imprint codes on tablets and capsules provided a much improved method of tablet and capsule identification. Although the system has major drawbacks (e.g., use of logos that are difficult to categorize, describe, and list), there has been faster determination of potential medication exposures (Marder et al., 2001; Symonds and Robertson, 1967). Similarly, the use of safety caps on medications and chemical compounds has reduced the number of exposures in children and may have been the single most important reason for reduction in morbidity and mortality since the early 1970s (Anonymous, 1982; Arena, 1959; Palmisano, 1981; Rodgers, 1996; Walton, 1982). Although there have been various public campaigns to use other child safety devices, the only data that exist are related to safety caps. Child-resistant packaging was required for various prescription drugs beginning in 1974. Looking at the period from 1974 to 1992 and comparing it with a previous period, estimates show a reduction of 460 child deaths and a mortality rate reduction of 45 percent as a result of this packaging (Rodgers, 1996). Figure 4-1 from that study

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Forging a Poison Prevention and Control System FIGURE 4-1 Child mortality rates due to the unintentional ingestion of oral prescription drugs, 1964–1992. SOURCE: Rodgers (1996). shows the drop in child mortality rates over the time period; Figure 4-2 shows the difference between the predicted rates with and without child-resistant packaging. Events both before and after September 11, 2001, have heightened national concerns regarding homeland security and the threat of radiologic, biological, and chemical weapon exposure. The Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) have recognized the importance of poison control centers as a component of an all-hazards emergency planning and response system that is integrated with state health departments and supports regional and hospital-based emergency service efforts. As discussed in Chapters 5 and 9, the incorporation of poison control centers in this manner has been variable and remains underdeveloped. This new potential role—combined with substantive changes in funding and federal oversight—clearly marks a break with the past and the beginning of a new period for poison control centers.

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Forging a Poison Prevention and Control System FIGURE 4-2 Fitted model for predicted child mortality rates due to unintentional ingestion of oral prescription drugs, 1964–1992. SOURCE: Rodgers (1996). POISON CONTROL CENTERS Origins Although the preceding overview provides a brief context for poison control centers, the detailed history of their development provides further insight into their current status and function. Edward Press, with the support of the AAP Illinois Chapter, the Illinois Department of Public Health, seven hospitals, five Chicago medical schools, the American Medical Association, the FDA, and others, formed a committee on April 1, 1953, to begin development of the first poison control center (Botticelli and Pierpaoli, 1992; Burda and Burda, 1997). By 1954, 11 centers had been established in the city of Chicago alone, with the

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Forging a Poison Prevention and Control System objective of providing information to physicians for treatment of children exposed to toxic agents. During this time, visiting nurses from the board of health also visited the homes of poisoning victims in Chicago. In 1961, the advisory committee of the poison control center in Chicago consolidated the 11 poison control centers into one information center at Presbyterian–St. Luke’s Hospital. In 1962, the Master Poison Control Center was established with Joseph R. Christian, M.D., as medical director, and Chicago pharmacist Gdalman as director responsible for operations. The advisory committee also resolved its concerns about professional liability exposure and agreed to allow direct calls to the poison control center from the public. Embraced as a lifesaving idea by the pediatric community, the number of centers rapidly increased nationally from 1953 to 1958, when 265 poison control centers were reported to exist. This expansion occurred with no consistent funding or formal organizational structure (Arena, 1983). It was not until the 1970s that emergency medicine became a potent force creating professional demand for improved poison information. The result was the extension of standardized poison and drug information and consistent access to toxicologists. By that time, more than 660 poison control centers had developed (Scherz and Robertson, 1978). Recognizing the changing epidemiological trends, poison control centers began in the 1970s to expand their efforts beyond a primarily pediatric focus to serving the full population. However, the prevention education in centers has continued to emphasize pediatric poisoning prevention. Evolution of Structure and Function As noted previously, poison control centers were established to provide drug and chemical toxicity information and patient management guidance to physicians. These services were expanded to handle telephone calls from laypersons in the 1960s. Initially, most centers consisted simply of a telephone and a designated individual to answer that telephone. The individual responding to the calls at times was a clerical person, pediatric house officer (physician in training, pharmacist), or other interested (or designated) person. Neither training nor educational materials were standardized. In 1957, the first efforts to standardize poison information were undertaken within the FDA by NCHPCC. These included (1) index cards containing information on drugs, chemicals, household products, and plants, and (2) a monthly newsletter summarizing the poisoning literature. NCHPCC also funded the publication of a book, The Clinical Toxicology of Commercial Products, with the first edition in 1957 (Food and Drug Administration).

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Forging a Poison Prevention and Control System In the 1970s, poison control centers began to offer clinical toxicology fellowship programs for physicians and other scientists. A medical subspecialty certificate of added qualification in medical toxicology became possible in 1994 for diplomates of the American Board of Emergency Medicine, the American Board of Pediatrics, or the American Board of Preventive Medicine through the American Board of Medical Specialties. Currently, candidates for this subspecialty certification must complete a residency in one of the sponsoring boards or other boards by petition and a medical toxicology fellowship affiliated with a poison control center. Professional activities by pharmacists and nurses have grown dramatically in both the management and operation of poison control centers. Centers no longer use clerical personnel to manage exposures. Beginning in the early 1980s, AAPCC developed and promoted criteria enabling nonphysicians to become specialists in poison information. As an adjunct to their extensively trained personnel, nonphysician, pharmacist, and nursing personnel could serve as a supervised poison information provider. Designations of poison control centers were made by each state health department, peaking in 1978 with 649 sites in the 50 states and 12 more in U.S. territories and the Virgin Islands (Scherz and Robertson, 1978) (Table 4-1). However, there were few large poison control centers and the number receiving more than 1,000 calls per year never exceeded 80. In 1970, less than 6 percent of poison control centers received more than 9 to 10 calls per day, or 3,285 to 3,650 per year (Manoguerra, 1976). In the absence of a federal certifying body or federal poison control center regulations for staffing and operations, AAPCC developed certification systems for both the centers and their personnel (Lovejoy et al., 1994). As a result of an increasing expectation for center certification, tenuous financial support, and economically driven service cutbacks by hospitals and teaching institutions, the number of centers dropped rapidly over three decades. In 1983, the number of centers had dropped to 395 and in 1994 to 87. By 2002, there were 64 centers reporting to the AAPCC Toxic Exposure Surveillance System (TESS) data collection system, with coverage of 99.8 percent of the U.S. population, a dramatic increase from the 52 percent of the population covered in 1993 (Lovejoy et al., 1994; Watson et al., 2003). Following introduction of the national toll-free number, 100 percent of the U.S. population is currently covered by 64 centers. The surviving poison control centers developed from the consolidation and expansion of the early centers (Rumack et al., 1978). Such centralization of information and treatment was shown early to reduce poisoning mortality; for example, in one hospital it declined from 8 to 4 percent (Teitelbaum, 1968). Reorganization of poison control centers largely has been driven by local economic mandates rather than by public health initiatives. Currently, several cen-

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Forging a Poison Prevention and Control System TABLE 4-1 Poison Information Centers: States, Territories, and Virgin Islands, 1978 Alabama 8 New Jersey 34 Alaska 5 New Mexico 6 Arizona 17 New York 21 Arkansas 8 North Carolina 8 California 9 North Dakota 7 Colorado 9 Ohio 13 Connecticut 10 Oklahoma 8 Delaware 1 Oregon 1 Florida 32 Pennsylvania 74 Georgia 11 Rhode Island 4 Hawaii 1 South Carolina 2 Idaho 3 South Dakota 2 Illinois 102 Tennessee 8 Indiana 33 Texas 21 Iowa 4 Utah 1 Kansas 14 Vermont 0 Kentucky 10 Virginia 19 Louisiana 5 Washington 11 Maine 1 West Virginia 16 Maryland 6 Wisconsin 5 Massachusetts 6 Wyoming 2 Michigan 28 Canal Zone 1 Minnesota 27 District of Columbia 1 Mississippi 13 Guam 1 Missouri 15 Puerto Rico 5 Montana 3 Virgin Islands 4 Nebraska 2 Total 50 States and the   Nevada 2 District of Columbia = 650   New Hampshire 1 Total = 661     SOURCE: Adapted from Scherz and Robertson (1978). ters supply parts or all of the service needs of other states. Some centers serve areas at a great distance (e.g., the Oregon Poison Center serves Alaska and the Rocky Mountain Poison and Drug Center in Colorado serves Hawaii). States that do not have onsite centers provide services such as education and outreach through community organizations and state public health agencies. Although concern has been expressed that states without poison control centers would be less well served than states with centers, there is no evidence to show decreased call rates in states without centers physically present, such as Alaska, Hawaii, Wyoming, Montana, North Dakota, and Idaho.

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Forging a Poison Prevention and Control System Evolution of Data Collection and Poisoning Surveillance Collection of data by early poison control centers was fragmented and generally nonstandardized. In 1957, NCHPCC collected limited data from centers and published a yearly statistical report for the aggregate of reporting centers approximately 24 months after the end of the data collection year. AAPCC developed the Toxic Exposure Surveillance System, a data collection system, in 1983. TESS is the data source for AAPCC annual reports (Watson et al., 2003). TESS was developed in part to supply marketable, comprehensive data for pharmaceutical companies and federal agencies (e.g., Consumer Product Safety Commission, or CPSC). TESS also provides poison control centers with a standardized poisoning exposure record. This system initially used “mark sense” forms (to be described later in this chapter), but has been advanced to digital format. Annual TESS summary data for reporting poison control centers are published annually in the American Journal of Emergency Medicine (Watson et al., 2003). During the past several years, changes to TESS have been funded by CDC and its Agency for Toxic Substances and Disease Registry. Funding in excess of $6 million has largely supported enhancement of the proprietary software underlying TESS and has not subsidized data collection by poison control centers. TESS provides useful exposure data, but captures only a fraction of the most seriously poisoned patients (Blanc et al., 1995; Hoppe-Roberts et al., 2000). From a historical perspective, a key shortcoming of TESS is that it did not develop as a public access database comparable to governmental sources of other vital statistics. The TESS data collection program is proprietary to AAPCC and thus is not managed by any public health or government agency. Consistent with this fact, the underlying software for both data collection and analysis was developed and remains owned by a private company with ties to AAPCC. As new data fields have been added to TESS over time, individual poison control centers must provide the additional time and personnel required to acquire the data without full compensating revenue. However, approximately $250,000 from the sale of data is returned to individual centers annually based on the number of cases submitted as partial compensation. This compensation from the AAPCC central office ranges from $3,000 to $7,000 per center each year. Individual centers reporting to the Committee estimated the net cost of providing such data (i.e., beyond that compensated) ranges from $50,000 to $100,000 per year. Federal agencies such as CPSC and the FDA, as well as most state agencies, also purchase TESS data reports.

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Forging a Poison Prevention and Control System BOX 4-3 Conclusions and Recommendations from Evaluation of the Poison Control System (1973) Major strengths of the poison control system The treatment of accidental poisonings is enhanced as more knowledge is disseminated The reporting system provides human experience information The total estimated cost (federal and nonfederal) for 1972 was $7,486,776 The estimate of annual cost savings to the public was $4,107,050 for 1972 Major deficiencies of the poison control system and recommendations for improvement The uneven distribution of poison centers geographically and by population could be eliminated by a national poison center The services of the poison control system are poorly advertised to the public, but advertising could readily be improved Many poison centers do not submit case histories to the Clearinghouse [NCHPCC], but providing technical assistance to centers could be an inducement to increase center cooperation The poison control system is not putting enough emphasis on prevention Summary poison statistics may not accurately reflect national incidence, morbidity, and mortality, but this potential deficiency can be removed by increasing the number of poison centers submitting case histories and improving reporting procedures Summary statistics are not geared to examining the operations of individual poison centers and are of marginal use to the centers; these needs can be met by modifying the format of the annual statistics and increasing feedback of center-related data to poison centers The poison control system has no mechanism for performing ongoing evaluation of its activities and should implement an evaluation system using indicators matched to a program structure Major strengths of federal poison control activities Clearinghouse cards Poison prevention activities Enforcing and regulating hazardous substances and poison prevention packaging Publication of the book Clinical Toxicology of Commercial Products Total federal expenditure in 1972 of $1,300,000 Major deficiencies of federal poison control center activities Acquisition of product information from manufacturers could be improved by developing and disseminating to manufacturers a recommended format with which to supply product information and a timetable for such submissions Insufficient advertising of services provided by poison centers could be improved by modifying Poison Prevention Week activities to include advertising of poison center services

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Forging a Poison Prevention and Control System Clearinghouse poisoning report forms and procedures are difficult for poison centers to use, but could be improved by redesigning the forms and routing sampling poison center opinion about clearinghouse services Clearinghouse procedures for disseminating product cards are irregular The federal poison control activities have no mechanism for performing ongoing evaluation and should implement an evaluation system using indicators matched to a program structure Major strengths of poison centers 90 percent of poison centers are able to provide service on a 24-hour basis All but one of the centers provides treatment information over the telephone 94 percent of the centers accept phone calls from the public The operation of a single poison center is estimated to cost an average of $10,860 per year Major deficiencies of poison centers The majority of poison centers are devoting no staff time for poison prevention activities and should increase their prevention efforts The majority of poison centers do not have their own special telephone number Only half of the poison centers are following up on cases and should make use of local government social services agencies to follow up cases Only half of the poison centers are keeping a record of phone calls NOTE: The report addresses the federal system and then individual centers. SOURCE: Food and Drug Administration (1973, pp. 107–131). Enactment and initial regulations created under the Hazardous Substances Labeling Act. Establishment of Poison Prevention Week. Legislation passed in 1967 limiting the number of aspirin tablets in baby aspirin bottles. Growth in the number of poison control centers and to a lesser extent the establishment of NCHPCC and publication of The Clinical Toxicology of Commercial Products (released during the period 1957–1959); periodically updated. The report estimated that in 1972 consumers saved $4 million and avoided 400,000 emergency department visits by receiving free treatment information by telephone from poison control centers.

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Forging a Poison Prevention and Control System PUBLIC OVERSIGHT FDA In 1979, the FDA’s NCHPCC reached its zenith with 45 staff members. The center provided support services but no direct funding to poison control centers. Participation in NCHPCC statistical reports was a voluntary center activity. The development of a taxonomy of poisoning by NCHPCC for standardized reporting was incomplete and no standardization of center organization, service delivery, or clinical outcomes assessment was achieved. As NCHPCC’s emphasis evolved into a monthly compilation of toxicology literature, the FDA became less committed to management of NCHPCC and finally ceased to work in this area in 1987. HRSA and Other Organizations Poison control centers do not operate within any single federal mandate having regulatory or reporting authority. Furthermore, there is no requirement that emergency departments, critical care units, or any other care facilities or providers contact or report poisoning cases to any center. Although some states, such as New York, have requirements for reporting of poisoning cases as well as food poisoning cases, the discrepancies among various databases suggest that capture of all cases does not occur. This may be due to definitional issues addressed in one of the Committee’s recommendations in Chapter 10. The center’s role is generally unclear to most health care providers; a center is generally regarded as a place that the public and professionals can call about poison exposures. Since 2000, more than $60 million have been infused into the AAPCC and poison control centers through the Poison Control Center Enhancement and Awareness Act (Pub. L. No. 106–174), which was enacted in 2000 and reauthorized in 2003 (see Appendix 4-A for the Reauthorization). HRSA and CDC were given responsibility by the Secretary of Health and Human Services for implementing the Act. HRSA administers stabilization and incentive grants to the poison control centers. These grants are reviewed each year for goals, progress, and financial accounting. Interestingly, the related HRSA grant guidelines have discouraged the use of such funds to support delivery of existing services (i.e., to provide fiscal stabilization); instead, they have been earmarked for “enhancement of services.” Thus, the Act has done little to stabilize poison control centers in dire financial need of support for basic service delivery. CDC administers funds to the AAPCC under the Act for upgrading TESS, developing a national poison control telephone number, and developing new nationwide media campaigns. AAPCC has received up to

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Forging a Poison Prevention and Control System $5 million per year to support projects such as revisions of a proprietary data collection instrument and development of a real-time surveillance tool that collects data from poison control centers. To date, no real-time data feedback are provided by AAPCC to the centers nor do the centers have real-time access to the electronic database; rather, they are notified by telephone about suspicious activities identified through this real-time tool. Furthermore, centers have only limited access to their own electronic and national data upon request. AAPCC also receives federal income from the Environmental Protection Agency and CPSC for access to TESS surveillance data. PUBLIC HEALTH LINKAGES As noted previously, public health agencies, for the most part, had little involvement with poison control centers until 2001, when bioterrorism and related activities created interest in poison control center activities. Few public health leaders were involved during the formative years of poison control centers. This may have been related in part to NCHPCC being located within a regulatory agency. A few centers have developed relationships with public health agencies, but only rarely have they received significant funding or other support. Furthermore, a few states have provided Maternal and Child Health Bureau funding to poison control centers (see Chapter 9). An Institute of Medicine report on the role of the public and private sectors in injury prevention mentions poisoning only briefly, despite listing it as the third leading cause of injury-related death. Furthermore, the report does not include AAPCC data collection and TESS in its list of more than 30 databases (Bonnie et al., 1999). Some public health agencies, particularly at the state level, have maintained close ties with their state’s poison control centers, but lack of funding has limited such participation. Public health authorities have indicated interest in drugs of abuse and other issues under their purview but, for example, have rarely been interested in unintentional drug ingestion in the home. The lack of collaboration with public health agencies also may be related to the observation that poison control centers have owned their data and most have required compensation from other agencies to share those data. State activities in poison control centers have been quite variable. New York had a particularly focused development in this area in coordination with the larger picture of injury control (Fisher, 1986; Fisher et al., 1986). A review of poison control statutes that existed by the early 1980s was conducted and some early strategic planning was suggested at about that time (Fisher, 1981; Russell and Czajka, 1984).

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Forging a Poison Prevention and Control System Integration of poison control centers and drug information centers was addressed at a number of sites in the late 1970s and early 1980s as pharmacists became more involved with their development (Czajka et al., 1979; Troutman and Wanke, 1983; Wanke et al., 1988). SUMMARY The following key messages can be drawn from the discussion provided in this chapter: Poison control centers and the work of dedicated poison specialists have had a significant impact on U.S. health care. Key achievements include: Development and implementation of medication safety caps. Establishment of limits on the number of children’s aspirin tablets and subsequently other over-the-counter medications in a bottle. Development of imprint code regulations to help speed identification of medications. Use of TESS data to encourage passage of federal regulations in 1997 to reduce the number of iron tablets in a container. Demonstration that nearly 80 percent of human exposures can be managed in the home using poison control center personnel guidance, thus reducing the burden on the health care system and providing reassurance to parents (Watson et al., 2003). Demonstration of the ability to provide an immediate response to public health exposure concerns, such as anthrax, and subsequent participation in bioterrorism responses. The current structure of poison control centers is quite variable and developed as a result of historical factors that may be irrelevant to current functional needs. Poison prevention efforts have historically focused on children, despite more recent recognition of greater risk for morbidity and mortality in adults. More emphasis has been placed on treating patients with drug abuse and alcohol problems as the role of poison control centers has broadened to include adults. Although medical toxicologists see such patients regularly as part of their management of critically ill patients, further integration of these aspects into poison control center services is warranted as part of the spectrum of poisoning treatment. Attention to the special problems of the elderly, along with the important contributions of pharmacists in reducing adverse reactions in this population, deserves attention as an aspect of development of poison control centers.

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Forging a Poison Prevention and Control System Funding for poison control centers is piecemeal, and centers often receive unfunded mandates for data provision and other services. A current example is the expectation of active participation in regional emergency planning and response and the provision of additional data for all-hazards emergency preparedness and response surveillance without dedicated resources. Furthermore, federal grants earmarked for poison control center enhancement have done little to stabilize centers in need of financial support for basic service delivery. There is considerable opportunity for coordination and cooperation between poison control centers and public health agencies at federal, state, and county levels. However, without federal or state points of accountability, many poison control center oversight roles have been assumed by the American Association of Poison Control Centers. These factors have led to a lack of integration of center data with the public health system.

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Forging a Poison Prevention and Control System Appendix 4-A Poison Control Center Enhancement and Awareness Act Amendments of 2003

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Forging a Poison Prevention and Control System 117 STAT. 2888 PUBLIC LAW 108–194—DEC. 19, 2003 Public Law 108–194 108th Congress   An Act Dec. 19, 2003 / [S. 686] To provide assistance for poison prevention and to stabilize the funding of regional poison control centers. Poison Control Center Enhancement and Awareness Act Amendments of 2003. 42 USC 201 note. 42 USC 300d–71 note. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, SECTION 1. SHORT TITLE. This Act may be cited as the “Poison Control Center Enhancement and Awareness Act Amendments of 2003”. SEC. 2. FINDINGS. The Congress finds the following:   (1) Poison control centers are our Nation’s primary defense against injury and deaths from poisoning. Twenty-four hours a day, the general public as well as health care practitioners contact their local poison centers for help in diagnosing and treating victims of poisoning and other toxic exposures. (2) Poisoning is the third most common form of unintentional death in the United States. In any given year, there will be between 2,000,000 and 4,000,000 poison exposures. More than 50 percent of these exposures will involve children under the age of 6 who are exposed to toxic substances in their home. Poisoning accounts for 285,000 hospitalizations, 1,200,000 days of acute hospital care, and 13,000 fatalities annually. (3) Stabilizing the funding structure and increasing accessibility to poison control centers will promote the utilization of poison control centers, and reduce the inappropriate use of emergency medical services and other more costly health care services. (4) The tragic events of September 11, 2001, and the anthrax cases of October 2001, have dramatically changed our Nation. During this time period, poison centers in many areas of the country were answering thousands of additional calls from concerned residents. Many poison centers were relied upon as a source for accurate medical information about the disease and the complications resulting from prophylactic antibiotic therapy. (5) The 2001 Presidential Task Force on Citizen Preparedness in the War on Terrorism recommended that the Poison Control Centers be used as a source of public information and public education regarding potential biological, chemical, and nuclear domestic terrorism. (6) The increased demand placed upon poison centers to provide emergency information in the event of a terrorist event

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Forging a Poison Prevention and Control System involving a biological, chemical, or nuclear toxin will dramatically increase call volume.   SEC. 3. AMENDMENT TO PUBLIC HEALTH SERVICE ACT.   Title XII of the Public Health Service Act (42 U.S.C. 300d et seq.) is amended by adding at the end the following:   “PART G—POISON CONTROL   “SEC. 1271. MAINTENANCE OF A NATIONAL TOLL-FREE NUMBER. 42 USC 300d–71. “(a) IN GENERAL.—The Secretary shall provide coordination and assistance to regional poison control centers for the establishment of a nationwide toll-free phone number to be used to access such centers. “(b) RULE OF CONSTRUCTION.—Nothing in this section shall be construed as prohibiting the establishment or continued operation of any privately funded nationwide toll-free phone number used to provide advice and other assistance for poisonings or accidental exposures. “(c) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be appropriated to carry out this section $2,000,000 for each of the fiscal years 2000 through 2009. Funds appropriated under this subsection shall not be used to fund any toll-free phone number described in subsection (b).   “SEC. 1272. NATIONWIDE MEDIA CAMPAIGN TO PROMOTE POISON CONTROL CENTER UTILIZATION. 42 USC 300d–72. “(a) IN GENERAL.—The Secretary shall establish a national media campaign to educate the public and health care providers about poison prevention and the availability of poison control resources in local communities and to conduct advertising campaigns concerning the nationwide toll-free number established under section 1271. “(b) CONTRACT WITH ENTITY.—The Secretary may carry out subsection (a) by entering into contracts with one or more nationally recognized media firms for the development and distribution of monthly television, radio, and newspaper public service announcements. “(c) EVALUATION.—The Secretary shall— “(1) establish baseline measures and benchmarks to quantitatively evaluate the impact of the nationwide media campaign established under this section; and “(2) prepare and submit to the appropriate congressional committees an evaluation of the nationwide media campaign on an annual basis. “(d) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to carry out this section $600,000 for each of fiscal years 2000 through 2005 and such sums as may be necessary for each of fiscal years 2006 through 2009.   “SEC. 1273. MAINTENANCE OF THE POISON CONTROL CENTER GRANT PROGRAM. 42 USC 300d–73. “(a) REGIONAL POISON CONTROL CENTERS.—The Secretary shall award grants to certified regional poison control centers for the purposes of achieving the financial stability of such centers, and for preventing and providing treatment recommendations for poisonings.  

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Forging a Poison Prevention and Control System   “(b) OTHER IMPROVEMENTS.—The Secretary shall also use amounts received under this section to— “(1) develop standardized poison prevention and poison control promotion programs; “(2) develop standard patient management guidelines for commonly encountered toxic exposures; “(3) improve and expand the poison control data collection systems, including, at the Secretary’s discretion, by assisting the poison control centers to improve data collection activities; “(4) improve national toxic exposure surveillance by enhancing activities at the Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry; “(5) expand the toxicologic expertise within poison control centers; and “(6) improve the capacity of poison control centers to answer high volumes of calls during times of national crisis. “(c) CERTIFICATION.—Except as provided in subsection (d), the Secretary may make a grant to a center under subsection (a) only if— “(1) the center has been certified by a professional organization in the field of poison control, and the Secretary has approved the organization as having in effect standards for certification that reasonably provide for the protection of the public health with respect to poisoning; or “(2) the center has been certified by a State government, and the Secretary has approved the State government as having in effect standards for certification that reasonably provide for the protection of the public health with respect to poisoning. “(d) WAIVER OF CERTIFICATION REQUIREMENTS.— “(1) IN GENERAL.—The Secretary may grant a waiver of the certification requirement of subsection (c) with respect to a noncertified poison control center or a newly established center that applies for a grant under this section if such center can reasonably demonstrate that the center will obtain such a certification within a reasonable period of time as determined appropriate by the Secretary. “(2) RENEWAL.—The Secretary may renew a waiver under paragraph (1). Effective date. “(3) LIMITATION.—In no instance may the sum of the number of years for a waiver under paragraph (1) and a renewal under paragraph (2) exceed 5 years. The preceding sentence shall take effect as if enacted on February 25, 2000. “(e) SUPPLEMENT NOT SUPPLANT.—Amounts made available to a poison control center under this section shall be used to supplement and not supplant other Federal, State, or local funds provided for such center. “(f) MAINTENANCE OF EFFORT.—A poison control center, in utilizing the proceeds of a grant under this section, shall maintain the expenditures of the center for activities of the center at a level that is not less than the level of such expenditures maintained by the center for the fiscal year preceding the fiscal year for which the grant is received. “(g) MATCHING REQUIREMENT.—The Secretary may impose a matching requirement with respect to amounts provided under a grant under this section if the Secretary determines appropriate.

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Forging a Poison Prevention and Control System “(h) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to carry out this section $25,000,000 for each of the fiscal years 2000 through 2004 and $27,500,000 for each of fiscal years 2005 through 2009.   “SEC. 1274. RULE OF CONSTRUCTION. 42 USC 300d–74. “Nothing in this part may be construed to ease any restriction in Federal law applicable to the amount or percentage of funds appropriated to carry out this part that may be used to prepare or submit a report.’’.   SEC. 4. CONFORMING AMENDMENT. 42 USC 14801 note. The Poison Control Center Enhancement and Awareness Act (42 U.S.C. 14801 et seq.) is hereby repealed.   Approved December 19, 2003.   LEGISLATIVE HISTORY—S. 686: SENATE REPORTS: No. 108–68 (Comm. on Health, Education, Labor, and Pensions). CONGRESSIONAL RECORD, Vol. 149 (2003): June 20, considered and passed Senate. Nov. 19, 20, considered and passed House, amended. Dec. 9, Senate concurred in House amendment.