A Review of Disaster-Related Carbon Monoxide Poisoning: Surveillance, Epidemiology, and Opportunities for Prevention

Shahed Iqbal, Scott A. Damon, and Fuyuen Y. Yip are with the Air Pollution and Respiratory Health Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA. Jacquelyn H. Clower is with Cazador, contracted to Air Pollution and Respiratory Health Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention. Sandra A. Hernandez is with the National Center for Environmental Health, Centers for Disease Control and Prevention.
American Journal of Public Health (Impact Factor: 4.55). 08/2012; 102(10):1957-1963. DOI: 10.2105/AJPH.2012.300674
Source: PubMed


We conducted a systematic literature review to better understand aspects of disaster-related carbon monoxide (CO) poisoning surveillance and determine potentially effective prevention strategies.

This review included information from 28 journal articles on disaster-related CO poisoning cases occurring between 1991 and 2009 in the United States.

We identified 362 incidents and 1888 disaster-related CO poisoning cases, including 75 fatalities. Fatalities occurred primarily among persons who were aged 18 years or older (88%) and male (79%). Hispanics and Asians accounted for 20% and 14% of fatal cases and 21% and 7% of nonfatal cases, respectively. Generators were the primary exposure source for 83% of fatal and 54% of nonfatal cases; 67% of these fatal cases were caused by indoor generator placement. Charcoal grills were a major source of exposure during winter storms. Most fatalities (94%) occurred at home. Nearly 89% of fatal and 53% of nonfatal cases occurred within 3 days of disaster onset.

Public health prevention efforts could benefit from emphasizing predisaster risk communication and tailoring interventions for racial, ethnic, and linguistic minorities. These findings highlight the need for surveillance and CO-related information as components of disaster preparedness, response, and prevention.

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    • "Not all flooding related CO poisonings and deaths are recognised as such and even fewer are published in journals. Iqbal et al have summarised the reasons for the underestimation of the total number of disaster related CO deaths10. For similar reasons, the true number and variety of appliances and circumstances in which people have been poisoned by CO associated with flooding is almost certainly under - represented in scientific literature. "
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    ABSTRACT: Introduction While many of the acute risks posed by flooding and other disasters are well characterised, the burden of carbon monoxide (CO) poisoning and the wide range of ways in which this avoidable poisoning can occur around flooding episodes is poorly understood, particularly in Europe. The risk to health from CO may continue over extended periods of time after flooding and different stages of disaster impact and recovery are associated with different hazards. Methods A review of the literature was undertaken to describe the changing risk of CO poisoning throughout flooding/disaster situations. The key objectives were to identify published reports of flood-related carbon monoxide incidents that have resulted in a public health impact and to categorise these according to Noji's Framework of Disaster Phases (Noji 1997); to summarise and review carbon monoxide incidents in Europe associated with flooding in order to understand the burden of CO poisoning associated with flooding and power outages; and to summarise those strategies in Europe which aim to prevent CO poisoning that have been published and/or evaluated. The review identified 23 papers which met its criteria. The team also reviewed and discussed relevant government and non-government guidance documents. This paper presents a summary of the outcomes and recommendations from this review of the literature. Results Papers describing poisonings can be considered in terms of the appliance/source of CO or the circumstances leading to poisoning.The specific circumstances identified which lead to CO poisoning during flooding and other disasters vary according to disaster phase. Three key situations were identified in which flooding can lead to CO poisoning; pre-disaster, emergency/recovery phase and post-recovery/delayed phase. These circumstances are described in detail with case studies. This classification of situations is important as different public health messages are more appropriate at different phases of a disaster. The burden of disease from poisoning caused by each potential source and at each phase of a disaster is different. CO poisoning is not compulsory and deaths associated with a flood but delayed for a period of months, for example due to a damaged boiler, may never be attributed to the flood as surveillance often ends once the floodwaters recede. The problem of under-reporting is crucial to our understanding of flooding-related poisoning. The indoor use of portable generators, cooking and heating appliances designed for use outdoors during periods of loss of mains power or gas is a particular problem. In the recovery phase, equipment for pumping, dehumidifying and drying out of properties poses a new risk. In the long term, mortality and morbidity associated with the renewed use of boilers which may have suffered covert damage in flooding is recognised but very difficult to quantify. Papers evaluating interventions were not found and where literature exists on prevention of CO poisoning in disaster situations, it is from the USA. Conclusions This paper for the first time describes the different risks of CO poisoning posed by the different phases of a disaster. There is a specific need to recognise that any room in a building can harbour a CO emitting appliance in flooding; wood burners and rarely used chimney flues may become particularly problematic following a flood. Recommendations 1) Public health workers and policy makers should consider establishing toolkits using the CDC toolkit approach; the acceptability of any intervention must be evaluated further to guide informed policy. 2) CO poisoning must form part of syndromic and event based surveillance systems for flooding and should be included in measures of the health impact of flooding. 3) CO monitors in the domestic environment should be sited not only in proximity to known CO emitters but also in locations where mobile or short term CO emitting appliances may be placed, including woodburners and infrequently used fireplaces.
    No preview · Article · Jul 2014 · PLoS Currents

  • No preview · Article · Jan 2012
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    ABSTRACT: Unintentional, non-fire-related (UNFR) carbon monoxide (CO) poisoning is a leading cause of poisoning in the United States. A comprehensive national CO poisoning surveillance framework is needed to obtain accurate estimates of CO poisoning burden and guide prevention efforts. This article describes the current national CO poisoning surveillance framework and reports the most recent national estimates. We analyzed mortality data from the National Vital Statistics System multiple cause-of-death file, emergency department (ED) and hospitalization data from the Healthcare Cost and Utilization Project's Nationwide Emergency Department Sample and Nationwide Inpatient Sample, hyperbaric oxygen treatment (HBOT) data from HBOT facilities, exposure data from the National Poison Data System, and CO alarm prevalence data from the American Housing Survey and the National Health Interview Survey. In the United States, 2,631 UNFR CO deaths occurred from 1999 to 2004, an average of 439 deaths annually. In 2007, there were 21,304 (71 per one million population) ED visits and 2,302 (eight per one million population) hospitalizations for confirmed cases of CO poisoning. In 2009, 552 patients received HBOT, and from 2000 to 2009, 68,316 UNFR CO exposures were reported to poison centers. Most nonfatal poisonings were among children (<18 years of age) and females; hospitalizations and deaths occurred more frequently among males and elderly people (>65 years of age). More poisonings occurred during winter months and in the Midwest and Northeast. UNFR CO poisoning poses a significant public health burden. Systematic evaluation of data sources coupled with modification and expansion of the surveillance framework might assist in developing effective prevention strategies.
    No preview · Article · Sep 2012 · Public Health Reports
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