Poison Control Centers and Toxicosurveillance: Real-time National Surveillance for Outbreaks of Chemical-Associated Illn

1. Poison Control Centers and Toxicosurveillance: Real-time National Surveillance for Outbreaks of Chemical-Associated Illness Joshua G Schier MD Commander, US Public Health Service Medical Toxicologist Centers for Disease Control and Prevention National Center for Environmental Health

2. Continuing Education Credits DISCLAIMER:In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. CDC, our planners, and the presenters for this seminar do not have financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or product under investigational use.

3. Poison Control Centers Poison Control Centers (PCCs) 61 PCCs over the United States Local State Multi-state

4. Poison Control Centers

5. Poison Control Centers Routine staffing by specialists in poison information (SPI�s) Pharmacists Nurses Physicians Advanced clinical toxicology training Managing Director Medical Director Board certified in Medical Toxicology

6. Poison Control Centers

7. Poison Control Centers More than 4.2 million calls in 2007 2.6 million human exposure calls 1.6 million information calls Drug interactions, teratogenicity, toxicity, adverse reactions, poison prevention, weapons of mass destruction More than 132,000 animal calls More than 4.2 million follow-up calls to confirm patient safety, provide additional information, and obtain outcome data

9. Poison Control Centers Data Collection Primary responsibility of SPIs is clinical case management Data entered into local server as caller provides it Basic demographic data (name, age, zip code, etc�) Clinical data 131 pre-coded clinical effects (signs and symptoms) 72 pre-coded treatment, decontamination and management options

10. Poison Control Centers Data Collection Examples of types of data: patient age substances involved route of exposure reason for the exposure location of the event clinical effects treatment level and site of care medical outcome Comment box (not uploaded)

11. Poison Control Centers Data management Upload in real-time to national poison center database American Association of Poison Control Centers Formerly the, �Toxic Exposure Surveillance System (TESS)� Currently the, �National Poisoning Data System (NPDS)� All 61 of these PCCs contribute data to AAPCC

12. NPDS Data Flow

13. What is NPDS? NPDS monitors and analyzes real-time data from individual poison control centers, to detect intentional and unintentional chemical exposures and illnesses

14. Poison Control Centers Utility of NPDS Store reports of cases from calls Only comprehensive poisoning surveillance database in the US Early identification of hazards (demographics) Focus prevention education Guide clinical research (toxicity of a drug) Post marketing surveillance Regulatory agencies to support/refute regulatory actions Identify trends Both in known exposures and� New types of exposures�.

15. Poison Control Centers Gamma-hydroxybutyric acid (GHB) Transient coma Bradycardia Apnea Came to light as the result of poison center-based observations MMWR 1990;39(47):861-863

16. Toxicosurveillance In 2003�. Charge to CDC to create a national chemical terrorism surveillance system Collaborative effort between AAPCC and CDC to use NPDS for this purpose Toxicosurveillance is born�.

17. Toxicosurveillance Goals Improve public health surveillance for chemical exposures Identify early markers of chemical events (including characteristic symptom complexes, temporal and regional increases in hospitalizations, and sudden increases in case frequency or severity) with the objective of providing a rapid and appropriate public health response Track ongoing events

18. Identifying Outliers and Aberrations The remarkable temporal consistency of NPDS data allows detection of outliers and aberrations These aberrations could represent: Chemical or bioterrorism incidents Contaminated products New drug or product hazards Emerging drugs of abuse

25. NPDS Toxicosurveillance Call volume surveillance Hourly Each local poison control center and national Threshold: historical baseline average + 3 SDs Clinical effect surveillance Daily national cumulative total of each clinical effect Threshold: historical baseline average + 2 SDs

26. NPDS Toxicosurveillance Case-based surveillance Collections of clinical effects for specific agents Limited to the 131 clinical effects in the system Tracking (product)

27. Toxicosurveillance

28. National Poisoning Data System 2006-2007 Complete rebuild of the system Funded through CDC Enhanced capability for data management Incorporating GIS functions Local centers have access to their data AAPCC and CDC have access to all data for toxicosurveillance purposes

29. National Poison Data System (NPDS)

30. Outlier Analysis Routine NPDS surveillance Outliers analyzed by AAPCC Toxicosurveillance Team Example of an clinical effect email alert with analysis below

31. Clinical Effect Outlier Example

32. NPDS � Monitoring Call volume and clinical effect monitoring performed at level of AAPCC AAPCC Toxicosurveillance Team responsible for investigation for all �alerts� (outliers) Follow-up with local poison control centers Monitor trends Identify potential events of public health significance Email correspondence with CDC and AAPCC personnel about outliers and explanations Located at different locations around the country

33. NPDS � CDC Team Multi-disciplinary, CDC Toxicosurveillance Team Epidemiology, statistics, medical toxicology Can do our own data searches for events of public health significance Create our own case definitions (call volume or clinical effect based surveillance) as needed for outbreaks of chemical associated illness Mainly clinical effects-based case definitions

34. Inside NPDS

35. NPDS � Reports

36. NPDS: Case-based Definitions

37. NPDS: Case-based Definitions

38. NPDS: Case-based Definitions

39. NPDS: Case-based Definitions Ricin in Nevada (2008)

40. NPDS: Case-based Definitions Human AND Dyspnea AND Cough/choke AND Respiratory arrest OR Pulmonary edema OR X-ray findings OR Excess secretions OR Coma AND Exposure

41. NPDS: Case-based Definitions Selenium in dietary supplements (2008)

42. NPDS: Case-based Definitions Human AND Exposure AND Ingestion AND Diarrhea OR Nausea AND Pain (not dermal, GI, ocular) OR Headache OR Muscle weakness OR Peripheral neuropathy OR Dietary supplement/homeopathic: unknown OR Multi-mineral dietary supplement OR Multi-mineral, multi-herbal dietary supplement OR Other amino acid dietary supplement

43. NPDS � Call Volume

44. NPDS � Call Volume

45. Example 1 - 2003

46. Sunday afternoon 30+ attendees 16 ill Nausea, vomiting, diarrhea �Funny tasting coffee� or bitter No kids were ill (drank fruit punch) Arsenic Poisonings: New Sweden, Maine

47. Brief timeline Day 1 1500 � First case to the ED Astute physician notified the infection control staff 1938: First call to PCC (Infection Control staff) Day 2 0300: Toxicologist paged 1400: TESS updated 2000: Arsenic identified in coffee & urine Mobilization of antidote stockpiles

48. Example 2 � Call Volume Outliers Methane exposure: N = 6, residence Riot control agents: multiple events Cyclohexamine exposure: N=11, workplace Terrorism exercises (TOPOFF)

49. Conclusions (Goals) Primary utility of NPDS in toxicosurveillance Improve public health surveillance for chemical exposures Identify early markers of chemical events with the objective of providing a rapid and appropriate public health response Track ongoing events Limitations Questionable utility for identification of a sentinel event Based on a voluntary, passive reporting system

50. Future Plans Increased collaboration between CDC and toxicosurveillance team Development of protocols for reviewing alerts and disseminating information Evaluate new algorithms Integration with BioSense Addition of GIS capability

51. Acknowledgements CDC Amy Wolkin MSPH Carolyn Monteilh PhD Colleen Martin MPH Adrianne Holmes MPH James Lando MD MPH AAPCC James R. Hirt MBA Stuart E. Heard PharmD Alvin C. Bronstein MD Douglas J. Borys PharmD Blaine Benson PharmD Richard Thomas PharmD

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