Poison Control Centers Role in Glow Product-Related Outbreak Detection: Implications for Comprehensive Surveillance System

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1 BRIEF REPORT Poison Control Centers Role in Glow Product-Related Outbreak Detection: Implications for Comprehensive Surveillance System Alvin F. Chu, MA, MPH, EdD; Steven M. Marcus, MD;, Bruce Ruck, PharmD. New Jersey Poison Information and Education System. Department of Preventive Medicine and Community Health/Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey Correspondence: Alvin F. Chu MA, MPH, EdD New Jersey Poison Information and Education System 0 Bergen Street Newark, New Jersey USA achu@njpies.org Keywords: early detection; glow products; Halloween; National Poison Data System (NPDS); New Jersey Poison Information and Education System (NJPIES); outbreaks; poison control centers; syndromic surveillance system Abbreviations: AAPCC = American Association of Poison Control Centers NJPIES = New Jersey Poison Information and Education System NPDS = National Poison Data System PCCs = poison control centers Received: 0 January 008 Accepted: May 008 Web publication: January 009 Abstract Introduction: The development of syndromic surveillance systems to detect bioterrorist attacks and emerging infectious diseases has become an important and challenging goal to many governmental agencies and healthcare authorities. This study utilized the sharp increase of glow product-related calls to demonstrate the utility of poison control data for early detection of potential outbreaks during the week of Halloween in 00. Methods: A review was conducted of the electronic records of exposures reported to the New Jersey Poison Information and Education System (NJPIES) Poison Control Hotline from 00 through 00 with generic code number 000 (glow products) set by the American Association of Poison Control Centers (AAPCC). Key information such as age, gender, time of the call, exposure reason, clinical effects, and medical outcomes along with telephone number, zip code, and county location were used in the analyses to determine the extent of the outbreak. Results: Analyses included a total of 9 glow product-related calls during the week of Halloween in 00 with a single-day high of 59 calls on Halloween Day. More than 90% of the glow product exposures were in children 0 years of age. The glow product-related calls on Halloween Day increased from calls in 00 to 59 calls in 00, a % increase during a six-year period. Conclusions: Poison control centers in the United States are equipped with a unique and uniform input data collection system the National Poison Data System that provides an important data source in the development of a comprehensive surveillance system for early outbreak detection. Chu AF, Marcus SM, Ruck B: Poison Control Centers role in the glow product-related outbreak detection: Implications for comprehensive surveillance system. Prehospital Disast Med 009;():8. Introduction The [US] Centers for Disease Control and Prevention (CDC) defines public health surveillance as the ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality and to improve health. In this context, the detection of outbreaks in the existing surveillance system relies on cases reported through the National Electronic Telecommunications System for Surveillance (NETSS). Reports to this system come from physicians and laboratories, and are intended to alert health and safety authorities about the unusual increase of disease occurrence and frequencies. This system is the primary means for detecting outbreaks. With recent increased concerns regarding the early detection of a bioterrorist attack and emerging infectious diseases, the development of real-time, or near real-time syndromic surveillance systems has become an important, yet challenging goal for many governmental agencies and healthcare authorities. Methods to detect outbreaks vary and may range from approaches such as collecting chief complaints on electronic logs from emergency depart- Prehospital and Disaster Medicine Vol., No.

2 Chu, Marcus, Ruck 9 ments to monitoring the sales of diarrheal drugs at local pharmacies. Some non-traditional ways, such as tracking school or work absenteeism or counting the numbers of people who cough on video cameras in public areas have been tested as well, and some of them have been deployed. 5 A number of studies have suggested that Poison Control Centers (PCCs) may reduce the number of unnecessary emergency department visits and decrease healthcare costs. 8 0 In addition, poison centers could play an important role in outbreak detection. This stems from the fact that poison center data are first-hand exposure data as they are reported directly by the patient or someone who cared for the patient at the time of the incident. Therefore, poison data may contain unique information that may not be available otherwise, and may facilitate detecting outbreaks at a relatively early stage. Derby et al investigated foodborne illness-related calls from a poison control center and found no match with laboratory-confirmed cases reported to the county health department. They concluded that PCC calls were not duplicative of the county health department s reports and suggested that these are two independent databases. Therefore, PCCs represent an additional data source to the prospective surveillance systems. Poison control centers collect many key data elements that can be used for outbreak detection and investigation. The PCC database contains fields such as the date and time of call, age, gender, telephone number, zip code and county of the patient/caller, exposure reason, exposure site, and substances involved. The clinical effect and medical outcomes of the exposure are other variables in the poison data that provide important information to detect outbreak at the early stage, or to conduct a follow-up investigation after the outbreak already had occurred. To demonstrate the utility of poison control data for detecting disease outbreaks, an unusual increase of glow product-related (glow sticks, necklaces, or bracelets) calls to the New Jersey Poison Information and Education System during Halloween week 00 is investigated. Methods The New Jersey Poison Information and Education System (NJPIES) is one of the PCCs certified by the American Association of Poison Control Centers (AAPCC) in the US, and it is the only poison control center in the state of New Jersey. With trained physicians, pharmacists, and nurses, NJPIES administers a -hour per day, seven-day per week, toll-free telephone hotline that provides management, education and consultation, and research concerning poisons and drugs for the general public, as well as medical communities and law enforcement agencies throughout the state. Using the computerized system National Poison Data System (NPDS) NJPIES collects information on each reported case of human poisoning exposure, including basic demographics, street address or location, reason of exposure and exposure substance, clinical effects, clinical management, and medical outcome of the affected individual. For the purpose of this study, electronic records from NJPIES collected during the week of Halloween, 00 were reviewed. All records with an AAPCC generic code number 000 (glow products) reported to NJPIES were selected. In order to delineate the extent of increase of the call volume, the number of the glow product-related calls were compared monthly, weekly, and daily from 00 to 00. Results Glow Products Outbreak of 00 During Halloween 00 ( October through 0 November), NJPIES received a total of 9 glow product-related calls. Of these, calls were received on Saturday, October (the weekend before Halloween), seven cases each on Sunday and Monday, cases were called in on the day before Halloween, 59 cases were reported on Halloween Day, and 9 calls came in on the day after Halloween (Figure ). Of these 9 calls, (9.9%) were human exposures and eight were pet-related exposures (seven dogs and one cat). Among the human exposure cases, 0 (5.8%) were children between years of age; (8.9%) were between the ages of 5 0 years; and seven (5.%) of the cases were 0 years. Age was not obtained for (.5%) of the cases. Gender was evenly distributed between the males (5; 9.%) and the females (; 50.%). Most exposures (0; 8.0%) occurred in the home, followed by (0.%) cases of exposure in the school setting. Five (.8%) cases were exposed in public areas and two cases did not specify the site of exposure. Nearly 95% of the calls were determined to be unintentional and six cases were classified as intentional misuse; all cases reported none or minimal clinical effects. Approximately 85% of the callers were either a mother, father, or grandparent to the patient and (0.%) callers identified themselves as a health care provider to the patients. On October (Saturday), the six-hour time period 5:0 hours (h) to :5 h was documented between the first and last glow product calls; on ober (a day before Halloween), a six-hour time period also was noted between the first and the last call. On the Halloween Day (Wednesday), the first call was received around :00 h and the last call at :00 a -hour time period. On 0 November,the calls continued to come in,by the end of the day NJPIES received 9 calls during this 5-hour time period. The weekday/weekend pattern also provided important information in this holiday-related outbreak. When Halloween Day occurred on a weekday (Monday through Thursday), a higher number of calls occurred during the weekend prior to Halloween Day (Table ). On the other hand, when Halloween occurred during the weekend (Friday through Sunday), it was less likely that an increase occurred during the weekdays. Retrospective View of Glow Product-Related Calls: Comparing glow product-related call volume by month between 00 through 00, the patterns are the same from January to December in each year with two significant increases occurring: one in July and the other in October (Figure ). Moreover, the number of glow-product calls seems to be on an increasing trend over the years during these two holidays (Table ). During the month of July, January February Prehospital and Disaster Medicine

3 0 Glow Product-Related Outbreak Detection Chu 009 Prehospital and Disaster Medicine Figure Number of glow product-related cases, October 00 00*, State of New Jersey *Data captured as of 0 November Sunday Monday Tuesday Wednesday Thursday Friday Saturday Oct Oct Oct Oct 8 Oct Oct 5 Oct 0 Nov 0 Oct 8 Oct 0 Oct 5 Oct 0 Nov 0 Oct 9 Oct Oct 5 Oct 0 Nov Oct 59 Oct 8 Oct Oct Oct 5 Oct 0 Nov 9 5 Oct 0 0 Nov Oct 0 8 Oct 8 Oct 9 Oct 5 Oct 5 Oct 0 0 Nov Oct Chu 009 Prehospital and Disaster Medicine Table Number of glow product-related cases: weekday/weekend pattern during one week prior to Halloween Day, State of New Jersey Prehospital and Disaster Medicine Vol., No.

4 Chu, Marcus, Ruck Chu 009 Prehospital and Disaster Medicine Figure Number of glow product-related cases by month, 00 00*, State of New Jersey *Data captured as of 0 November 00 Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total * ? Chu 009 Prehospital and Disaster Medicine Table Number of glow product-related cases by month, 00 00*, State of New Jersey *Data captured as of 0 November 00 the total number of the calls increased from 5 calls in 00 to 9 calls in 00 a % increase; similarly, in October, the total number of calls increased from 55 calls in 00 to 5 calls in 00 a 8% increase. Similar patterns also were observed on Halloween and the days before and after Halloween. On Halloween, there were calls reported to NJPIES in 00; however, in 00, 59 calls were received during that day a % increase when compared to 00. The number of the calls on ober and 0 November also increased by % and 550%, respectively, from 00 to 00. Discussion The results of this study demonstrated the ability of one PCC to detect an unusual pattern of poisoning exposures at an early stage of an outbreak. Normally, this center receives no more than five glow product-related calls per day. Occasionally, this number does reach as high as eight calls per day. During the week of 00 Halloween, NJPIES received a total of 9 glow product-related calls (including eight animal-related glow product calls). The findings of the current study demonstrate that the PCCs are strategically positioned to collect real-time data that may improve the early detection of outbreaks. In a relevant study, Foldy suggested a number of ways to improve information input and processing that can lead to a better surveillance system. Poison control centers throughout the US already are equipped with an unique and uniform input data collection system the National Poison Data System (NPDS). This system is maintained by the American Association of Poison Control Centers (AAPCC), and is the single largest database on poison January February Prehospital and Disaster Medicine

5 Glow Product-Related Outbreak Detection exposures in the US with > million reported poisoning cases annually; there are currently participating regional poison centers. The information in this system is collected in an electronic format and can be used immediately after it is entered. During the 00 glow product outbreak period, the PCCs staff closely monitored the development of the event by assessing the routine information collected within its database. Key information such as age, gender, exposure reason, clinical effects, and medical outcomes along with telephone number, zip code, and county location were analyzed in order to obtain a clear understanding of the outbreak and as to where and how the outbreak progressed. In addition, an was sent to other poison control centers throughout the country via the PoisonNet (an system that links all poison control centers in the US) to inquire about information of any unusual increase of the glow products in other states. Within four hours, more than six poison control centers responded with reports of a similar increase of glow products in their respective states. By the end of the week, nearly 0 poison control centers reported that they had experienced similar outbreaks dur- References. Centers for Disease Control and Prevention (CDC): Updated guidelines for evaluating public health surveillance system: recommendations from the guidelines working group. MMWR 00:50(No.RR-). Broome CV: Overview, policy, and systems Federal role in early detection preparedness systems. MMWR 005:5(Suppl); 9. Travers D, Barnett C, Ising A, Waller A: Timeliness of emergency department diagnoses for syndromic surveillance. Proc AMIA Symp 00;9.. Begier EM, Sockwell D, Branch LM, Davies-Cole JO, Jones LH, Edwards L, Casani JA, Blythe D: The National Capitol Region s Emergency Department Syndromic Surveillance System: Do chief complaint and discharge diagnosis yield different results? Emerg Infect Dis March 00. [cited 00 Nov 5]. Available at 5. Mostashari F, Fine A, Das D, Adams J, Layton M: Use of ambulance dispatch data as an early warning system for communitywide influenza like illness, New York City. J Urban Health 00;80(, suppl ):i5 i5. ing Halloween 00. This exercise further suggested that PCCs not only can accurately record and analyze outbreakrelated information collected locally, but also can obtain coordinate relevant information with other PCCs throughout the country. Conclusions The glow product outbreak on Halloween, 00 did not have a significant public health impact, in part because the chemical used in the glow products, dibutyl phthalate is considered to have a low acute toxicity. However, this outbreak investigation reveals the essential role of poison control centers to collect and provide important data during the early outbreak detection process, and in the development of more comprehensive surveillance systems. Acknowledgements The authors acknowledge the invaluable contribution of the poison specialist staff at the New Jersey Poison Information and Education System and a special note of thanks to Dr. Zdravko P. Vassilev for his review and feedback of this manuscript.. Heffernan R, Mostashari F, Das D, Besculides M, Rodriguez C, Greenko J, Steiner-Sichel L, Balter S, Karpati A, Thomas P, Phillips M, Ackelsberg J, Lee E, Leng J, Hartman J, Metzger K, Rosselli R,Weiss D: System descriptions New York City syndromic surveillance systems. MMWR 00:5(Suppl);.. Newton E. Video and click-stream data as surveillance tools. Presented at: the first national syndromic surveillance conference, September 00; New York, NY. 8. Marcus S, Chafee-Bahamon C, Arnold V, Lovejoy F: A regional poison control system. Effect on response to hypothetical poisoning. Am J Dis Child 98;8: Kelly N, Ellis M, Kirkland R, Holmes S Kozinetz C: Effectiveness of a poison center impact on medical facility visits. Vet Human Toxocol 99;9: Philips K, Homan R, Hiatt P, Luft H, Kearney T, Heard S, Olson K: The costs and outcomes of restricting public access to poison control centers. Results from a natural experiment. Med Care 998;: 80.. Derby MP, McNally J, Ranger-Moore J, Hulette L, Villar R, Hysong T, MacNeill E, Lebowitz M, Burgess J: Poison control center Based syndromic surveillance for foodborne illness. MMWR 005:5(Suppl);5 0.. Foldy SL: Linking better surveillance to better outcomes. MMWR 00:5(Suppl);. Prehospital and Disaster Medicine Vol., No.