2013 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 31st Annual Report

1WARNING: Comparison of exposure or outcome data from previous AAPCC Annual Reports is problematic. In particular, the identification of fatalities (attribution of a death to the exposure) differed from pre-2006 Annual Reports (see Fatality Case Review—Methods). Poison center death cases are described as all cases resulting in death and those determined to be exposure-related fatalities. Likewise, Table 22 (Exposure Cases by Generic Category) since year 2006 restricts the breakdown including deaths to single-substance cases to improve precision and avoid misinterpretation.

2This is the 31st Annual Report of the American Association of Poison Control Centers’ (AAPCC; http://www.aapcc.org) National Poison Data System (NPDS).(1) On 1 January 2013, fifty-seven regional poison centers (PCs) serving the entire population of the 50 United States, American Samoa, District of Columbia, Federated States of Micronesia, Guam, Puerto Rico, and the US Virgin Islands submitted information and exposure case data collected during the course of providing telephonic patient-tailored exposure management and poison information.

3NPDS is the data warehouse for the nation's 57 PCs. PCs place emphasis on exposure management, accurate data collection and coding, and responding to the continuing need for poison related public and professional education. The PC's health care professionals are available free of charge to users, 24-hours a day, every day of the year. PCs respond to questions from the public, health care professionals, and public health agencies. The continuous staff dedication at the PCs is manifest as the number of exposure, and information call encounters exceeds 3.0 million annually. PC encounters involve either an exposed human or animal (exposure call) or a request for information with no person or animal exposed to any foreign body, viral, bacterial, venomous, or chemical agent or commercial product (information call).

4The NPDS products database contains over 400,000 products ranging from viral and bacterial agents to commercial chemical and drug products. The product database is maintained and continuously updated by data analysts at the Micromedex Poisindex®System (Micromedex Healthcare Series [Internet database]; Greenwood Village, CO: Truven Health Analytics). A robust generic coding system categorizes the products data into 1,081 generic codes. These generic codes collapse into Nonpharmaceutical (562) and Pharmaceutical (519) groups. These two groups are divided into Major (68) and Minor (172) categories. The generic coding schema undergoes continuous improvement through the work of the AAPCC—Micromedex Joint Coding Group. The group consists of AAPCC members and editorial and lexicon staff working to meet best terminology practices. The generic code system provides enhanced report granularity as reflected in Table 22. The following 30 generic codes were introduced in 2013:

5Because the new codes were added at different times during the year, the numbers in Table 22 for these generic codes do not reflect the entire year. For completeness, certain codes of these categories require customized data retrieval until these categories have been in place for a year or more.

6Fifty-seven participating centers submitted data to AAPCC through 30 September, 2013, when one participating center closed with its calls picked up by another PC in its state, leaving 56 participating centers as of 31 December 2013.Fifty-four centers (95%) were accredited by AAPCC as of 1 July 2013. The entire population of the 50 states, American Samoa, the District of Columbia, Federated States of Micronesia, Guam, Puerto Rico, and the US Virgin Islands was served by the US PC network in 2013.(2,3,4,5).

7The average number of human exposure cases managed per day by all US PCs was 5,995. Similar to other years, higher volumes were observed in the warmer months, with a mean of 6,365 cases per day in July compared with 5,424 per day in December. On average, US PCs received a call about an actual human exposure every 14.4 seconds.

8Most PC operation management, clinical education, and instruction are directed by managing directors (most are PharmDs and RNs with American Board of Applied Toxicology [ABAT] board certification). Medical direction is provided by medical directors who are board-certified physician medical toxicologists. At some PCs, the managing and medical director positions are held by the same person.

9Calls received at US PCs are managed by health care professionals who have received specialized training in toxicology and managing exposure emergencies. These providers include medical and clinical toxicologists, registered nurses, doctors of pharmacy, pharmacists, chemists, hazardous materials specialists, and epidemiologists. Specialists in Poison Information (SPIs) are primarily registered nurses, PharmDs, and pharmacists who direct the public to the most appropriate level of care while also providing the most up-to-date management recommendations to health care providers caring for exposed patients. They may work under the supervision of a Certified Specialist in Poison Information (CSPI). SPIs must log a minimum of 2,000 calls over a 12-month period to become eligible to take the CSPI examination for certification in poison information. Poison information providers (PIPs) are allied health care professionals. They manage information-type and low acuity (non-hospital) calls and work under the supervision of a CSPI. Of note is the fact that no nursing or pharmacy school offers a toxicology curriculum designed for PC work and SPIs must be trained in programs offered by their respective PC. PCs undergo a rigorous accreditation process administered by the AAPCC and must be reaccredited every 5 years.

10Launched on 12 April 2006, NPDS is the data repository for all of the US PCs. In 2013, all 57 US PCs uploaded case data automatically to NPDS. All PCs submitted data in near real-time, making NPDS one of the few operational systems of its kind. PC staff record calls contemporaneously in 1 of 4 case data management systems. Each PC uploads case data automatically. The time to upload data for all PCs is 8.08 [7.10, 11.63] (median [25%, 75%]) minutes creating a near real-time national exposure database and surveillance system.

11The web-based NPDS software facilitates detection, analysis, and reporting of NPDS surveillance anomalies. System software offers a myriad of surveillance uses allowing AAPCC, its member centers, and public health agencies to utilize NPDS US exposure data. Users are able to access local and regional data for their own areas and view national aggregate data. Custom surveillance definitions are available along with ad hoc reporting tools. Information in the NPDS database is dynamic. Each year the database is locked prior to extraction of annual report data to prevent inadvertent changes and ensure consistent, reproducible reports. The 2013 database was locked on 27 October 2014 at 17:00 EDT.

12The information in this report reflects only those cases that are not duplicates and classified by the PC as CLOSED. A case is closed when the PC has determined that no further follow-up/recommendations are required or no further information is available. Exposure cases are followed to obtain the most precise medical outcome possible. Depending on the case specifics, most calls are “closed” within a few hours of the initial call. Some calls regarding complex hospitalized patients or cases resulting in death may remain open for weeks or months while data continue to be collected. Follow-up calls provide a proven mechanism for monitoring the appropriateness of management recommendations, augmenting patient guidelines and providing poison prevention education, enabling continual updates of case information as well as obtaining final/known medical outcome status to make the data collected as accurate and complete as possible.

13All tables except Tables 3B and 17B were generated directly by the NPDS web-based application and can thus be reproduced by each center. The figures and statistics in Tables 3B and 17B were created using SAS JMP version 9.0.0 (SAS Institute, Cary, NC) on summary counts generated by the NPDS web-based application.

14As previously noted, all of the active US PCs upload case data automatically to NPDS. This unique near real-time upload is the foundation of the NPDS surveillance system. This makes possible both spatial and temporal case volume and case based surveillance. NPDS software allows creation of volume and case-based definitions. Definitions can be applied to national, regional, state, or ZIP code coverage areas. Geocentric definitions can also be created. This functionality is available not only to the AAPCC surveillance team, but to every PC. PCs also have the ability to share NPDS real-time surveillance technology with external organizations such as their state and local health departments or other regulatory agencies. Another NPDS feature is the ability to generate system alerts on adverse drug events and other drug or commercial products of public health interest like contaminated food or product recalls. Thus, NPDS can provide real-time adverse event monitoring and surveillance of resilience response and situational awareness.

15Surveillance definitions can be created to monitor a variety of volume parameters or case-based definitions on any desired substance or commercial product in the Micromedex Poisindex products database and/or set of clinical effects or other parameters. The products database contains over 400,000 entries. Surveillance definitions may be constructed using volume or case-based definitions with a variety of mathematical options and historical baseline periods from 1 to 13 years. NPDS surveillance tools include the following:

16Volume Alert Surveillance Definitions

17Total Call Volume

18Human Exposure Call Volume

19Animal Exposure Call Volume

20Information Call Volume

21Clinical Effects Volume (signs and symptoms, or laboratory abnormalities)

22Case-Based Surveillance Definitions utilizing various NPDS data fields linked in Boolean expressions

23Substance

24Clinical Effects

25Species

26Medical Outcome and Others

27Syndromic Surveillance Definitions allow Boolean-based definitions utilizing various NPDS data fields to be run based on historical trends for user-defined periods of interest.

28Incoming data are monitored continuously and anomalous signals generate an automated email alert to the AAPCC's surveillance team or designated PC or public health agency staff. These anomaly alerts are reviewed daily by the AAPCC surveillance team, the PC, or the public health agency that created the surveillance definition. When reports of potential public health significance are detected, additional information is obtained via the NPDS surveillance correspondence system or phone as appropriate from reporting PCs. The PC then alerts their respective state or local health departments. Public health issues are brought to the attention of the Health Studies Branch, National Center for Environmental Health, Centers for Disease Control and Prevention (HSB/NCEH/CDC). This unique near real-time tracking ability is a unique feature offered by NPDS and the PCs.

29Clinical and medical toxicologists of the AAPCC surveillance team review surveillance definitions on a regular basis to fine-tune the queries. CDC, as well as State and local health departments with NPDS access as granted by their respective PCs, also have the ability to create surveillance definitions for routine surveillance tasks or to respond to emerging public health events.

30NPDS fatality cases can be recorded as DEATH or DEATH (INDIRECT REPORT). Medical outcome of death is given by direct report. Deaths (indirect reports) are deaths that the PC acquired from medical examiners or media, but did not manage nor answer any questions related specifically to that death.

31Although PCs may report death as an outcome, the death may not be the direct result of the exposure. We define exposure-related fatality as a death judged by the AAPCC Fatality Review Team to be at least contributory to the exposure. The definitions used for the Relative Contribution to Fatality (RCF) classification are given in Appendix B and the methods for selecting abstracts for publications are described in Appendix C. For details on the AAPCC fatality review process, see the 2008 annual report.(1)

32A focused Pediatric Fatality Review team, comprised of 4 pediatric toxicologists, evaluated cases of patients of 19 years and under. The panel reviewed the documentation of all such cases, with specific focus on the conditions behind the poisoning exposure and on finding commonality which might inform efforts at prevention. The pediatric fatality cases reviewed exhibited a bimodal age distribution. Exposures causing death in children ≤ 5 years of age were mostly coded as “Unintentional-General”, while those in ages over 12 years were mostly as “Intentional”. Often the Reason Code did not capture the complexities of the case. For example, there were few mentions of details such as the involvement of law enforcement or child protective services. While there were some complete and informative reports, in many narratives the circumstances which preceded the exposure thought responsible for the death were unclear or absent. In response to these findings, the pediatric fatality review team developed and distributed Pediatric Narrative Guidelines, with specific attention to the root cause of these cases. PCs are requested to heed these guidelines and the need for a more in-depth investigation of “causality.”

33Data from 806,347 information calls to PCs in 2013 (Table 1C) was transmitted to NPDS, including calls in optional reporting categories such as prevention/safety/education (24,249), administrative (25,878), and caller referral (47,682).

34Figure 2 shows that all drug ID calls decreased dramatically in mid-2009, again in late 2010 and late 2011, and continue to decrease in 2012 and 2013. Law enforcement drug ID calls also showed a decline. The most frequent information call was for drug ID, comprising 408,711calls to PCs during the year. Of these, 239,364 (58.6%) were identified as drugs with known abuse potential; however, these cases were categorized based on the drug's abuse potential without any knowledge of whether abuse was actually intended.

35While the number of drug information calls decreased 21.4% from 2012 (144,267 calls) to 2013 (113,378 calls), the distribution of these call types remained steady at 14.1% of all information request calls. The most common drug information requests were about drug–drug interactions, followed by other drug information, therapeutic use and indications, questions about dosage, and inquiries of adverse effects. Environmental inquiries comprised 2.3% of all information calls. Of these environmental inquiries, specific questions related to cleanup of mercury (thermometers and other) remained the most common followed by questions involving pesticides.

36Of all the information calls, poison information comprised 7.0% of the requests with inquiries involving general toxicity the most common followed by questions involving food preparation practices, safe use of household products, and plant toxicity.

37In 2013, the participating PCs logged 3,060,122 total encounters including 2,188,013 closed human exposure cases (Table 1A), 59,496 animal exposures (Table 1B), 806,347 information calls (Table 1C), 6,116 human confirmed non-exposures, and 150 animal confirmed non-exposures. An additional 570 calls were still open at the time of database lock. The cumulative AAPCC database now contains more than 60 million human exposure case records (Table 1A). A total of 16,392,826 information calls have been logged by NPDS since the year 2000.

38Figure 1 shows the human exposures, information calls and animal exposures by day since 1 January 2001. Second-order (quadratic) least squares regression of these data shows a statistically significant departure from linearity (declining rate of calls since mid-2007) for human exposure calls. Information calls are best described by a smoothing spline fit, and animal exposure calls have likewise been declining since mid-2005.

39A hallmark of PC case management is the use of follow-up calls to monitor case progress and medical outcome. US PCs made 2,515,811 follow-up calls in 2013. Follow-up calls were made in 46.1% of human exposure cases. One follow-up call was made in 22.0% of human exposure cases, and multiple follow-up calls (range, 2–121) were placed in 24.1% of cases.

40Figure 3 shows a graphic summary and analyses of Health Care Facility (HCF) exposure and HCF information calls. HCF exposure calls slightly departed from linearity but continued to increase at a steady rate, while the rate of HCF information calls has been declining since early 2005. This increasing use of the PCs for the more serious exposures (HCF calls) is important in the face of the decline in exposure and information calls. The 2 May 2006 exposure data spike on the figure was the result of 602 children in a Midwest school reporting a noxious odor which caused anxiety, but resolved without sequelae.

41Tables 22A (Nonpharmaceuticals) and 22B (Pharmaceuticals) provide summary demographic data on patient age, reason for exposure, medical outcome, and use of a health care facility for all 2,188,013 human exposure cases, presented by substance categories. The Pharmaceuticals category includes both licit and illicit drugs.

42Column 1: Name of the major, minor generic categories and their associated generic codes.

43Column 2: Number of Case Mentions (All Exposures) in grey shading, displays the number of times the specific generic code was reported in all human exposure cases. If a human exposure case has multiple instances of a specific generic code, it is counted only once.

44Column 3: Single Substance Exposures; this column was previously named “No. of Single Exposures” and was renamed in the 2009 report for clarity. This column displays the number of human exposure cases that identified only one substance (one case, one substance).

45The succeeding columns (Age, Reason, Treatment Site, And Outcome) show selected detail from these single-substance exposure cases. Death cases include both cases that have the outcomes of Death or Death (indirect report).These death cases are not limited by the relative contribution to fatality.

46Tables 22A and 22B restrict the breakdown columns to single-substance cases. Prior to 2007, when multisubstance exposures were included, a relatively innocuous substance could be mentioned in a death column when, for example, the death was attributed to an antidepressant, opioid, or cyanide. This subtlety was not always appreciated by the user of this table. The restriction of the breakdowns to single-substance exposures should increase precision and reduce misrepresentation of the results in this unique by-substance table. Single-substance cases reflect the majority (89.1%) of all exposures. In contrast, only 44.2% of fatalities are single substance exposures (Table 5).

47Tables 22A and 22B tabulate 2,575,837 substance exposures, of which 1,950,455 were single-substance exposures, including1,013,229 (52.0%) nonpharmaceuticals and 937,226 (48.0%) pharmaceuticals. In 19.6% of single- substance exposures that involved pharmaceutical substances, the reason for exposure was intentional, compared with only 3.6% that involved a nonpharmaceutical substance. Correspondingly, treatment in a health care facility was provided in a higher percentage of exposures that involved pharmaceutical substances (29.8%) compared with that of nonpharmaceutical substances (15.9%). Exposures to pharmaceuticals also had more severe outcomes. Of single-substance exposure-related fatal cases, 708 (70.7%) were pharmaceuticals compared with 293 (29.3%) nonpharmaceutical.

48The age and gender distribution of human exposures is outlined in Table 3. Children younger than 3 years were involved in 35.5% of exposures and children younger than 6 years accounted for approximately half of all human exposures (48.0%). Male predominance was found among cases involving children younger than 13 years, but this gender distribution was reversed in teenagers and adults, with females comprising the majority of reported exposures.

49As shown in Table 2, of the 2,188,013 human exposures reported, 71.8% of calls originated from a residence (own or other) but 93.5% actually occurred at a residence (own or other). Another 20.3% of calls were made from a HCF. Beyond residences, exposures occurred in the workplace in 1.6% of cases, schools (1.3%), health care facilities (0.3%), and restaurants or food services (0.2%).

50Exposure during pregnancy occurred in 7,384 women (0.3% of all human exposures). Of those with known pregnancy duration (n = 6,830), 31.5% occurred in the first trimester, 37.0% in the second trimester, and 31.5% in the third trimester. Most (73.9%) were unintentional exposures and 19.6% were intentional exposures. There was one death of a pregnant woman in 2013.

51Most human exposures, 1,922,316 (87.9%), were acute cases (single, repeated, or continuous exposure occurring over 8 hours or less) compared with 1,328 acute cases of 2,477 fatalities (53.6%). Chronic exposures (continuous or repeated exposures occurring over > 8 hours) comprised 2.1% (46,900) of all human exposures. Acute-on-chronic exposures (single exposure that was preceded by a continuous, repeated, or intermittent exposure occurring over a period of > 8 hours) numbered 188,899 (8.6%).

52The reason for most human exposures was unintentional (79.9%) with unintentional general (54.2%), therapeutic error (12.5%), and unintentional misuse (5.6%) of all exposures (Table 6A).

53Of the total 289,699 therapeutic errors, the most common scenarios for all ages included: inadvertent double dosing (28.2%), wrong medication taken or given (16.2%), other incorrect dose (13.6%), doses given/taken too close together (10.3%), and inadvertent exposure to someone else's medication (8.0%). The types of therapeutic errors observed are different for each age group and are summarized in Table 6B.

54Intentional exposures accounted for 16.2% of human exposures. Suicidal intent was suspected in 10.5% of cases, intentional misuse in 2.5%, and intentional abuse in 2.2%. Unintentional exposures outnumbered intentional exposures in all age groups with the exception of ages 13–19 years (Table 7). Intentional exposures were more frequently reported than unintentional exposures in patients aged 13–19 years. In contrast, of the 1,218 reported fatalities with RCF 1–3, the major reason reported for children ≤ 5 years was unintentional while most fatalities in adults (> 20 years) were intentional (Table 8).

55Ingestion was the route of exposure in 83.4% of cases (Table 9), followed in frequency by dermal (7.0%), inhalation/nasal (6.1%), and ocular routes (4.3%). For the 1,218 exposure-related fatalities, ingestion (80.9%), inhalation/nasal (10.2%), unknown (8.9%), and parenteral (5.1%) were the predominant exposure routes. Each exposure case may have more than one route.

56The NPDS database allows for the coding of up to 131 individual clinical effects (signs, symptoms, or laboratory abnormalities) for each case. Each clinical effect can be further defined as related, not related, or unknown if related. Clinical effects were coded in 810,259 (37.0%) cases (17.8% had 1 effect, 9.5% had 2 effects, 5.1% had 3 effects, 2.2% had 4 effects, 1.0% had 5 effects, and 1.4% had > 5 effects coded). Of the clinical effects coded, 77.8% were deemed related to the exposure, 9.9% were considered not related, and 12.3% were coded as unknown if related.

57The majority of cases reported to PCs were managed in a non-HCF (68.7%), usually at the site of exposure, primarily the patient's own residence (Table 10); 1.5% of cases were referred to a HCF but they refused referral. Treatment in a HCF was rendered in 27.5% of cases.

58Of the 601,642 cases managed in a HCF, 286,690(47.7%) were treated and released, 99,117(16.5%) were admitted for critical care, and 67,114(11.2%) were admitted to a noncritical unit.

59The percentage of patients treated in a HCF varied considerably with age. Only 11.8% of children ≤ 5 years and only 14.7% of children between 6 and 12 years were managed in a HCF compared with 54.1% of teenagers (13–19 years) and 41.7% of adults (age, ≥ 20 years).

60Table 11 displays the medical outcome of human exposure cases distributed by age. Older age groups exhibit a greater number of severe medical outcomes. Table 12 compares medical outcome and reason for exposure, and shows a greater frequency of serious outcomes in intentional exposures.

61The duration of effect is required for all cases which report at least one clinical effect and have a medical outcome of minor, moderate, or major effect (n = 503,501; 23.0% of exposures). Table 13 demonstrates an increasing duration of the clinical effects observed with more severe outcomes.

62Tables 14 and 15 outline the use of decontamination procedures, specific physiological antagonists (antidotes), and measures to enhance elimination in the treatment of patients reported in the NPDS database. These should be interpreted as minimum frequencies because of the limitations of telephone data gathering.

63Ipecac-induced emesis for poisoning continues to decline as shown in Tables 16A and 16B. Ipecac was administered in only 42 (0.0%) of pediatric exposures in 2013. The continued decrease in ipecac syrup use over the last 2 decades is likely a result of ipecac use guidelines issued in 1997 by the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists and updated in 2004.(6,7) In a separate report, the American Academy of Pediatrics not only concluded that ipecac should no longer be used routinely as a home treatment strategy, but also recommended disposal of home ipecac stocks.(8) A decline was also observed since the early 1990s for reported use of activated charcoal. While not as dramatic as the decline in use of ipecac, reported use of activated charcoal decreased from 3.7% of pediatric cases in 1993 to just 0.9% in 2013.

64Table 17A presents the most common 25 substance categories, listed by frequency of human exposure for cases with more serious outcomes (moderate, severe, and death). This ranking provides an indication where prevention efforts might be focused, as well as the types of serious exposures PCs regularly manage. It is relevant to know whether exposures to these substances are increasing or decreasing.

65To better understand these relationships, we examined exposures with more serious outcomes per year over the last 13 years for the change over time for each of the 68 major generic categories via least-square linear regression. The serious outcome exposure calls per year over this period were increasing for 39 and decreasing for 29, respectively, of the 68 categories. The change over time for the 13 yearly values was statistically significant (p < 0.05) for 45 of the 68 categories. Table 17B shows the 25 categories which were increasing most rapidly. Statistical significance of the linear regressions can be verified by noting the 95% confidence interval on the rate of increase excluding 0 for all, but 3 of the 25 categories. Figure 5 shows the linear regressions for the top 4 increasing categories in Table 17B.

66Tables 17C and 17D present exposure results for children and adults, respectively, and show the differences between substance categories involved in pediatric and adult exposures.

67Table 17E reports the 25 categories of substances most frequently involved in pediatric (≤ 5 years) fatalities in 2013.

68Table 17F reports the 25 drug ID categories most frequently queried in 2013, highlighting the value of drug ID information to the AAPCC, public health, public safety, and regulatory agencies. Internet-based resources do not afford the caller the option to speak with a health care professional if needed. Proper resources to continue this vital public service are essential, especially since the top 10 substance categories include antibiotics as well as drugs with widespread use and abuse potential such as opioids and benzodiazepines.

69Table 17G reports the 25 substance categories most frequently reported in exposures involving pregnant patients.

70Total encounters peaked in 2008 at 4,333,012 calls with 2,491,049 human exposure calls and 1,703,762 information calls. Total encounters decreased 9.3% from 3,373,025 in 2012 to 3,060,122 in 2013. Information calls decreased by 21.4% from 1,025,547 calls in 2012 to 806,347 in 2013, with a 26.8% decrease in drug identification calls and a 8.5 % decrease in HCF information calls. Human exposures decreased by 3.8% from 2,275,141 to 2,188,013 cases.

71Figure 4 shows the year-to-year change since 2000 as a percentage of year 2000 for human exposure calls broken down into cases with more serious outcomes (death, major effect, and moderate effect) and less serious outcomes [minor effect, no effect, not followed (non-toxic), not followed (minimal toxicity possible), unable to follow (potentially toxic), and unrelated effect]. Since 2000, cases with more serious outcomes have increased by 4.5% [95% CI (4.0%, 4.9%)] per year from 108,148 cases in 2000 to 171,583 cases in 2013. However, cases with less serious outcomes have consistently decreased since 2008 by 3.7% [95% CI (−4.4%, −3.1%)] per year from 2,339,460 in 2008 to 2,015,505 cases in 2013. This decrease in less serious exposures has driven the overall decrease in human exposures since 2008.

72Likewise, we see a consistent increase in exposure calls from HCFs (Figure 3) and for the more severe exposures (Figure 4), despite a decrease in calls involving less severe exposures.

73Table 19A shows the modest variation in the distribution of suicides and pediatric deaths over the past 2 decades as reported to the NPDS national database. Within the last decade, the percentage of exposures determined to be suspected suicides ranged from 30.3%% to 53.9%, and the percentage of pediatric cases has ranged from 1.5% to 3.2%.The relatively large change seen for 2011 and 2012 reflects the large increase in indirect death reports in those years. Analyses of suicides and pediatric deaths for direct and indirect reports are shown in Table 19B.

74Table 20 provides the number of times the specific plant was reported to NPDS (n = 46,376). The 25 most commonly involved plant species and categories account for 39.7% of all plant exposures reported. The top 3 categories in the table are essentially synonymous for unknown plant and comprise 12.8% (5,955/46,376) of all plant exposures. For several reasons, it was not possible to make a precise identification in these three groups. The top most frequent plant exposures where a positive plant identification was made were the following (descending order): Phytolacca americana (L.) (Botanic name), Spathiphyllum species (Botanic name), Cherry (Species unspecified), Ilex species (Botanic name), Philodendron (Species unspecified), Caladium species (Botanic name of all species of the genus caladium) and Malus species (Botanic name)

75A list of cases (Table 21) and summary of cases (Tables 4, 5, 8, 9, 18, and 22) are provided for fatal cases for which there exists reasonable confidence that the death was a result of that exposure (exposure-related fatalities). Tables 11, 12, and 19 list all deaths, irrespective of the RCF. Beginning in 2010, cases with outcome of Death, Indirect Report were not further reviewed by the AAPCC fatality review team, and the RCF was determined by the individual PC review team.

76There were 925 deaths (indirect) and 1,552 deaths. Of these 2,477 cases, 2,113 were judged to be exposure-related fatalities (RCF = 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory). The remaining 361 cases were judged as follows: 84 as RCF—probably not responsible; 34 as 5-clearly not responsible; and 246 as 6-unknown.

77Deaths are sorted in Table 21 according to the category, substance deemed most likely responsible for the death (Cause Rank), and then patient age. The Cause Rank permits the PC to judge 2 or more substances as indistinguishable in terms of cause, for example, 2 substances which appear equally likely to have caused the death could have Substance Rank of 1, 2 and Cause Rank of 1, 1. Additional agents implicated are listed below the primary agent in the order of their contribution to the fatality.

78As shown in Table 5, a single substance was implicated in 89.1% of reported human exposures, and 10.9% of patients were exposed to 2 or more drugs or products. The exposure-related fatalities involved a single substance in 538 cases (44.2%), 2 substances in 295 cases (24.2%), 3 in 152 cases (12.5%), and 4 or more in the balance of the cases.

79In Table 21, the Annual Report ID number [bracketed] indicates that the abstract for that case is included in Appendix C. The letters following the Annual Report ID number indicate: i = Death, Indirect report (occurred in 895, 42.4% of cases), p = prehospital cardiac and/or respiratory arrest (occurred in 462 of 2,113, 21.9% of cases), h = hospital records reviewed (occurred in 497, 23.5% of cases), and a = autopsy report reviewed (occurred in 1,230, 58.2% of cases). The distribution of NPDS RCF was as follows: 1 = Undoubtedly responsible in 572 cases (27.1%), 2 = Probably responsible in 1,344 cases (63.6%), and 3 = Contributory in 197 cases (9.3%). The denominator for these Table 21 percentages is 2,113.

80Table 4 presents the age and gender distribution for these 1,218 exposure-related fatalities (excluding death, indirect). The age distribution of reported fatalities shows an increase in deaths in children (< 20 years old) compared with that of the past years, with 99 cases representing 8.1% of fatalities, an absolute increase of 26 child fatalities and a 35.6% increase in that age group. The age distribution of reported fatalities in adults (age, ≥ 20 years) is similar to that of prior years with 1,115 of 1,218 (91.5%) fatal cases occurring in that age group and 4 (0.3%) of fatalities occurring in unknown age patients. While children ≤ 5 years were involved in the majority of exposures, the 29 deaths in this group comprised just 2.4% of the exposure-related fatalities. However, it is noted that this represented a 38% increase in fatalities over 2012. While most (67.2%) of the fatalities occurred in 20- to 59-year-old individuals, the percentage is slightly decreased from prior years.

81Table 21 lists each of the 2,113 human fatalities (including death, indirect report) along with all of the substances involved for each case. Please note that the substance listed in column 3 of Table 21 (alternate name) was chosen to be the most specific generic name based upon the Micromedex Poisindex product name and generic code selected for that substance. Alternate names are maintained in the NPDS for each substance involved in a fatality. The cross-references at the end of each major category section in Table 21 list all cases that identify this substance as other than the primary substance. This alternate name may not agree with the AAPCC generic categories used in the summary tables (including Table 22).

82Table 18 lists the top 25 minor generic substance categories associated with reported fatalities and the number of single substance exposure fatalities for that category—miscellaneous sedative/hypnotics/antipsychotics, miscellaneous cardiovascular drugs, opioids, and miscellaneous stimulants and street drugs lead this list followed by miscellaneous alcohols, acetaminophen combinations, acetaminophen alone, selective serotonin reuptake inhibitors, and miscellaneous fumes/gases/vapors. Note that Table 18 is sorted by all substances to which a patient was exposed (i.e., a patient exposed to an opioid may have also been exposed to 1 or more other products) and shows single-substance exposures in the right-hand column.

83The first-ranked substance (Table 21) was a pharmaceutical in 1,710 (80.9%) of the 2,113 fatalities. These 1,710 first-ranked pharmaceuticals included:

84690 analgesics (110 acetaminophen/hydrocodone, 109 methadone,106 acetaminophen, 98 oxycodone, 58 morphine, 34 salicylate, 26 fentanyl, 23 tramadol, and 20 opioid)

85414 stimulants/street drugs [255 heroin, 56 methamphetamine, 52 cocaine, and 15 amphetamines (hallucinogenic)]

86174 cardiovascular drugs (30 verapamil, 28 amlodipine, 18 cardiac glycoside, 15 diltiazem, 16 metoprolol, 11 carvedilol, and 11 propranolol)

87133 antidepressants (34 amitriptyline, 20 bupropion, 14 venlafaxine, 10 doxepin, 10 citalopram, and 8 lithium)

88100 sedative/hypnotic/antipsychotics (23 alprazolam, 20 quetiapine, 7 zolpidem, 6 benzodiazepine, and 5 diazepam)

89The exposure was acute in 1,183 (56.0%), A/C = acute on chronic in 282 (13.3%), C = chronic exposure in 98 (4.6%), and U = unknown in 550 (26.0%).

90A total of 1,204 tissue concentrations for 1 or more related analytes were reported in 582 cases. Most of these (1,197) involved fatalities with RCF = 1–3, and are listed in Table 21, while all tissue concentrations are available to the member centers through the NPDS Enterprise Reports. These 128 analytes included the following: 234 acetaminophen, 94 ethanol, 73 salicylate, 52 carboxyhemoglobin, 34 morphine, 27 alprazolam, 26 digoxin, 25 diphenhydramine, 25 oxycodone, 22 hydrocodone, 22 lithium, 22 methadone, 19 benzoylecgonine, and 19 morphine (free).

91Route of exposure was as follows: ingestion only in 1,322 cases (62.6%), inhalation/nasal in 135 cases (6.4%) and parenteral in 78 cases (3.7%). Most other routes were combination routes or unknown.

92The intentional exposure reason was: abuse in 863 cases (40.8%), suspected suicide in 691 cases (32.7%), and misuse in 48 cases (2.3%). Unintentional exposure reason was: environmental in 90 cases (4.3%), therapeutic error in 37 cases (1.8%), and misuse in 6 cases (0.3%). Adverse drug reaction was the reason in 47 (2.2%).

93Although children younger than 6 years were involved in the majority of exposures, they comprised 51 of 2,477 (2.1%) of fatalities. These numbers are similar to those reported since 1985 (Table 19A, all RCFs and includes indirect deaths). Table 8 (RCF 1–3, excludes indirect deaths) shows the percentage fatalities in children ≤ 5 years related to total pediatric exposures was 29/1,049,475 = 0.00276%. By comparison, 1,115/833,563 = 0.13% of all adult exposures involved a fatality. Of these 29 pediatric fatalities, 24 (82.8%) were reported as unintentional and 3 (10.3%) were coded as resulting from malicious intent (Table 8).

94The 33 fatalities in children ≤ 5 years in Table 21 (includes death, indirect reports, and RCF 1–3) included 14 pharmaceuticals and 19 nonpharmaceuticals. The first-ranked substances associated with these fatalities included smoke (9), disc battery (2), hydromorphone (2), methadone (2), amitriptyline (2), and 16 other substances (1 each).

95In the age range 6–12 years, there were 6 reported fatalities, 4 of which were unintentional environmental, 1 was intentional suspected suicide, and 1 was intentional abuse (Table 8). The 11 fatalities listed in Table 21 (includes death, indirect reports, and RCF 1–3) included 7 smoke, 2 carbon monoxide, 1 freon, and 1 methadone.

96In the age range of 13–19 years, there were 64 reported fatalities, an increase of 19 (42%) and included 57 intentional, 3 unintentional, 2 adverse reaction, and 2 unknown reason (Table 8). The 78 fatalities listed in Table 21 (includes death, indirect reports and RCF 1–3) included 67 pharmaceuticals and 11 nonpharmaceuticals. The first-ranked pharmaceuticals associated with these fatalities included heroin (4), acetaminophen (3), methadone (3), oxycodone (3), drug, unknown (3), acetaminophen/hydrocodone (2), diphenhydramine (2), metformin (2), alprazolam (2), quetiapine (2), amphetamine (hallucinogenic), 2C-E (2), methamphetamine (2), methylenedioxymethamphetamine (MDMA) (2), THC homolog (2), 4-acetoxy-N,N-dimethyltryptamine (2), amphetamine (2), amphetamine (hallucinogenic) (2) and the remainder with1 substance each. The first ranked nonpharmaceutical associated with these fatalities included: cyanide (3), carbon monoxide (2),ethanol (1), methanol (1), freon (1), substance (non-drug) unknown (1), aldicarb (1), and dinitrophenol (1).

97A total of 31deaths of pregnant women have been reported from the years 2000 through 2013. The majority (27 of 31) were intentional exposures (misuse, abuse, or suspected suicide). There was 1 death in pregnant women reported to NPDS in 2013.

98A key component of the NPDS surveillance system is the variety of monitoring tools available to the NPDS user community. In addition to AAPCC national surveillance definitions, 35 PCs utilize NPDS as part of their surveillance programs. The Centers for Disease Control and Prevention (CDC), 6 state health departments and 1 state police department run surveillance definitions in NPDS. Since Surveillance Anomaly 1, generated at 2:00 pm EDT on 17 September 2006, over 230,000 anomalies have been detected. More than 1,500 were confirmed as being of public health significance with PCs working collaboratively with their local and state health departments and in some instances the CDC on the public health issues identified.

99At the time of this report, 353 surveillance definitions run continuously, monitoring case and clinical effects volume and a variety of case-based definitions from food poisoning to nerve agents. These definitions represent the surveillance work by many PCs, state health departments, the AAPCC, and the Health Studies Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention (CDC).

100Automated surveillance continues to remain controversial as a viable methodology to detect the index case of a public health event. Uniform evaluation algorithms are not available to determine the optimal methodologies.(9) Less controversial is the benefit to situational awareness that NPDS can provide.(10) Typical NPDS surveillance data detects a response to an event rather than an event prediction. This aids in situational awareness and resilience during and after a public health event.

101A current example of the involvement of the PC system and NPDS can be seen in the following. In January 2010, the AAPCC introduced two generic codes for electronic cigarettes (e-cigarettes): one for the e-cigarette delivery system and one for the liquid nicotine refills. As the amount of nicotine in e-cigarettes and their refills were not initially regulated by the Food and Drug Administration or any states, they could represent a unique poisoning hazard. As the refills were not required to be sold in child resistant containers, the potentially large amount of nicotine in these products (some containing over 100 mg/ml) could potentially produce serious toxicity in both adults and children, if inhaled, swallowed or spilled on the skin. And although flavored cigarettes have been banned by the FDA since September 2009, there were no restriction on e-cigarette flavorings. Flavors such as black cherry, café mocha, peanut butter cup, and ice cream potentially represent an additional attraction to children.

102The first exposure to an e-cigarette product was noted in September 2010, with the first child exposure in November 2010. A gradual increase in the number of exposures occurred until the beginning of 2013 when a dramatic increase in the number of exposures to e-cigarettes and their refills was seen (Figure 6). The total number of nonpharmaceutical nicotine exposures has increased, driven primarily by exposures to e-cigarette products. E-cigarette exposure calls peaked in April 2014 and comprised 35% of all nicotine-related single exposure calls. In children, e-cigarettes now account for roughly 25% of exposures, while in other age groups, e-cigarettes exposures have surpassed other tobacco products and account for as many as 65% of exposures. E-cigarette exposures in children under age 5 have serious outcomes in only 1.9% of cases compared with 5.3% in other ages. A decline in exposures has been seen since April 2014, possibly reflecting increased scrutiny on e-cigarettes and increased state and local regulation. Please note that the data for 2014 are considered preliminary since the 2014 database is not locked.

103The exposure cases and information requests reported by PCs in 2013 do not reflect the full extent of PC efforts which also include poison prevention activities and public and health care professional education programs.

104NPDS exposure data may be considered as providing “numerator data”, in the absence of a true denominator; that is, we do not know the number of actual exposures that occur in the population. NPDS data include only those exposures which are reported to PCs.

105NPDS 2000–2013 call volume data clearly demonstrate a continuing decrease in total exposure calls. This decline has been apparent and increasing since mid-2007, and reflects the decreasing use of the PC for less severe exposures. However, in contrast, during this same period, exposures with a more severe outcome (death, major, moderate) and HCF calls have continued a consistent increase. Possible contributors to the declining PC access include declining US birth rates (especially since exposure rates are much higher in children ≤ 5 years of age), increasing use of text rather than voice communication, and increased use of and reliance on internet search engines and web resources. To meet our public health goals, PCs will need to understand and meet the public's 21st-century communication preferences. We are concerned that failure to respond to these changes may result in a retro-shift with more people seeking medical care for exposures that could have been managed at home by a PC. Likewise, minor exposures may progress to more severe morbidity and mortality because of incorrect internet information or no PC management. The net effect could be more severe poisoning outcomes because fewer people took advantage of PC services, with a resultant increased burden on the national health care infrastructure as may be reflected in the increased number of cases managed in a health care facility this year.

106NPDS statistical analyses indicate that all analgesic exposures including opioids and sedatives are increasing year over year. This trend is shown in Table 17B and Figure 5. NPDS data mirror CDC data that demonstrates similar findings.(10) Thus, NPDS provides a real-time view of these public health issues without the need for data source extrapolations.

107One of the limitations of NPDS data has been the perceived lack of fatality case volume compared with that of other reporting sources. However, when change over time is studied, NPDS is clearly consistent with other public health fatality analyses. One of the issues leading to this concern is the fact that medical record systems seldom have common output streams. This is particularly apparent with the various electronic medical record systems available. It is important to build a federated approach similar to the one modeled by NPDS to allow data sharing, for example, between hospital emergency departments and other medical record systems including medical examiner offices nationwide. Enhancements to NPDS can promote interoperability between NPDS and electronic medical records systems to better trend poison-related morbidity and mortality in the United States and internationally.

108Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the United States. The near real-time, always current status of NPDS represents a national public health resource to collect and monitor US exposure cases and information calls.

109Changes in encounters in 2013 shown in Figures 1, 3, and 4 include the following:

110total encounters (all exposure and information calls) decreased by 9.3%;

111all information calls decreased 21.4%, drug ID calls decreased 26.8%, and human exposures decreased 3.8%;

112HCF information calls decreased 8.5% and HCF exposures decreased 0.1% notwithstanding an overall steady increase since 2000;

113human exposures with less serious outcomes decreased 4.1%, while those with more serious outcomes (minor, moderate, major or death) increased 0.4% notwithstanding an overall 4.5% yearly increase since 2000;

114The categories of substance exposures in cases with more serious outcomes increasing most rapidly are as follows: sedative/hypnotics/antipsychotics, followed by analgesics, antidepressants, and cardiovascular drugs.

115These data support the continued value of PC expertise and the need for specialized medical toxicology information to manage the more severe exposures, despite a decrease in calls involving less severe exposures. PCs must consider newer communication approaches that match current public communication patterns in addition to the traditional telephone calls.

116The continuing mission of NPDS is to provide a nationwide infrastructure for public health surveillance for all types of exposures, public health event identification, resilience response, and situational awareness tracking. NPDS is a model system for the nation and global public health.

117The American Association of Poison Control Centers (AAPCC; http://www.aapcc.org) maintains the national database of information logged by the country’s regional poison centers (PCs) serving all 50 United States, Puerto Rico, and the District of Columbia. Case records in this database are from self-reported calls: they reflect only information provided when the public or health care professionals report an actual or potential exposure to a substance (e.g., an ingestion, inhalation, or topical exposure), or request information/educational materials. Exposures do not necessarily represent a poisoning or overdose. The AAPCC is not able to completely verify the accuracy of every report made to member centers. Additional exposures may go unreported to PCs and data referenced from the AAPCC should not be construed to represent the complete incidence of national exposures to any substance(s).