Toxicology A special contribution from the American Association of Poison Control Centers. 2003 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System WILLIAM A. WATSON, PHARMD, TOBY L. LITOVITZ, MD, WENDY KLEIN-SCHWARTZ, PHARMD, MPH, GEORGE C. RODGERS, JR, MD, PHD, JESSICA YOUNISS, MBA, NICOLE REID, MED, WAYNE G. ROUSE, MCSD, REBECCA S. REMBERT, BS, DOUGLAS BORYS, BSPHARM Toxic Exposure Surveillance System (TESS) data are used to support regulatory actions; and form the basis of compiled by the American Association of Poison Control postmarketing surveillance of newly released drugs and Centers (AAPCC) on behalf of US poison centers. These products. data are used to identify hazards early, focus prevention From its inception in 1983, TESS has grown dramati- education, guide clinical research, direct training, and detect cally, with increases in the number of participating poison chem/bioterrorism incidents. TESS data have prompted centers, population served by those centers, and reported product reformulations, repackaging, recalls, and bans; are human exposures (Table 1A).1-20 The American Association of Poison Control Centers gratefully acknowledges the generous financial contribution of McNeil Consumer and Specialty Pharmaceuticals in support of the compilation and production of this report. The compilation of these data was also supported, in part, by the US Centers for Disease Control and Prevention, Cooperative Agreement U50/CCU323406-01. US poison centers make possible the compilation and reporting of this comprehensive description of human exposures to potentially toxic substances through their meticulous documentation of each case using standardized definitions and compatible computer systems. Partic- ipating centers include: Regional Poison Control Center, Birmingham, AL; Alabama Poison Center, Tuscaloosa, AL; Arizona Poison and Drug Information Center, Tucson, AZ; Banner Poison Control Center, Phoenix, AZ; Arkansas Poison and Drug Information Center, Little Rock, AR; California Poison Control System—Fresno/Madera Division, CA; California Poison Control System—Sacramento Division, CA; California Poison Control System—San Diego Division, CA; California Poison Control System—San Francisco Division, CA; Rocky Mountain Poison and Drug Center, Denver, CO; Connecticut Poison Control Center, Farmington, CT; National Capital Poison Center, Washington, DC; Florida Poison Information Center, Tampa, FL; Florida Poison Information Center, Jacksonville, FL; Florida Poison Information Center, Miami, FL; Georgia Poison Center, Atlanta, GA; Illinois Poison Center, Chicago, IL; Indiana Poison Center, Indianapolis, IN; Iowa Statewide Poison Control Center, Sioux City, IA; Mid-America Poison Control Center, Kansas City, KS; Kentucky Regional Poison Center, Louisville, KY; Louisiana Drug and Poison Information Center, Monroe, LA; Northern New England Poison Center, Portland, ME; Maryland Poison Center, Baltimore, MD; Regional Center for Poison Control and Prevention Serving Massachusetts and Rhode Island, Boston, MA; Children’s Hospital of Michigan Regional Poison Control Center, Detroit, MI; DeVos Children’s Hospital Regional Poison Center, Grand Rapids, MI; Hennepin Regional Poison Center, Minneapolis, MN; Mississippi Regional Poison Control Center, Jackson, MS; Missouri Regional Poison Center, St. Louis, MO; Nebraska Regional Poison Center, Omaha, NE; New Hampshire Poison Information Center, Lebanon, NH; New Jersey Poison Information and Education System, Newark, NJ; New Mexico Poison and Drug Information Center, Albuquerque, NM; New York City Poison Control Center, New York, NY; Long Island Regional Poison and Drug Information Center, Mineola, NY; Finger Lakes Regional Poison and Drug Information Center, Rochester, NY; Central New York Poison Center, Syracuse, NY; Western New York Poison Center, Buffalo, NY; Carolinas Poison Center, Charlotte, NC; Cincinnati Drug and Poison Information Center, Cincinnati, OH; Central Ohio Poison Center, Columbus, OH; Greater Cleveland Poison Control Center, Cleveland, OH; Oklahoma Poison Control Center, Oklahoma City, OK; Oregon Poison Center, Portland, OR; Pittsburgh Poison Center, Pittsburgh, PA; The Poison Control Center, Philadelphia, PA; Penn State Poison Center, Hershey, PA; San Jorge Children’s Hospital Poison Center, Santurce, PR; Palmetto Poison Center, Columbia, SC; Tennessee Poison Center, Nashville, TN; Southern Poison Center, Memphis, TN; Central Texas Poison Center, Temple, TX; North Texas Poison Center, Dallas, TX; Southeast Texas Poison Center, Galveston, TX; Texas Panhandle Poison Center, Amarillo, TX; West Texas Regional Poison Center, El Paso, TX; South Texas Poison Center, San Antonio, TX; Utah Poison Control Center, Salt Lake City, UT; Virginia Poison Center, Richmond, VA; Blue Ridge Poison Center, Charlottesville, VA; Washington Poison Center, Seattle, WA; West Virginia Poison Center, Charleston, WV; and Children’s Hospital of Wisconsin Poison Center, Milwaukee, WI. ©1985-2004 by the American Association of Poison Control Centers. Published by permission. All rights reserved. Reprints are available at a cost of $10 each. Address requests to AAPCC, 3201 New Mexico Ave, Suite 330, Washington, DC 20016. doi: 10.1016/j.ajem.2004.06.001 335 336 AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 22, Number 5 ■ September 2004 TABLE 1A. Growth of the AAPCC Toxic Exposure Surveillance contains data (not presented here) on animal poison expo- System sures (133,397 cases, primarily companion animals), human No. of Population Human Exposures/ confirmed nonexposures (7,071), animal confirmed nonex- Participating Served Exposures Thousand posures (406), and information calls (1,167,776). An addi- Year Centers (Millions) Reported Population tional 4,500 duplicate human exposure reports (reported to more than one participating poison center) were excluded. 1983 16 43.1 251,012 5.8 This total of 3,708,732 cases and information calls reported 1984 47 99.8 730,224 7.3 to TESS in 2003 does not reflect the full extent of poison 1985 56 113.6 900,513 7.9 1986 57 132.1 1,098,894 8.3 center effort. In addition, nearly 2.7 million follow-up calls 1987 63 137.5 1,166,940 8.5 were placed by poison centers during the year to provide 1988 64 155.7 1,368,748 8.8 further patient guidance, confirm compliance with recom- 1989 70 182.4 1,581,540 8.7 mendations, and gather final outcome data. Follow-ups were 1990 72 191.7 1,713,462 8.9 done in 44% of human exposure cases. One follow-up call 1991 73 200.7 1,837,939 9.2 was made in 22% of cases; and multiple follow-up calls 1992 68 196.7 1,864,188 9.5 (range 2 to 86) were placed in 22% of cases. 1993 64 181.3 1,751,476 9.7 The data do not directly identify a trend in the overall 1994 65 215.9 1,926,438 8.9 incidence of poisonings in the US because of changing 1995 67 218.5 2,023,089 9.3 center participation from year to year and changes in center 1996 67 232.3 2,155,952 9.3 1997 66 250.1 2,192,088 8.8 use. Comparison of data from the 49 states (and the District 1998 65 257.5 2,241,082 8.7 of Columbia) that were covered by participating centers for 1999 64 260.9 2,201,156 8.4 the entirety of both 2002 and 2003 shows an increase of 2000 63 270.6 2,168,248 8.0 0.4% in the number of reported human poison exposures 2001 64 281.3 2,267,979 8.1 from 2002 to 2003. 2002 64 291.6 2,380,028 8.2 Information call subcategories were implemented in 2003 64 294.7 2,395,582 8.1 TESS in 2002. A total of 1,167,776 information calls were Total 36,216,578 reported to TESS in 2003, including 139,043 calls coded in optional reporting categories such as administrative, imme- diate referral, and prevention/safety/education (Table 1B). The cumulative AAPCC database now contains 36.2 These latter call types were reported inconsistently as they mil2lion human poison exposure cases. This report includes were not required to be reported by participating poison 2,395,582 human exposure cases reported by 64 participat- centers. Overall, the volume of information calls handled by ing poison centers during 2003, an increase of 0.7% com- US poison centers increased 5.1% from 2002 to 2003. pared to 2002. The most frequent information call was for drug identi- fication, comprising 617,414 calls to poison centers during the year. Of these, 103,020 (16.7%) could not be identified CHARACTERIZATION OF PARTICIPATING CENTERS over the telephone. Of the drug identification calls, 74.4% were received from the public, 12.7% from health profes- Of the 64 reporting centers, 62 submitted data for the sionals, and 11.8% from law enforcement. Forty-six percent entire year. Fifty-one of the 64 participating centers were of drug identification requests involved drugs sometimes certified as regional poison centers by the AAPCC at the involved in abuse, however these cases were categorized end of 2003. The annual human exposure case volume by based on the abuse potential, generally without knowledge center ranged from 11,458 to 110,459 (mean 38,388) for of whether abuse was actually intended. centers participating for the entire year. Penetrance, calcu- Drug information calls (174,631 calls) comprised 15.0% lated for states that were served by centers participating in of all information calls. Of these 19.6% were questions TESS for the entire year, ranged from 5.9 to 17.6 exposures about drug-drug interactions, 14.4% were questions about per 1,000 population with a mean of 8.1 reported exposures therapeutic use and indications, and 10.7% were questions per 1,000 population. Penetrance is defined as the number of about adverse effects. Environmental inquiries comprised human poison exposure cases reported per 1,000 individuals 3.2% of all information calls. Of these, 26.0% related to per year in the population served. clean-up of mercury thermometers and 12.8% involved The entire population of the 50 states, the District of pesticides.