Pool Chemical–associated Injuries in Public and …€ NEISS requires “All parts (>50% of...
Transcript of Pool Chemical–associated Injuries in Public and …€ NEISS requires “All parts (>50% of...
Pool Chemical–associated Injuries in
Public and Residential Settings—
United States, 2003–2012Michele C. Hlavsa, RN, MPH
Sarah A. Collier, MPH
Michael J. Beach, PhD
6th International Swimming Pool & Spa Conference
March 17–20, 2015
National Center for Emerging and Zoonotic Infectious Diseases
Healthy Swimming Program
Pool Chemical—associated Health EventIndianapolis, 2012*
� Chlorine and acid likely
mixed and generated toxic
chlorine gas due equipment
failure and/or operator
error
� ~200 patrons and staff
members affected
� ~70 taken to hospital
� >5 admitted
* Source: Indianapolis Star, June 21, 2012.
Reports of Pool Chemical—associated Health Events
� Case reports
• Fisher AA. Clin Dermatol 1987;5(3):36–40.
• Shippert BW. Ann Emerg Med 2010;55(4):370–2.
� Series reports
• Thomas HL, Murray V. J Public Health 2008;
30(4):391–7.
• CDC. MMWR 2009;58(18);489–93.
• CDC. MMWR 2011;60(39);1343–7.
• Hlavsa MC et al. MMWR 2014;63(19);427–30.
• Anderson AR et al. J Environ Health 2014;
76(9):10–5.
National Electronic Injury Surveillance System(NEISS)
� Captures data on emergency department (ED)* visits
for injuries associated with consumer products
* US term “emergency department (ED)” same as UK term “accident and emergency (A&E)”.
NEISS Data Fields for Each Report
� Product code(s), where pool chemical code=938
� Incident location
� Patient disposition
� Most severe diagnosis
� Most seriously injured body part
� Patient
• Age
• Sex
• Race/ethnicity
� Narrative
NEISS
� Captures data on ED visits for injuries associated
with consumer products
� Collects injury data from a nationally representative
probability sample of ~100 hospitals across the
United States
• Weigh each case based on inverse probability of
hospital being selected
– Calculate national estimate and
95% confidence interval (CI)
– Calculate rate per 100,000 person-years using
U.S. Census population estimates** Source: www.census.gov/popest/data
0
1,000
2,000
3,000
4,000
5,000
6,000
2003 2005 2007 2009 2011
Na
tio
na
l A
nn
ua
l E
stim
ate
Year
Pool Chemical–associated Injuries, by Year
United States, NEISS, 2003–2012*
* Source: Hlavsa MC et al. MMWR 2014;63(19);427–30.
Pool Chemical–associated InjuriesUnited States, NEISS, 2012
� 4,876 (95% CI: 2,821–6,930) injuries
• 109 actual injuries diagnosed in NEISS ED’s
� Incident location
• 1,759 (95% CI: 718–2,799) occurred at residence
• 1,998 (95% CI: 1,057–2,940) occurred at unknown
location
� Patient disposition
• 4,394 (95% CI: 2,804–5,983) treated and released
or examined and released without treatment
• No deaths
Pool Chemical–associated InjuriesUnited States, NEISS, 2012
Data
Field
Actual
Count
Weighted
Estimate95% CI
Annual Rate
per 100,000
Injury diagnosis
Poisoning* 50 2,167 1,219–3,116 0.7
Dermatitis/
conjunctivitis33 1,581 385–2,778 —
Chemical burns 9 469 16–922 —
Other 17 657 234–1,081 —
Injured body part
All parts
(>50% of body)†55 2,218 1,269–3,167 0.7
Eyeball 34 1,525 572–2,478 —
Other 20 1,133 419–1,847 —* Poisoning includes ingestion as well as inhalation of vapors, fumes, or gases.† NEISS requires “All parts (>50% of body)” when poisoning is injury diagnosis.
Pool Chemical–associated InjuriesUnited States, NEISS, 2012
Patient
Demographic
Actual
Count
Weighted
Estimate95% CI
Annual Rate
per 100,000
Age (in years)
0–17 53 2,289 965–3,613 3.1
18–45 23 850 421–1,278 0.7
46–64 28 1,518 811–2,225 1.9
>65 5 218 0–441 —
Sex
Male 72 3,144 1,832–4,456 2.0
Female 37 1,731 894–2,569 1.1
Pool Chemical–associated InjuriesUnited States, NEISS, 2012
Patient
Demographic
Actual
Count
Weighted
Estimate95% CI
Annual Rate
per 100,000
Patient
race/ethnicity
White,non-
Hispanic (NH)
66 3,468 2,536–4,401 —
Black, NH 14 309 69–549 —
Hispanic 7 443 0–1,062 —
Other 1 6 0–18 —
Unknown 21 649 34–1,264 —
Day of WeekSeason
Summer*
Non-
Summer
Timing of Pool Chemical–associated
Health Events (n=109) — NEISS, 2012
Weekend
Weekday
* Saturday before Memorial Day (end of May)–Labor Day (beginning of September).
NEISS Narratives and Published Reports
� NEISS injuries frequently occurred when
• Handling without using personal protective
equipment
• Adding to water just before patient enters
– Frequently in hotel/motel or residential pools
• Failing to secure chemicals away from children
� Contributing factors
• Pool operators and residential pool owners lack
knowledge of basic pool chemical safety
• Standard pool equipment allows for situations
where concentrated chlorine and acid mix
Limitations of NEISS Data
� Underestimate
• Snapshot of only pool chemical–associated
injuries leading to ED visits
� Data Missing
• Incident location
• Patient race/ethnicity
� Misclassification of events possible
• Example: dermatitis resulting from Pseudomonas
infection or chemical exposure
� Water chemistry can change quickly making it
difficult to confirm exact chemical etiology
Treated Recreational Water–associatedIllness Outbreaks — United States, 2009–2010*
EtiologyLaboratory
ConfirmationOutbreak Count
Count of
Outbreak-
associated Cases
Infectious Confirmed 35 488
— 7 146
Chemical Confirmed 0 0
— 11 367
Unknown — 4 29
Total — 57 1,030
* Source: Hlavsa MC et al. MMWR 2014; 63(01);6-10.
Pool Chemical–associated Injuries
� Problem: Preventable
� Solution: 3E’s
• Enforcement: Model Aquatic Health Code (MAHC)
– Michael Beach: Today @ 13:40–14:00
• Education: Completing operator training which
include pool chemical safety (MAHC requirement)
• Engineering: Disabling chemical feed if
recirculation system at no or low flow (MAHC
requirement)
Resources
• Video available in
English* and
translated† into
o Spanish
o Portuguese
o French
o Russian
*English video developed by ACC and the U.S. Chlorine Institute.† Translations provided by the World Chlorine.
• FREE from CDC
thanks to the
American
Chemistry
Council (ACC)
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
National Center for Emerging and Zoonotic Infectious Diseases
Healthy Swimming Program