CSTE ANNUAL MEETING CSTE POSITION STATEMENT 1998-EH 1 TITLE: Proposal to Adopt New or Amended Surveillance Definitions for Four Environmental Conditions ISSUE: Surveillance case definitions for infectious disease conditions have been approved by the CSTE and published (MMWR 1990;39(No.RR-13), MMWR 1997;46(RR-10) but definitions for non-infectious disease conditions have not.  BACKGROUND AND JUSTIFICATION: Use of surveillance definitions is critical to the analysis of surveillance data for comparison among reporting jurisdictions and over time. In November 1996, the Centers for Disease Control and Prevention’s (CDC) Health Information Systems and Surveillance Board (HISSB) established a steering committee to direct the development of surveillance definitions for noninfectious conditions in the areas of environmental and occupational health, injury, child and maternal health, and chronic disease. The surveillance definitions for noninfectious conditions are intended to provide guidance to states interested in conducting surveillance for these conditions, and to promote uniform reporting of cases and events at the local, state, and national level. National experts and state and federal partners participated in developing and reviewing these surveillance definitions during the past year. The environmental health task force members have prepared draft surveillance definitions for four conditions. One of these conditions currently has a surveillance definition that was approved by the CSTE membership but it has been reviewed and revised for this activity; the remaining two definitions are new. Accompanying each of the attached definitions is a list of the working group members who participated in developing or revising the definition, and a list of people who reviewed the final document.  POSITION TO BE ADOPTED: CSTE recommends: 1) Adoption of the new surveillance definitions for the following conditions (attached): Hazardous substances emergency events, Carbon monoxide poisoning, and Disaster casualty. 2) Adoption of the amended National Public Health Surveillance System case definition for the following condition (attached): Elevated blood lead in children. 3) That state and territorial health departments planning to conduct surveillance for these conditions utilize the attached surveillance definitions. 4) That the environmental surveillance definitions that are approved by CSTE be published in an MMWR along with the other CSTE-approved noninfectious disease/condition surveillance definitions. COORDINATION WITH OTHER ORGANIZATIONS: Agencies for Response: National Center for Environmental Health,CDC National Institute of Occupational Safety and Health, CDC Agency for Toxic Substances and Disease Registry, CDC Agencies for Information: Environmental Protection Agency  National Environmental Health Agency CONTACT PERSON: Henry Anderson, MD Bureau of Public Health, Wisconsin Division of Health One West Wilson Street Madison, WI 53701 Phone: 608-266-1253 Fax: 608-266-1253 E-mail: anderha@dhfs.state.wi.us Hazardous Substances Emergency Events  Type of Surveillance Hazard Surveillance Definition  Hazardous substances emergency events are defined as sudden uncontrolled or illegal releases or threatened releases of at least one hazardous substance or the hazardous by-product of a substance. A substance is considered hazardous if it might reasonably be expected to cause adverse human health outcomes. Case Classification Confirmed: • There was a release of at least one hazardous substance and the amount released had to be removed, cleaned up, or neutralized according to federal, state, or local law, or • There was a release of a hazardous substance to the air or water at a level that would reasonably be expected to cause adverse human health outcomes, or • There was a threatened release of at least one hazardous substance, in an amount that would have had to be removed, cleaned up, or neutralized according to federal, state, or local law and the threat led to an action (for example, an evacuation) that could have affected the health of employees, responders, or the general public  Suspected: • There was a release of at least one hazardous substance, but there was insufficient information to judge whether the amount released had to be removed, cleaned up, or neutralized according to federal, state, or local law, or • There was a release of a hazardous substance to the air or water but their was insufficient information to judge whether if the level would reasonably be expected to cause adverse human health outcomes, or • There was a threatened release of at least one hazardous substance that led to an action (for example, an evacuation) that could have affected the health of employees, responders, or the general public, but there was insufficient information to judge whether the amount of hazardous substance that might have been released had to be removed, cleaned up, or neutralized according to federal, state, or local law Comment Several data sources are used to obtain the maximum amount of information about these events. These sources include, but are not limited to, records or oral reports of state environmental protection agencies, police and fire departments, state and county emergency management agencies, industries involved, witnesses, victims, media, and hospitals. Currently hazardous substances emergency events surveillance is funded in 13 states by cooperative agreements with the Agency for Toxic Substance and Disease Registry (ATSDR). Since petroleum products are not in the legislative mandate of ATSDR, events involving petroleum products exclusively are not reported to ATSDR Hazardous Substances Emergency Event Surveillance (HSEES) system. Also, only definite cases are reported to HSEES. If you would like further information about the HSEES system you may contact: Agency for Toxic Substances and Disease Registry Division of Health Studies  Attn: Chief, Epidemiology and Surveillance Branch (E-31) 1600 Clifton Road, N.E. Atlanta, Georgia, 30333 Hazardous Substances Emergency Events Definition Workgroup Members Maureen Orr - lead contact Division of Health Studies, Epidemiology and Surveillance Branch Agency for Toxic Substances and Disease Registry Henry Anderson Wisconsin Dept of Health and Social Services Council of State and Territorial Epidemiologists Wendy Kaye Patricia Price-Green Division of Health Studies, Epidemiology and Surveillance Branch Agency for Toxic Substances and Disease Registry Greg Piaciatelli Hazard Section, Surveillance Branch, National Institute for Occupational Health and Safety Centers for Disease Control and Prevention Ginger Gist  President Elect, National Environmental Health Association Agency for Toxic Substances and Disease Registry Enrique Paz-Argandona National Center for Environmental Health, Centers for Disease Control and Prevention Brian J. Hughes Robin Moore Alabama Department of Public Health, Division of Epidemiology Chrystine Kelley Colorado Department of Public Health & Environment, Hazardous Materials and Waste Management Division Debbi Cooper Iowa Department of Public Health, Division of Health Protection Larry Souther Site Assessment and Consultation, Minnesota Department of Health Joe Fahner Mississippi State Department of Health Lori Harris Missouri Department of Health, Bureau of Environmental Epidemiology Bill Bullard Wanda Lizak Welles Rebecca Wilburn New York State Department of Health, Bureau of Toxic Substance Assessment Susan Randolph Occupational Surveillance Branch, North Carolina Department of Health and Human Services Elizabeth Esseks Oregon Health Sciences University Richard Leiker Center for Disease Prevention and Health Statistics, Oregon Health Division Diann J. Miele Rhode Island Department of Health, Office of Environmental Health Risk Assessment John F. Villanacci Richard Harris  Melissa Samples-Ruiz Julie Borders Texas Department of Health, Bureau of Epidemiology Lucy Harter Washington Department of Health, Office of Toxic Substances James Drew Wisconsin Division of Health, Bureau of Public Health Surveillance Case Definition for Acute Carbon Monoxide Poisoning Type of surveillance: Outcome Clinical Description  There is no consistent constellation of signs and symptoms resulting from acute carbon monoxide poisoning, nor are there any pathognomonic clinical signs or symptoms which would unequivocally indicate a case of acute carbon monoxide poisoning. The clinical presentation of acute carbon monoxide (CO) poisoning varies not only with the duration and magnitude of exposure, but also between individuals with the same degree of exposure and/or same venous carboxyhemoglobin (COHb) level.  Clinical signs and symptoms of acute carbon monoxide poisoning that are commonly reported to health care professionals include, but are not limited to: headache, nausea, lethargy (or fatigue), weakness, abdominal discomfort/pain, confusion, and dizziness.  Other signs and symptoms reported include: visual disturbances including blurred vision, numbness and tingling, ataxia, irritability, agitation, chest pain, dyspnea (shortness of breath) on exertion, palpitations, seizures, and loss of consciousness.  Clinical Case Definition There is no clinical case definition for acute carbon monoxide poisoning. There are no pathognomonic clinical signs or symptoms that would unequivocally indicate a case of acute carbon monoxide poisoning (without laboratory confirmation). See Clinical Description and Laboratory Criteria for Diagnosis. Laboratory Criteria for Diagnosis A blood specimen with an elevated carboxyhemoglobin (COHb) concentration, as determined by a validated method (e.g., photometric, gas chromatography). Elevated levels of carboxyhemoglobin should be interpreted in light of endogenous production, patient smoking status, and exposures to second hand smoke (1). Case Classification Confirmed: Notification Systems:  Clinicians/Medical Examiners/Coroners: (1) A report of a patient with signs and symptoms consistent with acute carbon monoxide poisoning with a laboratory confirmed elevated COHb level (See Laboratory Criteria for Diagnosis), OR; (2) a report of a patient with signs and symptoms consistent with acute carbon monoxide poisoning (in the absence of clinical laboratory data), with supplementary evidence in the form of environmental monitoring data suggesting exposure from a specific poisoning source.  - OR - Hyperbaric Treatment Facilities: A report of a patient who has received hyperbaric treatment for acute carbon monoxide poisoning, regardless of carboxyhemoglobin concentration reported.  - OR - Laboratories: A report of a blood specimen (in the absence of clinical and environmental laboratory data) with a carboxyhemoglobin level that is equal to or greater than a volume fraction of 0.12, ie. 12%. [Note: This level was selected to identify those people whose COHb levels are likely to cause clinically apparent adverse health effects, while attempting to minimize the number of chronic smokers reported as acutely poisoned (1) (see comment section).] Administrative Data: ICD﷓9 Coded Data: (1) A record in which the Nature of Injury code N﷓986 "Toxic effect of CO" is listed, OR; (2) a record in which an External Cause of Injury code (E﷓code), indicating exposure to carbon monoxide (exclusively) is listed, ie. E868.3, E868.8, E868.9, E952.1, or E982.1. -OR- ICD-10 Coded Data: A record in which T58, Toxic Effect of Carbon Monoxide, is listed -OR- ICD-10-CM (under development) coded data: A record in which T58, Toxic Effect of Carbon Monoxide, is listed Probable Case: Notification Systems: Clinicians/Medical Examiners/Coroners: In the absence of clinical and environmental monitoring data: (1) A report of a patient with signs and symptoms consistent with acute carbon monoxide poisoning and the same history of environmental exposure as that of a confirmed case, OR, (2) a report of a patient with smoke inhalation secondary to conflagration. - OR - Laboratories: A report of a blood specimen with a carboxyhemoglobin level that is equal to or greater than a volume fraction of 0.09, i.e. 9% and less than a volume fraction of 0.12, i.e. 12% (9<COHb%<12). Administrative Data: ICD-9 Coded Data: A record in which an E﷓code indicating acute carbon monoxide poisoning inferred from motor vehicle exhaust gas exposure is listed, ie. E868.2, E952.0, or E982.0. Suspected Case:  Notification Systems: Clinicians/Medical Examiners/Coroners: A report of a patient with signs and symptoms consistent with acute carbon monoxide poisoning and a history of present illness consistent with exposure to carbon monoxide. Administrative Data: ICD-9 Coded Data: In the absence of an N﷓986 code: (1) a record in which an E﷓code that mentions CO exposure is listed (E818.0﷓.9, E825.0﷓.9, E844.0﷓.9, E867, E868.0, E868.1, E890.2, E891.2), (2) a record in which an E-Code where carbon monoxide exposure is plausible is listed (E838.0﷓.9, E951.0, E951.1, E951.8, E962.2, E968.0, E981.0, E981.1, E981.8, E988.1). - OR - ICD-10 Coded Data: In the absence of T58 code, a record in which a code that mentions CO exposure, is listed (X47, X67, Y17). [Note: The December 1997 draft of ICD-10-CM omits these codes.] - OR - Worker’s Compensation Data: A report of a person with carbon monoxide poisoning documented in the record. Comment: The descriptions provided for identifying cases of acute carbon monoxide poisoning utilize a variety of sources of data that one may use or integrate into a surveillance system. These data elements are from commonly available data that may be consistently utilized by all states. Additional state specific databases may have greater detail and professional discretion is encouraged when using alternative or supplemental databases. These definitions should be updated as the clinical, diagnostic, and epidemiologic state-of-the-art evolves and as new data sources become available.  The case descriptions provided are designed to ascertain cases of acute carbon monoxide poisoning regardless of the source of the exposure. Information on the history of the poisoning incident and the suspected exposure sources should be reviewed for targeting prevention efforts/interventions (see comments on persons with occupational exposure). The surveillance case definitions for acute carbon monoxide poisoning have been formulated to address the general population. There are several sub-populations which may be more or less susceptible to the adverse health effects of carbon monoxide intoxication, due to pre-disposing environmental and physiologic conditions (see below). Separate surveillance case definitions for sub-populations have not been formulated at this time as it is unclear from the published peer-reviewed literature whether these groups suffer more extreme outcomes from poisoning at lower levels of exposure and/or lower levels of carboxyhemoglobin saturation. In addition it is unclear whether the reporting sources would be able to consistently differentiate these sub-populations based on the information currently available in their databases. The following sub-populations have been identified in the literature as having special concerns with respect to acute carbon monoxide poisoning: 1. Persons Exposed to Tobacco Smoke: Active and passive exposure to tobacco smoke elevates carboxyhemoglobin levels as a result of inhalation of combustion by-products. Data from the National Health and Nutrition Evaluation Survey, II , 1976-80, revealed that self reported current smokers showed larger variability in COHb levels along with a relative insensitivity of this group to incremental changes in the environmental burden of CO when compared with the never smoking group. NHANES, II also reported that approximately 95.9% of the current smokers had a concentration of COHb less than or equal to 9% (1). 2. Children: It is known that children have a higher minute ventilation per unit body weight than adults and that children have been reported to be more susceptible to the acute adverse health effects from exposure to CO. It is acknowledged that while children may accumulate COHb faster than adults, it is unclear whether they experience more severe outcomes at lower levels of COHb saturation, therefore a unique surveillance case definition has not been formulated at this time. 3. Fetal Exposure/Pregnancy: It is known that fetal blood has a higher affinity for CO than does adult hemoglobin and this is an important distinction considered by the clinician when treating the pregnant patient. It is unclear, at this time whether a unique surveillance case definition for this subgroup based on maternal COHb levels is necessary for reporting purposes. 4. Persons Living at Altitude: It is known that persons living at altitude experience faster loading of COHb as result of a leftward shift of the oxygen-hemoglobin dissociation curve. It is unclear whether persons at altitude experience more severe outcomes at lower levels of COHb saturation, therefore, a unique surveillance case definition for this sub-group has not been formulated at this time  5. Persons with Pre-morbid Conditions: It is known that sub-populations with conditions of low oxygen saturation (e.g.; chronic obstructive pulmonary disease) and conditions with decreased oxygen delivery to the tissues (e.g.; ischemic heart disease) experience adverse health effects with increased COHb levels. It is unclear whether these sub-groups experience more severe outcomes at lower levels of COHb saturation, therefore, unique surveillance case definitions for these sub-populations have not been formulated at this time. 6. Persons with Occupational Exposure: Occupational exposure to carbon monoxide is not uncommon. The outcomes from acute CO poisoning at work are no different than then consequences of other sources of exposure. It is important to gather information on potential occupational exposures as this information is important for preventing future poisonings. References: 1. National Center for Health Statistics, EP Radford and TA Drizd: Blood carbon monoxide levels on Persons 3-74 Years of Age: United States, 1976-80. Advance Data From Vital and Health Statistics, No. 76. DHHS Pub. No. (PHS) 82-1250. Public Health Service, Hyattsville, Md. March 17, 1982. Acute Carbon Monoxide Poisoning Work Group: Lauren B. Ball, DO, MPH - Chair Air Pollution and Respiratory Health Branch Division of Environmental Hazards and Health Effects National Center for Environmental Health (NCEH) Centers for Disease Control and Prevention (CDC) Steven C. Macdonald, PhD, MPH Formerly with: U. Washington, Seattle on assignment with Surveillance and Programs Branch, NCEH, CDC Currently with: Office of Epidemiology, Washington State Department of Health  Onno W. van Assendelft, MD, PhD National Center for Infectious Disease, CDC Consultant to National Environmental Health Laboratory Services, NCEH, CDC J. Rex Astles, PhD Health Scientist Centers for Disease Control and Prevention Division of Laboratory Systems Public Health Practice Program Office, CDC Jane McCammon National Institute of Occupational Safety and Health, CDC Michael Heumann, MPH, MA Epidemiologist Oregon Health Division Mary Lou Fleissner, DrPH Brian Toal, MSPH Connecticut Department of Public Health Neil B. Hampson, MD Pulmonary and Critical Care Medicine/Hyperbaric Medicine Virginia Mason Medical Center, Seattle, WA Acute Carbon Monoxide Poisoning Surveillance Case Definition Reviewers : Richard Ehrenberg, MD Gregory M. Piacitelli National Institute for Occupational Safety and Health, CDC Note: additional reviews are being solicited from other CO experts - names to be included when commentary received. Surveillance Case Definition for Disaster Casualty Type of surveillance: Outcome Clinical description A casualty of a disaster can present with any number of adverse health outcomes including injuries, mental illness, infection or death caused by either the direct or indirect result of the disaster. Definition of a Disaster Casualty A disaster is an ecological disruption causing human, material, or environmental losses which exceed the ability of the affected community to cope using its own resources, often calling for outside assistance. Disasters can be divided into two broad categories. One category is natural disasters caused by the forces of nature, including but not limited to earthquakes, tsunamis, tropical storms, volcanic eruptions, hurricanes, cyclones, typhoons, landslides, avalanches, floods, wildfires, tornadoes, and blizzards. The second category is human-generated disasters in which the principal direct causes are identifiable human actions, deliberate or otherwise, including but not limited to, severe pollution incidents, war, airplane crashes. A casualty of a disaster is a person, who either as a direct or indirect result of exposure to the disaster, experienced an adverse health outcome including death, injury, or disease.  Case Classification Confirmed:  Disaster caused casualty: A fatality, injury, illness or other adverse health condition (e.g. mental health disorders) diagnosed by a public/private health care provider (e.g. physicians, medical examiners/coroners, nurses, working at hospitals, relief shelters, and private practice clinics, etc.) and documented in their records as resulting from the direct force of the disaster or from disaster-related activities such as evacuation, clean-up, loss of electricity, or other events that would not have occurred in the absence of the disaster event (e.g. a car crash with adverse health outcomes resulting from a flooded road or an animal bite resulting from animals leaving their natural environment because of the disaster). This information is collected from health care providers records by public health officials at the local, state and federal level (e.g. including but not limited to local health departments, state health departments, federal health institutions, disaster relief agencies such as state emergency management agencies, the American Red Cross). Disaster related casualty: A fatality, injury or illness or other adverse health conditions (e.g. mental health disorders) diagnosed by a public/private health care provider (e.g. Physicians, Medical Examiners/ Coroners and Nurses working at hospitals, relief shelters, practice clinics, etc.) and documented in their records as resulting from a pre-existing condition (e.g. pre-existing heart disease, endemic health problems, or other adverse health conditions) that was exacerbated by the deteriorating, interrupted public services or disruptions of normal public health programs in the pre, during or post disaster phase (e.g. infectious diseases due to sanitation problems, asthma exacerbation due to changes in the air quality). This information is collected by public health officials at the local, state and federal level (e.g. including but not limited to local health departments, state health departments, federal health institutions, disaster relief agencies such as state emergency management agencies, the American Red Cross). Possible:  A fatality, injury, illness or other adverse health conditions (e.g. mental health disorder) that occurred during a disaster or during pre or post disaster activities and was diagnosed by a public/private health care provider (e.g. physicians, medical examiners/ coroners and nurses working at, but not limited to, hospitals, relief shelters, and practice clinics), and collected by a public health officials at the local, state and federal level (e.g. including but not limited to local health departments, state health departments, federal health institutions, disaster relief agencies such as state emergency management agencies, the American Red Cross) but for which there is insufficient information to clearly determine whether is was related, either directly or indirectly, to the disaster. [Note: When tabulating possible cases it is important to recognize background levels of cases.] Surveillance Case Definition for Disaster Casualty Work Group Enrique Paz, NCEH Josephine Malilay, NCEH  Maureen Orr, ATSDR Eric Noji, WHO/Geneva Carol Pertowski, NCEH Gib Parrish, NCEH Debra Combs, NCEH Michael McGeehin, NCEH Bruce Brackin, CSTE Joseph Koester, USGS Curt Barrett, NOAA Michael Hunsucker, NOAA Betsy Hilborn, EPA J. Eleonora Sabadell, NSF Joanne Walker Shields, University of Washington, Washington  Laurie Willshire, ARC, Washington, D.C.  Kim Blindauer, NCEH Claude De Ville, PAHO Elevated Blood Lead Levels Among Children Surveillance Case Definition Type of surveillance Exposure surveillance Laboratory criteria for diagnosis Whole blood lead concentration, as determined by a CLIA-certified facility, greater than or equal to 10µg/dL (0.48µmol/L) in a child (person < 16 years of age) Case classification Suspected: a single capillary blood specimen with elevated lead concentration Probable: two capillary blood specimens, drawn greater than 12 weeks apart, both with elevated lead concentration  Confirmed: one venous blood specimen with elevated lead concentration, or two capillary blood specimens, drawn within 12 weeks of each other, both with elevated lead concentration Comment Elevated blood lead levels, as defined above, should be used for the purposes of surveillance only to apply standard criteria for case classification and may not correspond to action levels determined by individual programs or providers. Elevated Blood Lead Levels Among Children Case Definition Work Group  Adrienne S. Ettinger, MPH Epidemiologist - Division of Environmental Hazards and Health Effects National Center for Environmental Health Nedra Whitehead, MS, Division of Environmental Hazards and Health Effects, National Center for Environmental Health Robert Jones, PhD Division of Environmental Health Laboratory Sciences, National Center for Environmental Health Rita Gergely Director Childhood Lead Poisoning Prevention Program, Iowa Department of Public Health Ed Norman, PhD. Director Childhood Blood Lead Surveillance Program, North Carolina DEHNR - Division of Environmental Health Joan Dorfman, MD, MPH Section Chief - Surveillance and Data Management, Childhood Lead Poisoning Prevention Branch, California Department of Health Services Michael Spence, MD, MPH Medical Director and State Laboratory Director, State of Montana Department of Public Health and Human Services Marcie Cavacas Childhood Lead Poisoning Prevention Program, Connecticut Department of Health Jane Fornoff, D.Phil. Quality Control Analyst, Illinois Department of Public Health Steve Steindel, PhD. Division of Laboratory Systems, Public Health Practice Program Office Robert Goyer, PhD. National Institute of Environmental Health Sciences, National Institutes of Health George Rhoads, MD, MPH Endowed Professor of Public Health, University of Medicine & Dentistry of New Jersey/Rutgers-The State University of New Jersey, Environmental and Occupational Health Sciences Institute Steering Committee for Case Definitions for Non-infectious Conditions, Environmental Health Task Force Members Henry Anderson/current co-chair CSTE/Wisconsin DOH Lauren Ball NCEH/DEHHE Sherri Berger ATSDR/DHS Kim Blindauer  CSTE Rebecca Calderon EPA Elizabeth Hilborn EPA Richard Ehrenberg NIOSH Paul Garbe NCEH/DEHHE Pamela Meyer NCEH/DEHHE Maureen Orr/current co-chair ATSDR/DHS Carol Pertowski/former co-chair NCEH/DEHHE Peter Thornton NEHA Onno W. van Assendelft NCEH/DEHLS Joanne Walker Shields  Environmental Health Programs, Washington State Department of Health