Council of State and Territorial Epidemiologists

Template for Placing Diseases or Conditions Under National Surveillance

All ‘permanent’ verbiage that should be retained within the position statement is in BLACK font. Please do not delete or modify any black font text. Instructions to the author are currently in BLUE font. All blue fonts must be deleted prior to final submission of the position statement in addition to the instructions on the first page. This will help keep the position statements uniform in format and content.

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Council of State and Territorial Epidemiologists

Template for Placing Diseases or Conditions Under National Surveillance, Revised 2012

Submission Date:

Committee: (Drop down field provided – double click the text box, select one)

Title:Public Health Reporting and National Notification for Carbon Monoxide Poisoning

I. Statement of the Problem

Carbon monoxide (CO) is a colorless, odorless, nonirritating gas that is produced through the incomplete combustion of hydrocarbons. Sources of CO include combustion devices (e.g., boilers and furnaces), motor-vehicle exhaust, generators and other gasoline or diesel-powered engines, gas space heaters, woodstoves, gas stoves, fireplaces, tobacco smoke, and various occupational exposures. CO poisoning is a leading cause of unintentional poisoning deaths in the United States; it is responsible for approximately 450 non-intentional deaths and 20,000 emergency department (ED) visits each year.1-2Language on fire-related (Kathy)

II. Background and Justification

CSTE adopted the Surveillance Case Definition for Acute Carbon Monoxide Poisoningin 1998 (position statement EH-1), and the Updates to 1998 Case Definition for Acute Carbon Monoxide Poisoning Surveillancein 2007 (position statement EH-03).

This position statement describes methods for inclusion of CO poisoning in standard public health reporting, based on use of CO exposure and CO poisoning case data available from Poison Control Centers as the core case-ascertainment source, and case notification to CDC by means of the on-going American Association of Poison Control Centers (AAPCC) National Poison Data System (NPDS).3The position statement describes four tiers of surveillance activities, which can vary depending upon the resources available: PCC only; case-finding using multiple data sources, including PCC; case-finding using multiple data sources with matching and record linkage; and, case-finding using multiple data sources with individual case investigation. The position statement further describes selected case-ascertainment data sources. CDC has described these methods as follows: “Surveillance and analysis of data from NPDS and secondary sources might provide a more comprehensive description of the burden of CO exposure in the United States and assist in the development of interventions better targeted to high-risk populations.”4

Establishing surveillance for carbon monoxide poisoning based on case information from Poison Control Centers has special value in the disaster setting.5-8

III. Statement of the desired action(s) to be taken(select the desired action(s) to be taken)

1. Establish standard reporting and notification methods for Carbon Monoxide Poisoning and recommend that any State or Territory conducting surveillance for this condition use these standard methods.

2. CSTE recommends that States and Territories conducting surveillance according to these methods support notification and sharing of case information to CDC by means of the American Association of Poison Control Centers (AAPCC) National Poison Data System.

3. CSTE recommends that CDC publish data on Carbon Monoxide Poisoning as appropriate in MMWR and other venues.

4. This condition should be added to the Nationally Notifiable Condition List asnotifiable.

CSTE recommends that all States and Territories enact laws (statue or rule/regulation as appropriate) to make this condition reportable in their jurisdiction.

IV. Goals of Surveillance

Public health surveillance data systems for CO poisoning operate for multiple purposes:

  • Immediate response, to block the occurrence of further cases
  • Planning and evaluation of prevention programs
  • Estimation of the magnitude of the problem and tracking of trends over time
  • Identification of high-risk areas and population sub-groups
  • Assessment of the effectiveness of preventive policies and practices, such as legal requirements for installation of CO alarms in residences
  • Investigation of novel exposure pathways and previously unknown determinants

Public health jurisdictions vary in their CO poisoning prevention program practices. Although very few use surveillance data for immediate response, New York Cityis a good example of a “best practice” at the local level: calls to the Poison Center can result in rapid dispatch of a municipal fire department vehicle. Best practices in most jurisdictions focus on program evaluation and planning. When resources are available to conduct thorough case investigations, compile a de-duplicated database from cases ascertained from multiple sources, and analyze, interpret and disseminate the resultant information (the state of Mane is a good example of this “best practice”), then public health practitioners and their partners can focus preventive policies and program activities on the known exposure pathways and other determinants.

Experience gained from investigations of CO poisoning outbreaks (such as those related to post-storm power outages) has shown both the limitations of secondary data analysis and the challenges of attempting to establish ad-hoc case ascertainment methods based upon reporting. The establishment and maintenance of data systems based on reporting of CO poisoning, which are useful for routine surveillance of the sporadic cases, finds particular value during an outbreak.

V. Methods for Surveillance: Surveillance for Carbon Monoxide Poisoning should use the following recommended sources of data and the extent of coverage listed in Table V.

Describe the sources of data specified for case identification: clinician reporting, laboratory reporting, reporting by other entities (e.g., hospitals, veterinarians, pharmacies), death certificates, hospital discharge or ambulatory/outpatient records, extracts from electronic medical records, telephone survey, school-based survey, etc., or some combination of these as appropriate. Distinguish between reporting from sentinel sites and population-wide case identification. Recommended format for Table V is provided below.

Every jurisdiction in the US has a Poison Control Center (PCC) staffed by specialists who assess calls for information regarding exposures to toxic substances and calls for assistance regarding illnesses where a toxic substance is suspected of being the cause, and dispense medical advice under the authority and control of a Medical Director.When state law or rule requires reporting of carbon monoxide poisoning by clinicians, PCCs are required to report. Language in the reporting rule should refer to PCCsexplicitly.

Reporting of carbon monoxide poisoning by PCCs constitutes the core case finding method. Surveillance systems vary, and are described here as operating in four hierarchical tiers, each inclusive of the one which is less comprehensive:

  1. PCC only
  2. Multi-source case-finding (includes PCC)
  3. Multi-source case-finding with matching, for linkage and de-duplication
  4. Multi-source case-finding with matching and case-investigation

When resources are available, surveillance activities operating at tier 4 have the greatest effectiveness.

Paragraph on trade-offs in tier 2 vs tier 3 (Prakash)

Multi-source case-finding includes CO poisoning case ascertainment from laboratory reporting of carboxyhemoglobin (COHb) test results, case-based reporting from hospital emergency departments (EDs), case-based reporting from Medical Examiners and Coroners, automated reporting from electronic medical records, and review of death certificates and administrative records (such as workers compensation).

Each source used for CO poisoning case ascertainment has different characteristics: it may have good sensitivity/completeness (few false negatives); it may have good positive predictive value (few false positives);it may have good timeliness; it may include many unique cases (not found in other data sources);and/or it may have high information value (including facts about the route of exposure or other contributing factors which are less reliable in other sources).No single data source possesses all of these characteristics.

Poison Control Center data has high information value andcontains many uniques. Cases where CO exposure is well documented, such as by air monitoring equipment, but the individual is asymptomatic, may not be found in other data sources. Calls to PCC can have very good timeliness; rapid dispatch of a municipal fire department vehicle in New York City as a consequence of a call to the PCC is an illustrative example. Every 3-5 minutes, PCCs send electronic case information to the American Association of Poison Control Centers (AAPCC) for the National Poison Data System (NPDS). Anomaly alert analysis is conducted by NPDS every hour; toxicosurveillance staff confirm clusters found this way with the originating PCC; and, alerts can be issued. Surveillance staff in the CDC National Center for Environmental Health have full access to NPDS data, and staff in state and territorial health agencies can be enabled similarly. The sensitivity of PCC reporting is moderate: many of the most severe cases are missed, such as out-of-hospital deaths.

Laboratory reporting of carboxyhemoglobin (COHb) test results has high information value for clinical aspects, but low information value for details of exposure. It also contains few unique cases, and has low PPV due to high COHb values in heavy smokers.

Case-based reporting from Medical Examiners and Coroners (ME/C) has good sensitivity for the most severe cases (out-of-hospital deaths may be uniquely found here), and good PPV. Details from death investigations can provide excellent information value about exposure pathways and other contributing factors. ME/C data often has low timeliness.

Case-based reporting from hospital EDs has good sensitivity and good PPV, but may havelow information value for details of exposure.Clarifying language (Leslie)

Automated reporting from electronic medical records is an unproven method for CO poisoning case ascertainment with a high potential for great utility in the future.Add language on EDs? Meaningful use??

Review of death certificates and administrative records, such as workers compensation records, obviously has low timeliness, but may have high sensitivity. Information about work-relatedness, for example, may be best found in this manner.

Table V. Recommended sources of data for case identification and extent of coverage for ascertaining cases of [condition].

Source of data for case identification / Coverage
Population-wide / Sentinel sites
Clinician reporting (includes reporting from Poison Centers) / X
Laboratory reporting / X
Reporting by other entities (hospitals) / X
Death certificates / X
Hospital discharge or outpatient records / X
Extracts from electronic medical records / X
Telephone survey
School-based survey
Other ______

VI. Criteria for case identification

If the method for surveillance described in the previous section includes case identification by reports of individual cases from traditional partners (e.g., clinicians, labs, hospitals) to governmental public health agencies, then describe the reporting criteria which trigger the case reports. If case-finding is based on secondary analysis of administrative or clinical data (such as vital records, hospital or EMS databases), describe the method used to identify cases separately for each data source. This section should provide suggested criteria to be applied by medical care providers (i.e., based on clinical judgment and clinical diagnosis) and laboratory staff.

A. Narrative: A description of suggested criteria that may be for case ascertainment of a specific condition.

In this subsection, where case-finding is based on reporting, use narrative text to allow the criteria for reporting to be clearly understood by clinicians and institutional staff who bear responsibility for sending case reports. As appropriate, describe in three separate labeled parts:

  • Clinical presentation criteria
  • Laboratory criteria for diagnosis
  • Criteria for epidemiologic linkage

The suggested criteria for reporting should include specification of whether reporting is to be all-inclusive, or limited to reporting only when the condition is work-related; likewise, include specification of whether condition reporting is to be on-going and routine, or limited to reporting only when there are multiple cases indicative of an outbreak. If the method for surveillance includes case identification by reports of individual cases to governmental public health agencies, then specify the suggested reporting timeframe: immediate reporting of cases versus standard reporting of cases; specify if a subset of cases of the condition are handled differently (see CSTE List of Nationally Notifiable Conditions for examples of immediate and standard categories in disease/condition subtypes ).

Where case-finding is based on secondary analysis of administrative or clinical data, use narrative text to allow the criteria for case-finding to be clearly understood by the data analysts. Examples are: “A person whose healthcare record contains a diagnosis of [[condition]]” or “A person whose death certificate lists [[condition]] as a cause of death or a significant condition contributing to death.”

B. Table of criteria to determine whether a case should be reported to public health authorities

In this subsection, use tables to express the suggested criteria appropriate to guide development of computerized algorithms for electronic case-reporting processes. Recommended format for Table VI-B is provided below.

Where case-finding is based on secondary analysis of administrative or clinical data, use a separate column for each specified data source.

Table VI-B. Table of criteria to determine whether a case should be reported to public health authorities.

Criterion / Reporting
Disease or Condition Subtype / Reporting
Disease or Condition Subtype / Reporting
Disease or Condition Subtype
Clinical Evidence
Laboratory Evidence
EpidemiologicalEvidence

C. Disease-specific data elements

Disease-specific data elements are expected to be included in all reports of individual cases to governmental public health agencies for all reportable conditions, regardless of whether the report is submitted by telephone, by use of a standard paper-based form, or electronically. Disease-specific data elements are in addition to the common data elements that are to be reported for all individual case reports (see CSTE position statement 09-SI-01 “Common Core Data Elements for Case Reporting and Laboratory Result Reporting” Public health authorities do not expect that the initial report will contain all the information necessary for case investigation and case classification for all cases reported, for all conditions. For many conditions, the process of case investigation requires obtaining further case information from a clinician or directly from a case. Disease-specific data elements that are included when case information is sent from state health agencies to CDC (“notification”) generally differ from that obtained in the initial report.The focus here is on the disease-specific data elements to be included in the initial report. In this subsection, list these disease-specific data elements. (Do not list the common data elements, which are expected to be included for all conditions in all reports of individual cases.)

Where case finding is based on secondary analysis of administrative data, include list of data elements expected to be extracted from source data repositories for each record.

VII. Case Definition for Case Classification

A. Narrative:Description of criteria to determine how a case should be classified.

Case definitions contain criteria for case classification. Describe, in three separate labeled parts:

  • Clinical Criteria
  • Laboratory Criteria for Diagnosis
  • Epidemiologic Linkage

Stratify as appropriate, providing criteria for: complete clinical presentation vs. a “clinically compatible” case; laboratory confirmed vs. supportive laboratory results; epidemiologic linkage to a laboratory-confirmed case vs. epidemiologic linkage to any other case.

B. Classification Tables

As appropriate, list criteria for:

  • Suspected Cases: cases where clinical features were compatible with the diagnosis, but either further investigation is required or investigation of the case did not provide supporting evidence for the diagnosis
  • Probable Cases: cases where alternative etiologies were investigated and excluded, and/or where substantial supportive information for the diagnosis was found
  • Confirmed Cases: cases with the highest level of certainty.

Include Table VII-B in main body of position statement section VII, subsection B. Recommended format for Table VII-B is provided below. Where appropriate, such as where case finding may be based on both reporting and secondary analysis of administrative data, list case classifications separately for each data source which is specified for case identification.

Table VII-B. Criteria for defining a case of [condition].

Criterion / Suspected / Probable / Confirmed
Clinical Evidence
Laboratory evidence
Epidemiologic evidence
Criteria to distinguish a new case

VIII. Period of Surveillance

Indicate whether surveillance is expected to be on-going or limited to a specific time period.

IX. Data sharing/release and print criteria

As appropriate, describe:

  • Expectations for sharing of case data (dataflow/notification from state/territorial health agency to CDC)and limitations on data sharing (e.g., states and territories will send CDC data for selected cases based on case classification; states and territories will send core/generic data or supplemental/extended data)
  • Limitations on data re-release by CDC(e.g., only fully de-identified case data will be released by CDCto the general public, other releasesby CDC require signed data sharing agreements using a format pre-approved by the state/territorial health agency) [refer to CDC-CSTE Intergovernmental Data Release Guidelines Working Group (DRGWG) Report: CDC-ATSDR Data Release Guidelines and Procedures for Re-release of State-Provided Data (available at as necessary]
  • Restrictions on the printing of counts of case data (e.g.,CDC publication criteria will exclude selected cases from final printed counts based on case classification; provisional case report data will not be used by CDC until verification procedures are complete).

X. References