PROBLEM/CONDITION: Every year in the United States, thousands of toxic substance incidents harm workers, first responders, and the public with the potential for catastrophic consequences. Surveillance data enable public health and safety professionals to understand the patterns and causes of these incidents, which can improve prevention efforts and preparation for future incidents. PERIOD COVERED: 2010-2014. DESCRIPTION OF SYSTEM: In 2010, the Agency for Toxic Substances and Disease Registry (ATSDR) initiated the National Toxic Substance Incidents Program (NTSIP), and it was retired in 2014. Nine state health departments participated in NTSIP surveillance: California, Louisiana, North Carolina, New York, Missouri, Oregon, Tennessee, Utah, and Wisconsin. The states conducted surveillance on acute toxic substance incidents, defined as an uncontrolled or illegal acute (lasting <72 hours) release of any toxic substance including chemical, biologic, radiologic, and medical materials. Surveillance focused on associated morbidity and mortality and public health actions. This report presents an overview of NTSIP and summarizes incidents and injuries from the nine participating states during 2010-2014. RESULTS: During 2010-2014, participating state health departments reported 22,342 incidents, of which 13,529 (60.6%) met the case definition for acute toxic substance incidents, and included 6,635 injuries among 5,134 injured persons, of whom 190 died. A trend analysis of the three states participating the entire time showed a decrease in the number of incidents with injuries. NTSIP incidents were 1.8 times more likely and injured persons were 10 times more likely to be associated with fixed facilities than transportation. Natural gas, carbon monoxide, ammonia, and chemicals used in illegal methamphetamine production were the most frequent substances in fixed-facility incidents. Sodium and potassium hydroxide, hydrochloric acid, natural gas, and sulfuric acid were the most frequent substances in transportation-related incidents. Carbon monoxide was the most frequent substance in incidents with a large number of injured persons, and chemicals used in illegal methamphetamine production were the most frequent substance in incidents involving decontamination. Incidents most frequently occurred during normal business days (Monday through Friday) and hours (6:00 a.m.-5:59 p.m.) and warmer months (March-August). The transportation and warehousing industry sector had the largest number of incidents (4,476); however, most injured persons were injured in their private residences (1,141) or in the industry sectors of manufacturing (668), educational services (606), and real estate rental and leasing (425). The most frequently injured persons were members of the public (43.6%), including students. Injured first responders, particularly police, frequently were not wearing any chemically protective equipment. Respiratory system problems (23.9%) were the most frequently reported symptoms among injured persons and, in a related finding, volatilization was the most frequent type of release in incidents with injured persons. INTERPRETATION: Industrial and transportation incidents occur frequently and have the potential for catastrophic outcomes. However, exposures to toxic substances occur frequently in other settings. Carbon monoxide, natural gas, and chemicals used in illegal methamphetamine production are commonly found in places where persons live, work, attend school, and recreate and are large contributors to incidents affecting the public. Having active NTSIP state surveillance programs did appear to improve the incidents with morbidity and/or mortality, but these programs have ended. PUBLIC HEALTH ACTION: Archived NTSIP public use data are available to download from the website for analysis. There are also many publications and reports on the website to help understand chemical risks. In addition, jurisdictions might choose to collect surveillance data themselves in a similar manner to what NTSIP states did. Chemical incident surveillance data can be used by public health and safety practitioners, worker representatives, emergency planners, preparedness coordinators, industries, and emergency responders to prepare for and prevent chemical incidents and injuries. As noted by the U.S. Chemical Safety Board, more action needs to be taken to prevent large industrial incidents. Although preventing such incidents might not be in the realm of public health, describing the public health implications and preparing for them is. Another important finding of NTSIP is that industrial incidents are only part of the problem. For example, a large number of persons were injured in a private residence or vehicle (22.2%) and an educational facility (11.8%). Public health professionals must resourcefully target prevention and preparedness to protect vulnerable populations in locations where they might spend time (e.g., schools, daycares, nursing homes, recreational areas, jails, prisons, and hospitals). Reducing the threat of chemical incidents and injuries in the United States will require a concerted effort with a variety of stakeholders including industry and labor, responder groups, policymakers, academia, and citizen advocacy groups.

BACKGROUND: Carbon monoxide (CO) is an insidious gas responsible for approximately 21,000 emergency department visits, 2300 hospitalizations, and 500 deaths in the United States annually. We analyzed 10 combined years of data from two Agency for Toxic Substances and Disease Registry acute hazardous substance release surveillance programs to evaluate CO incident-related injuries. METHODS: Seventeen states participated in these programs during 2005-2014. RESULTS: In those 10years, the states identified 1795 CO incidents. Our analysis focused on 897 CO incidents having injured persons. Of the 3414 CO injured people, 61.0% were classified as general public, 27.7% were employees, 7.6% were students, and 2.2% were first responders. More than 78% of CO injured people required hospital or pre-hospital treatment and 4.3% died. The location for most injured people (39.9%) were homes or apartments, followed by educational facilities (10.0%). Educational services had a high number of people injured per incident (16.3%). The three most common sources of CO were heating, ventilation, and air conditioning systems; generators; and motor vehicles. Equipment failure was the primary contributing factor for most CO incidents. CONCLUSIONS: States have used the data to evaluate trends in CO poisoning and develop targeted public health outreach. Surveillance data are useful for setting new policies or supporting existing policy such as making CO poisoning a reportable condition at the state level and requiring CO alarms in all schools and housing. Public health needs to remain vigilant to the sources and causes of CO to help reduce this injury and death.

IntroductionFirst responders, including firefighters, police officers, emergency medical services, and company emergency response team members, have dangerous jobs that can bring them in contact with hazardous chemicals among other dangers. Limited information is available on responder injuries that occur during hazardous chemical incidents. METHODS: We analyzed 2002-2012 data on acute chemical incidents with injured responders from 2 Agency for Toxic Substances and Disease Registry chemical incident surveillance programs. To learn more about such injuries, we performed descriptive analysis and looked for trends. RESULTS: The percentage of responders among all injured people in chemical incidents has not changed over the years. Firefighters were the most frequently injured group of responders, followed by police officers. Respiratory system problems were the most often reported injury, and the respiratory irritants, ammonia, methamphetamine-related chemicals, and carbon monoxide were the chemicals more often associated with injuries. Most of the incidents with responder injuries were caused by human error or equipment failure. Firefighters wore personal protective equipment (PPE) most frequently and police officers did so rarely. Police officers' injuries were mostly associated with exposure to ammonia and methamphetamine-related chemicals. Most responders did not receive basic awareness-level hazardous material training. CONCLUSION: All responders should have at least basic awareness-level hazardous material training to recognize and avoid exposure. Research on improving firefighter PPE should continue. (Disaster Med Public Health Preparedness. 2018;12:211-221).

Methamphetamine (meth), a highly addictive drug, can be illegally manufactured using easily acquired chemicals; meth production can cause fires, explosions, injuries, and environmental contamination. To analyze injury incidence and trends, data on 1,325 meth-related chemical incidents reported to the Agency for Toxic Substances and Disease Registry's (ATSDR) Hazardous Substances Emergency Events Surveillance (HSEES) system and National Toxic Substance Incidents Program (NTSIP) by the five participating states (Louisiana, Oregon, Utah, New York, and Wisconsin) with complete information during 2001-2012 were examined. The findings suggested that meth-related chemical incidents increased with the drug's popularity (2001-2004), declined with legislation limiting access to precursor chemicals (2005-2007), and increased again as drug makers circumvented precursor restrictions (2008-2012). Seven percent of meth-related chemical incidents resulted in injuries to 162 persons, mostly members of the general public (97 persons, including 26 children) and law enforcement officials (42). Recent trends suggest a need for efforts to protect the general public, particularly children and law enforcement officials. Because individual state legislative actions can result in increased illegal meth production in neighboring states, a regional approach to prevention is recommended.

PROBLEM/CONDITION: Acute chemical incidents (i.e., uncontrolled or illegal release or threatened release of hazardous substances lasting <72 hours) represent a substantial threat to the environment, public health and safety, and community well-being. Providing a timely and appropriate public health response can prevent or reduce the impact of these incidents. REPORTING PERIOD: 1999-2008. DESCRIPTION OF SYSTEM: The Hazardous Substances Emergency Events Surveillance (HSEES) system was operated by the Agency for Toxic Substances and Disease Registry (ATSDR) during January 1991-September 2009 to describe the public health consequences of chemical releases and to develop activities aimed at reducing the harm. This report summarizes types, frequency, and trends in public health actions taken in response to hazardous substance incidents in the nine states (Colorado, Iowa, Minnesota, New York, North Carolina, Oregon, Texas, Washington, and Wisconsin) that participated in HSEES during its last 10 full years of data collection (1999-2008). RESULTS: Of the 57,975 HSEES incidents that occurred during 1999-2008, a total of 15,203 (26.2%) incidents resulted in at least one public health action taken to protect public health. Evacuations were ordered in 4,281 (7.4%) HSEES incidents, shelter in place was ordered in 509 (0.9%) incidents, and access to the affected area was restricted in 10,345 (25.9%) incidents. Decontamination occurred in 2,171 (3.7%) incidents; 13,461 persons were decontaminated, including 1,152 injured persons. Actions to protect public health (e.g., environmental sampling or issuance of health advisories) were taken in 6,693 (11.5%) incidents. The highest number of evacuations and orders to shelter in place occurred in Washington (n = 558 [16.1%] and n = 121 [3.2%], respectively). Carbon monoxide and ammonia releases resulted in the highest percentage of orders to evacuate and shelter in place. The most frequently reported responders to chemical incidents were company response teams. INTERPRETATION: The most frequent public health response was restricting access to the area (26% of incidents), public health actions (12%), evacuation (7%), decontamination (4%), and shelter-in-place (1%). Ammonia and carbon monoxide were associated with adverse health effects in the population and the most public health response actions. Therefore, these chemicals can be considered a high priority for prevention and response efforts. Public Health Implications: States and communities can collaborate with facilities to use the information collected through community right-to-know legislation and this report to improve chemical safety and protect public health and the environment, such as being prepared to handle the most common chemicals in their area and probable public health actions.

OBJECTIVE: To evaluate the validity of proxy interviews in obtaining information on persons with rapidly fatal diseases such as malignant mesothelioma (MM). METHODS: Persons with MM diagnosed in 2002 through 2005 in New York and New Jersey and 1997-2004 in Wisconsin were eligible for inclusion in the project. Persons with MM and their family member proxy were interviewed using the same questionnaire designed by ATSDR to collect information on potential direct or indirect occupational and environmental exposure to asbestos, genetic, and health related malignancy predisposition, and exposure to tobacco products. Descriptive statistics and the McNemar/Durkalski test were used to analyze 33 matched pairs. RESULTS: The overall study confirmed a generally high ability of proxies to give interviews of comparable quality and completeness when asked dichotomous questions. The reliability of information collected from proxies varied by topic and family relationship. CONCLUSIONS: Family proxy interviews, using dichotomous responses, can serve as an acceptable source of information about health and exposure-related risk factors for MM.

OBJECTIVES: Methamphetamine (meth) is a highly addictive drug of abuse that can easily be made in small illegal laboratories from household chemicals that are highly toxic and dangerous. Meth labs have been found in locations such as homes, outbuildings, motels, and cars. Its production endangers the "cook," neighbors, responders, and the environment. This article describes surveillance data used to examine the emergence and public health impacts of illicit clandestine meth labs, as well as two states' efforts to thwart lab operations and prevent responder injuries. METHODS: We analyzed data collected from 2001 to 2008 by 18 states participating in the Agency for Toxic Substances and Disease Registry's Hazardous Substances Emergency Events Surveillance (HSEES) Program to examine the occurrence and public health impacts of clandestine meth production. RESULTS: HSEES data indicate that the majority of clandestine meth lab events occurred in residential areas. About 15% of meth lab events required evacuation. Nearly one-fourth of these events resulted in injuries, with 902 reported victims. Most victims (61%) were official responders, and one-third were members of the general public. Since 2004, with the implementation of local and federal laws and prevention activities, the number of meth lab events has declined. Increased education and training of first responders has led to decreased injuries among police officers, firefighters, and emergency medical personnel. CONCLUSIONS: HSEES data provided a good data source for monitoring the emergence of domestic clandestine meth production, the associated public health effects, and the results of state and federal efforts to promote actions to address the problem.