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DRAFT REPORT

Benchmarking Risk of Injury and Death from TSSA-

Regulated Activities against Other Jurisdictions

Prepared for: TSSA

7 August 2015

Benchmarking Risk of Injury and Death from TSSA-Regulated Activities against Other Jurisdictions

7 AUGUST 2015 II

Contents 1. Introduction .............................................................................................................................................. 3

1.1 Report Structure ................................................................................................................................. 3

1.2 Considerations for Data Interpretation .............................................................................................. 4

2. Methods .................................................................................................................................................... 4

2.1 Development, Augmentation, and Refinement of Search Terms ....................................................... 4

2.2 Review of the Academic Literature ..................................................................................................... 4

2.3 Broad Web-based Research ................................................................................................................ 5

2.4 Organization-specific Searches ........................................................................................................... 5

3. Results ....................................................................................................................................................... 5

3.1 Elevating Devices ................................................................................................................................ 5

3.2 Amusement Devices ........................................................................................................................... 7

3.3 Ski Lifts .............................................................................................................................................. 11

3.4 Boilers and Pressure Vessels ............................................................................................................. 12

3.5 Carbon Monoxide Poisoning (Fuels) ................................................................................................. 13

4. Discussion ................................................................................................................................................ 18

4.1 Regulatory Variation ......................................................................................................................... 18

4.2 Performance Reporting Variation ..................................................................................................... 19

4.3 Usefulness of Performance Benchmarking ....................................................................................... 20

References .................................................................................................................................................. 21

Appendix A - Relevant search terms. .......................................................................................................... 25

Appendix B - List of organizations with mandates similar to that of TSSA ................................................. 26

Appendix C - Population estimates for jurisdictions of relevance .............................................................. 28

Appendix D - Studies of injuries/deaths from carbon monoxide poisoning ............................................... 32


DRAFT: 7 AUGUST 2015 3

1. Introduction

As an adjunct to its Annual Public Safety Performance Report (ASPR), the Technical Standards and Safety

Authority (TSSA) is interested in improving its understanding of its performance in managing risks to the

public relative to similarly mandated organizations in other jurisdictions. This report describes TSSA

public safety incident data in the context of incidents reported by other similar organizations. In most

respects, the report is similar to a previous report (RSI, 2014), except for the more extensive analysis of

carbon monoxide poisonings included in this report. The purpose or replicating the prior analysis is to

maintain a complete discussion in a single report that is updated annually.

The ongoing exercise has three main objectives:

1. To update findings from a previous report (RSI, 2014) summarizing international statistics regarding injury and death associated with TSSA-regulated activities, in order to provide ongoing context for analysis of cross-jurisdictional variation in regulatory and reporting requirements.

2. To facilitate dialogue with regulators in other jurisdictions on public safety and risk management regarding the collection of data and its interpretation to support improvements in the safety of regulated technological systems.

3. To assist with the communication of the level of risk faced by the Ontario public.

This report is not intended as a comment on the success or failure in risk management by the TSSA or by any other institution. The levels of risk cited or estimated in this report should not be used to infer or imply the tolerability of current levels of risk from various sources and activities. Rather, this report seeks to compare safety levels across international jurisdictions in order to provide insight for a broader discussion centered on variability in regulatory and performance reporting requirements. While the focus is on international comparisons, incident data from the British Columbia Safety Authority (BCSA), perhaps the organization most similar to the TSSA, are also included for comparison.

1.1 Report Structure

The remainder of this section includes a discussion of important considerations in understanding and interpreting the data presented. Section 2 describes the project approach and methods. Section 3 provides tables summarizing risks from TSSA-regulated sectors and making comparisons with similar risks in international jurisdictions. Subsections 3.1 to 3.4 update previously summarized data (RSI 2014) regarding performance in technology sectors related to elevating and amusement devises, ski lifts, boiler and pressure vessels. Compared to the previous report (RSI, 2014), the current report provides more information on injuries and deaths associated with carbon monoxide poisoning. Carbon monoxide poisoning statistics are summarized in subsection 3.5. Section 4 discusses cross-jurisdictional variability in regulatory and reporting requirements, which may help explain the observed disparities and inform the process for TSSA performance benchmarking in the future. Section 5 provides key messages and conclusions.


DRAFT: 7 August 2015 4

1.2 Considerations for Data Interpretation

This report summarizes and reviews information from international jurisdictions on injuries associated with technologies that are regulated by the TSSA. As previously described, comparability of these data to TSSA’s data is limited due to substantial variations in the characteristics of the data including the following:

Differing populations covered by injury and fatality data, including entire jurisdictional populations, hidden tourist population inflow, subpopulations that are engaged in the activity (e.g. amusement park attendees), or populations that are the focus of a specific statistical report (e.g. children);

sources of data, such as national fatality records, or estimations made from actual numbers from a sample of reporting centers (e.g., the CPSC NEISS);

regulatory data for jurisdictions with different regulatory categories, numbers of devices, and performance metrics;

definitions of injuries that are captured;

definitions of causal factors;

the time period included in the numbers reported; and

expression of the denominator value and units in incidence rates, for example in units of per million general population per year, or a subpopulation of device users, or occupational group, or the number of passenger miles.

Recognition of these constraints informs a discussion of the limitations of benchmarking efforts, and the possibility of standardizing reporting formats among jurisdictions who are interested in collecting and sharing more comparable data to improve safety in all jurisdictions.

2. Methods

The following steps have been taken to ensure a systematic approach to the search for information.

2.1 Development, Augmentation, and Refinement of Search Terms

Initial search terms and phrases were selected based on our understanding of the TSSA’s mandates and general knowledge regarding the types of regulatory and performance information required to conduct an appropriate analysis. As the research progressed, the search strategy was refined. Appendix A provides a list of main and partnered search terms and phrases used in identifying relevant regulatory and performance information.

2.2 Review of the Academic Literature

Peer-reviewed literature was searched using Web of Science, Pubmed, Google Scholar, and Medline as the primary bibliographic databases With the exception of data on carbon monoxide poisoning, this approach did not prove very successful, given that most information is released through private or public regulatory institutions, rather than independent academic research publications.



2.3 Broad Web-based Research

The academic literature search was supplemented with a review of the grey literature, identified by inputting the search terms listed in Appendix A into the Google Search Engine. This helped to identify a broader array of references as well as further key organizations with mandates similar to the TSSA.

2.4 Organization-specific Searches

Appendix B identifies key organizations with mandates similar to that of the TSSA that were researched independently of the broad web search.

3. Results

For the purposes of this analysis, risk summaries are provided for Elevating Devices, Ski Lifts, Amusement Devices, Boilers and Pressure Vessels, and Fuels. For the fuels program, the focus in this report is on injuries from exposure to carbon monoxide (CO), as this causes the greatest number of injuries. Data on Boilers and Pressure Vessels involve mainly occupational risks. Exposure to CO can occur in occupational and non-occupational settings. All other comparisons are focused on the risk to the public rather than on occupational risks associated with these technologies. Estimates of relevant populations by jurisdiction and year, used to calculate injury and fatality rates, are included in Appendix C.

No international organization was identified with a mandate identical to that of the TSSA. The British Columbia Safety Authority (BCSA) regulates a very similar set of activities and is considered the best regulatory comparator. While its data is included for comparison in the summary tables, the BCSA is not included in the discussion due to the international focus of this report. Key data sources included the United States Consumer Product Safety Commission (CPSC) and its National Electronic Injury Surveillance System (NEISS) and the European Lift Association, which presents data on elevating device injury across the European Union.

3.1 Elevating Devices

Obtaining data on injury and fatality risks associated with elevators and escalators is difficult, and not all information available is from regulatory agencies. A further challenge is that many organizations may not distinguish between risks from different types of elevating devices or may only be concerned with a certain type (e.g., elevators but not escalators). This can make performance benchmarking complicated and obscure proper comparisons

Key findings for risks associated with elevators and escalators in international jurisdictions are listed in Tables 1A and 1B, respectively. Cells left blank do not indicate a value of zero, but rather that information was not reported. Most European data was obtained from a single presentation by the European Lift Association, where little information was available on the reporting process or definition of “injury.” This differs from the TSSA and BCSA distinction between permanent and non-permanent (or major and minor) injuries. While for the purposes of this report these categories have been combined into a single “injury” total, it should be noted that non-permanent injuries (such as superficial injuries like scrapes and bruises) make up the majority of this figure. Meanwhile, for example, the substantial difference in the United Kingdom 2002 and 2011 injury rate suggests the possibility that the ELA reporting process may produce statistics that underestimate the risk.



Table 1A Injuries and deaths associated with elevators

Jurisdiction, Year (Reference) Injuries Deaths Rate (Per 1M pop/yr)

Ontario, 2015 (TSSA) 127 0 9.77 injuries


British Columbia, 2014 (BCSA, 2014a) 62 (see page 8)

01 13.39 injuries

British Columbia, 2013 (BCSA, 2014) (all elevating devices)

38 0 8.29 injuries

United Kingdom 2001 (HASS & LASS, 2002; hospital visits)

1,722 29.07 injuries

United Kingdom, 2011 (ELA, 2013) 141 2.2 injuries

Unites States, 2014 (CPSC NEISS)2 10,969 34.40 injuries

United States, 2013 (CPSC NEISS) 11,172 36.19 injuries

United States 1992-2009 (McCann, 2013) 89 (deaths to passengers while

at work)

0.016 deaths (while at work)3

United States 1997 to June 2010 (McCann, 2013)

91 (deaths to passengers while

not at work)

0.016 deaths (while not at

work)4

United States 1992-2003 (McCann & Zaleski, 2006; excludes 176 work-related deaths occurring outside of the elevator)


at work)

0.02 deaths (while at work)

United States 1997-2006 (McCann & Zaleski, 2006)


not at work

0.02 deaths (while not at

work)

Belgium, 2011 (ELA, 2013) 13 1.3 injuries

Czech Republic, 2010 (ELA, 2013) 2 0.2 injuries

Denmark, 2010 (ELA, 2013) 1 1 0.2 injuries 0.2 deaths

Finland, 2010 (ELA, 2013) 39 7.3 injuries

France, 2011 (ELA, 2013) 270 4.1 injuries

Germany, 2011 (ELA, 2013) 65 2 0.8 injuries 0.025 deaths

Hungary, 2010 (ELA, 2013) 1 0.1 injuries

Italy, 2010 (ELA, 2013) 99 1.6 injuries

Luxembourg, 2009 (ELA, 2013) 1 2 injuries

Norway, 2011 (ELA, 2013) 2 0.4 injuries

Romania, 2010 (ELA, 2013) 11 2 0.5 injuries

1 All severe cases were related to railway incidents (page 8); it can be inferred that there were no fatalities related to elevator incidents 2 National injury estimate: http://www.cpsc.gov/cgibin/NEISSQuery/PerformEstimates.aspx. The code for “Elevators or other lifts (excl. escalators, hoists, jacks, forklifts and automotive lifts)” is 1889 (see NEISS Coding Manual at http://www.cpsc.gov//Global/Neiss_prod/completemanual.pdf) 3 The population number (292,390,920) was obtained by averaging over 2000-2009. 4 The population number (294,012,918) was obtained by averaging over 2000-2010.

http://www.cpsc.gov/cgibin/NEISSQuery/PerformEstimates.aspx



0.09 deaths

Switzerland, 2011 (ELA, 2013) 27 3.5 injuries

Tehran, 1999-2003 (Khaji and Ghodsi, 2014)

63 (“serious injury”)

15 1.73 serious injuries

0.41 deaths5

Greece, 1998–2010 (Zarikas et al., 2013) 52 (34 non-fatal)6

18 0.44 injuries (0.29 non-fatal)

0.15 deaths7

Table 1B Injuries and deaths associated with escalators




United States, 2003 (O’Neil et al., 2008) 7,300 24.9 injuries

United States, 1997-June 2010 (McCann, 2013)


not at work)

0.01 deaths8

United States, 2006 (McCann & Zaleski, 2006) 24 0.01 deaths

Unites States, 2014 (CPSC NEISS) 12,7749 40.1 injuries


United Kingdom 2001 (HASS & LASS, 2002) 3,157 53.30 injuries

Switzerland, 2000-2010 (Schminke et al., 2012)

173 2.02 injuries

3.2 Amusement Devices

Benchmarking of amusement devices also presented certain challenges. Primarily, TSSA regulates fixed and traveling rides, including inflatable rides, water slides, go-carts, and ski lifts; this does not appear to reflect the mandate of some international jurisdictions. In the United States, for example, there is federal oversight only for mobile site rides, and none for fixed-site amusement devices (Mikol, 2007). Even though oversight for mobile site rides is conducted by the CPSC, it regulates such a broad set of technologies that little focus can be put on amusement device safety regulations. This can make comparison of the TSSA and CPSC and their associated statistics problematic. State law regulates injury surveillance and dictates the type of information collected, which allows the International Association of Amusements Parks and Attractions to track injury data. However, the outcomes of this surveillance are not released to the public (Mikol, 2007). Most information uncovered discusses amusement device injury in the context of medical case studies, with little data regarding annual incidence and overall risk. European data is presented in a report from the European Commission Directorate-General for Health and Consumer Protection (2005)

5 The population number (7,278,182.5) was obtained by averaging 1996 and 2006 census data (6,758,845 and 7,797,520, respectively). http://www.citypopulation.de/php/iran-tehrancity.php 6 Data from table 7 of the publication: (NIN-no injury; LET-fatal injury) 7 The population number (10,677,920) was obtained by averaging population numbers over 2000-2010 8 The population number (294,012,918) was obtained by averaging over 2000-2010 9 National injury estimate: http://www.cpsc.gov/cgibin/NEISSQuery/PerformEstimates.aspx. The code for escalators is 1890 (see NEISS Coding Manual at http://www.cpsc.gov//Global/Neiss_prod/completemanual.pdf)




derived from the European Union Public Health Information Network (EUPHIN) database, which tracks emergency room visits resulting from incidents at “Amusement Parks”, including circuses, Tivoli, zoos, animal parks, fairgrounds, and holiday recreation centers. Since the EUPHIN project ended in 2002, this information is somewhat out of date. Table 2 summarizes data on injuries and deaths on amusement rides in Ontario, British Columbia, the United States, and some European countries.

Table 2 Injuries and deaths associated with amusement devices




British Columbia, 2014 (BCSA, 2014a10) 11 2.38 injuries

British Columbia, 2013 (BCSA, 2014) 12 0 2.62 injuries

United States, 2006 (CPSC 417 rides) 17,767 59.5 injuries

United States, 2011 (Safety Council, 2011) 1,204 3.86 injuries

Unites States, 2014 (CPSC NEISS) 27,91711 87.55 injuries


United States, 2010 (Woodcock, 2014; analysis based on data from NEISS)

13,770 (reviewed and

revised national estimate)12

44.35 injuries

United States, 2013 (IAAPA, 201413)

1,356 (attendance-

based estimate) 1,221

(ridership-based estimate)

4.7 (per 1M attendance) 0.9 (per 1M

patron-rides)

United States, 2012 (IAAPA, 2014) 1,424 (attendance-



4.6 injuries per 1M attendance 0.9 injuries per 1M patron-rides


based estimate)

4.3 injuries per 1M attendance 0.8 injuries per

1M patron-rides

10 page 8 at http://safetyauthority.ca/sites/default/files/sos_2014.pdf 11 National injury estimate: http://www.cpsc.gov/cgibin/NEISSQuery/PerformEstimates.aspx. The code for “Amusement attractions (incl. rides)” is 1293 (see NEISS Coding Manual at http://www.cpsc.gov//Global/Neiss_prod/completemanual.pdf) 12 746 records in the probability sample (used as the basis for the national estimate) were reviewed and 270 were excluded; 476 records were used as the basis of the revised estimate. 13 Fixed-site amusement ride injuries. Data from the IAAPA survey that included amusement and theme parks, tourist attractions, and family entertainment centers.




1,415 (ridership-based

estimate)





1M patron-rides





1M patron-rides





1M patron-rides




4.6 injuries per 1M attendance) 0.7 injuries per

1M patron-rides





1M patron-rides





1M patron-rides





1M patron-rides







1M patron-rides)

United States, 2013 (CPSC, 2015) 17,377 (estimated

number of ED-treated injuries

for inflatable amusements)

55.15 injuries

United States, 2012 (CPSC, 2015) 18,841 (same as above)

60.03 injuries

United States, 2011 (CPSC, 2015) 14,492 46.27 injuries









United States, January 2003 to December 2013 (CPSC, 2015)

12 (reported deaths)

0.0036 deaths14

United States, 2011 (International Association of Amusement Parks and

Attractions, 2011)

1415 (61 hospitalizations)

4.58 injuries

Canada, 1990-2009 (McFaull and Keays, 2013)

674 (CHIRPP surveillance

data on injuries associated with

inflatable amusement structures)

Not calculated15

Austria, 2001 (DG for Health and Consumers, 2005)

240 29.99 injuries

Belgium, 2001 (DG for Health and Consumers, 2005)

1,880 188 injuries

Denmark, 2001 (DG for Health and Consumers, 2005)

1,250 234.52 injuries

Finland, 2001 (DG for Health and Consumers, 2005)

340 65.75 injuries

14 The population number (303,828,782) was obtained by averaging over 2003-2013 15 CHIRPP is not population-based; data are collected from all 11 pediatric and 4 general hospitals across Canada



France, 2001 (DG for Health and Consumers, 2005)

960 16.34 injuries

Germany, 2001 (DG for Health and Consumers, 2005)


Greece, 2001 (DG for Health and Consumers, 2005)


Ireland, 2001 (DG for Health and Consumers, 2005)

180 47.66 injuries

Italy, 2001 (DG for Health and Consumers, 2005)

720 12.48 injuries

Luxembourg, 2001 (DG for Health and Consumers, 2005)

30 68.85 injuries

Netherlands, 2001 (DG for Health and Consumers, 2005)

625 39.4 injuries

Portugal, 2001 (DG for Health and Consumers, 2005)

2,400 235.34 injuries

Spain, 2001 (DG for Health and Consumers, 2005)

110 2.77 injuries

United Kingdom, 2001 (DG for Health and Consumers, 2005)


3.3 Ski Lifts

Data on ski lift risk in international jurisdictions was perhaps the most difficult to find. Academic data dealt almost exclusively with the risks associated with skiing and snowboarding, with little consideration of those arising from the lifts. Most data on ski lift risk is anecdotal in nature, with no mention of annual statistics. The few identified publications dealing with injury and fatality figures rely on long-term trends, as the yearly number of incidents is too low to be used directly. Further, data for most of the United States was difficult to acquire, as passengers falling out of chairlifts – one of the key sources of ski lift injury – is not usually recorded by state regulatory agencies; Colorado is one exception, being required to report falls resulting in injury to the Colorado Passenger Tramway Board (NSAA, 2012). As an example of how many injuries might be excluded by neglecting falls from chairlifts, 227 falls resulting in injury were recorded over an 11-season period in Colorado; 196 (86%) of these were attributed to skier error (NSAA, 2012). That other states might overlook these incidents could call into question state and national estimates for risk associated with ski lifts. Table 3 shows available data on injuries and deaths associated with ski lifts.

Table 3. Injuries and deaths associated with ski lifts.




British Columbia, 2009 to June 2014 (BCSA, 2014a)

1116 0 0.44 injuries17

16 Table 7.1-1 on p. 48 17 The population number (4,500,175) was obtained by averaging across 2009-2013



Deropement incidents on passenger ropeways

British Columbia, 2013 (BCSA, 2014) “Passenger ropeways”:

includes tramways, gondolas, chairlifts, rope tows and passenger conveyors

27 5.89 injuries

Unites States, 2014 (CPSC NEISS) 817+ (sample count) 18

United States 1973-Oct 2014 (NSAA, 2014)19

0.293 (average annual # of passenger fatalities)20

0.001 deaths21

United States 1973-2012 (NSAA, 2012) 0.33 0.001 deaths

New Zealand 2000-2005 (Smartt & Chalmers, 2009; injuries resulting in

hospitalization)

44 (7.33/year) 1.78 injuries

Colorado 2001-2012 (injuries from falls from lifts) (NSAA, 2012)

227(18.92/year) 3.97 injuries

3.4 Boilers and Pressure Vessels

Injuries associated with these devices occur mostly in occupational settings. As members of the public are not usually in the plants containing the boilers and pressure vessels, their exposure is limited. Data on injuries and deaths from incidents with boilers and pressure vessels are summarized in Table 4. . Note that rates are not calculated as numbers reported cover very different population sizes.

Table 4. Injuries and deaths associated with boilers and pressure vessels.


Ontario, 2015 (TSSA) 0 0 0 injuries

Ontario, 2014 (TSSA) 0 0 0 injuries

British Columbia, 2014 (BCSA, 2014a) (includes boiler, pressure vessel, and

refrigeration incidents)

022 0

18 Sample count from: http://www.cpsc.gov/cgibin/NEISSQuery/PerformEstimates.aspx. The code for ski lifts is 3283 (see NEISS Coding Manual at http://www.cpsc.gov//Global/Neiss_prod/completemanual.pdf). NEISS Injury data are gathered from emergency departments of 100 hospitals selected as a probability sample of over 5000 hospitals with emergency departments. Numbers for injuries associated with ski lifts were not extrapolated to give a national estimate 19 NSAA Ski Lift Safety Fact Sheet. October 31, 2014. http://www.nsaa.org/media/214677/Lift_Safety_Fact_Sheet_10_31_14.pdf 20 12 injuries during a 41-year period 21 The population number (298,307,193.5) was obtained by averaging over 2000-2013 22 The four injuries reported in 2014 were from exposure to ammonia in refrigeration (see pages 8 and 22)


http://www.cpsc.gov/Global/Neiss_prod/completemanual.pdf



British Columbia, 2013 (BCSA, 2014) (includes boiler, pressure vessel, and

refrigeration incidents)

22 0

Unites States, 2014 (CPSC NEISS) 36+ (sample count) 23

United States 2013 (CPSC NEISS) 26+24

3.5 Carbon Monoxide Poisoning (Fuels)

Carbon monoxide (CO) is a colourless and odourless gas that results from incomplete combustion of

fuels (e.g., natural gas, gasoline, oil, wood, coal). People can be exposed to CO in a domestic

settings and at work from furnaces, cooking appliances, water heaters, space heaters, boilers,

motor vehicles, generators and other tools or equipment that burn fuel. During winter months, the

use of heaters increases. If not functioning or ventilated properly, heaters can release high amounts

of CO. CO binds to hemoglobin at a rate 200-250 times greater than oxygen and significantly

reduces the oxygen-carrying capacity of blood. Exposure to relatively small amounts of CO in the air

can disrupt oxygen transport in the body and cause tissue hypoxia (inadequate oxygen supply). At

low CO concentrations, signs and symptoms of intoxication (headache, dizziness, and nausea) are

nonspecific and can be attributed to other causes. At very high concentrations, CO poisoning results

in unconsciousness and death (CDC, 2005; de Juniac et al., 2012; Henn et al., 2013). Children,

pregnant women, and people with pre-existing diseases, such as ischemic heart disease or chronic

obstructive pulmonary disease, are at higher risk of a severe outcome (Harduat-Morano and

Watkins, 2011).

TSSA's Fuels Safety Program regulates the transportation, storage, handling and use of natural gas,

propane, butane, hydrogen, digester gas, landfill gas, fuel oil, gasoline, and diesel25. Information on

CO poisonings associated with these fuels was, therefore, of primary interest. However, we also

included data on all unintentional non-fire related poisonings as a group, even though a fraction of

unintentional non-fire-related poisoning cases may be associated with burning of solid fuels (e.g.,

coal, wood).

As risk factors for CO poisoning change over time, only data for 2000 and later years were collected. Publications that include earlier data were disregarded. If a publication contains recent data and data for earlier periods, both were extracted into the Appendix D table.

The following reports were excluded:

23 Sample count from: http://www.cpsc.gov/cgibin/NEISSQuery/PerformEstimates.aspx. The code for boilers is 308 (see NEISS Coding Manual at http://www.cpsc.gov//Global/Neiss_prod/completemanual.pdf). NEISS Injury data are gathered from emergency departments of 100 hospitals selected as a probability sample of over 5000 hospitals with emergency departments. Numbers for injuries associated with boilers were not extrapolated to give a national estimate 24 As with all NEISS Injury data are gathered from emergency departments of 100 hospitals selected as a probability sample of over 5000 hospitals with emergency departments. Numbers were not extrapolated to give a national estimate 25 Information from Technical Standards & Safety Authority (TSSA) at https://www.tssa.org/regulated/fuels/Default.aspx



intentional CO poisonings or poisonings of unknown intent;

fire-related poisonings or poisonings with unknown relatedness to fire;

CO poisonings during power outages related to natural disasters;

Jurisdiction associated with the poisoning is not sufficiently clear to allow for an estimate of the source population such that rate calculations are not possible.

Data on injuries and deaths from CO poisoning are summarized in Table 5. More details can be

found in Appendix D. Identified articles include data on injuries/deaths from CO poisoning

associated with the use of gas, petrol26/diesel, oil, and with the use of consumer products.

However, in most analyzes, all unintentional non-fire-related CO poisonings were combined. The

contribution of poisonings associated with burning of solid fuel is unknown in these cases. The

contribution of CO poisonings from solid fuels may change over time and differ from population to

population. According to data from the UK (Co-Gas Safety, 2012), 30% of deaths (average) from

unintentional CO poisoning in 1995-2012 were related to burning of solid fuel. There appears to be

a trend towards a decrease in the proportion of deaths from CO poisonings associated with solid

fuel. In the US (CPSC 2014a), the estimated number of carbon monoxide deaths associated with the

use of consumer products was 156 for the period 2009-2011. Of these, only 13 (8%) were from

burning solid fuel and 6 (4%) were from burning unspecified fuel.

Some reports include a very detailed breakdown of cases by type of device/fuel used. It was not possible to extract data at this level of details.

Table 5. Annual rates of injuries and deaths from CO poisoning27

Jurisdiction Year Rate (per 1M per year) Reference

Injury Death

Incident associated with gas

Ontario, 2015 (TSSA)

2015 2.56 0.21 TSSA, 2015

Ontario, 2014 TSSA

2014 2.79 0.24 TSSA, 2014

British Columbia 2013 3.27 (non-fatal) 0.87 BC Safety Authority, 2014

British Columbia 2007-2013 3.53 (non-fata) 0.29 BC Safety Authority, 2014a

UK28 2010-2011 No data 0.29 Co-Gas Safety, 2013

UK 29 1996-2007 No data 0.3530 de Juniac et al., 2012

Great Britain 2012-2013 5.05 0.1531 Cross Government Group on Gas Safety and Carbon Monoxide (CO) Awareness Annual Report 2013-2014

26 “Gasoline” in the U.S. 27 This table includes data for the most recent year for which it is believed the data are fairly complete. More information (injuries and deaths by year, season, gender, age, circumstances etc.) can be found in Appendix D 28 Data for mains and portable gas combined 29 Data for liquefied petroleum gas and mains gas combined 30 Population average for 2000-2007 (60,141,183) was used for calculation of rates. 31 The population estimate for 2012 was used to calculate rates.




Injury Death

US32 2009-2011 No data 0.18 Consumer Product Safety Commission (CPSC), 2014a

Incident associated with oil

UK 2010-2011 No data 0 Co-Gas Safety, 2013

US 2009-2011 No data 0.006 Consumer Product Safety Commission (CPSC), 2014a

UK 1996-2007 No data 0.00433 de Juniac et al., 2012

Incident associated with petrol/diesel

UK 2010-2011 No data 0.06 Co-Gas Safety, 2013

US 2009-2011 No data 0.22 Consumer Product Safety Commission (CPSC), 2014a

Incident associated with generators and other engine-driven tools

US 2004-2013 No data 0.34 Consumer Product Safety Commission (CPSC), 2014c

US 1999-2012 No data 0.2434 Consumer Product Safety Commission (CPSC), 2013

Unintentional non-fire related poisonings

UK 2007 No data 0.46 de Juniac et al., 2012

England and Wales 2012 No data 0.4435 Fisher et al., 2014

England 2001-2010 4.9 (hospitalizations)36

No data Ghosh et al., 2015

US 2004-2006 70 (ED visits) 6 (hospitalizations)37

No data Centers for Disease Control and Prevention (CDC), 2008

US 2001-2003 (injuries) 2001-2002 (deaths)

52.7 (ED visits) 5.8 (hospitalizations)

1.738 CDC, 2005

US 1999-2004 No data 1.5339 CDC, 2007

US 2005 14.240 (hospitalizations)

No data Iqbal et al., 2010

US 2007 71 (ED visits) 8 (hospitalizations41

No data Iqbal et al., 2012ab

2009 No data 1.4342

32 Data for natural, liquid petroleum and unspecified gas combined 33 Population average for 2000-2007 (60,141,183) was used for calculation of rates 34 Population average over 2000-2012 35 Rate calculated by the study authors 36 Rate calculated by the study authors 37 Rates calculated by the study authors 38 Rates calculated by the study authors 39 Rate calculated by the study authors 40 Rate calculated by the study authors 41 Rates calculated by the study authors 42 Rate calculated by the study author

http://www.ncbi.nlm.nih.gov/pubmed/?term=Fisher%20DS%5BAuthor%5D&cauthor=true&cauthor_uid=24533843

http://www.ncbi.nlm.nih.gov/pubmed/?term=Centers%20for%20Disease%20Control%20and%20Prevention%20(CDC)%5BCorporate%20Author%5D





Injury Death

US, Minnesota 2007 64.4 (ED visits) 5.4 (hospitalizations)

1.743 Minnesota Environmental Public Health Tracking, 2009

US, Florida 2005-2007 (ED visits) 1999-2007 (hospitalizations and deaths)

14.2 (ED visits) 3.2 (hospitalizations)

1.544 Harduar-Morano and Watkins, 2011

US, Maine 2000-2003 (ED visits) 1999-2003 (hospitalizations and deaths)

86 (ED visits) 7 (hospitalizations)45

2 deaths were identified; rate not calculated

Graber and Smith 2007

US, Michigan 2013 No data 2.63 Michigan Department of Health and Human Services, 2015

Iran, Tabriz 2007-2009 346 28 Dianat and Nazari 2011

Iran, East Azerbaijan province

2003-2008 171 19 Nazari et al., 2010

Non-fire related occupational fatalities

U.S. 1992-2008 No data 0.17 per 1M full-time equivalent workers per year46

Henn et al., 2013

Unintentional non-fire related exposures (poison control center calls)

US 2000-2009 23.247 CDC, 2011

US, Minnesota 2007 103.648 Minnesota Environmental Public Health Tracking, 2009

As discussed in several publications, in particular by Ghosh et al., 2015, the number of cases of CO

poisoning may be underestimated as a result of:

misdiagnosis due to the nonspecific symptoms;

non-confirmation of diagnosis on hospital records and death certificates due to lack of awareness of CO poisoning by clinicians;

short half-life of CO in blood (4-6 h); confirming CO exposure is difficult if blood testing was delayed.

43 Rates calculated by study authors 44 Rates calculated by study authors 45 Rates calculated by study authors 46 Rate calculated by study authors 47 Rate calculated by study authors 48 Rate calculated by study authors

http://www.ncbi.nlm.nih.gov/pubmed/?term=Harduar-Morano%20L%5BAuthor%5D&cauthor=true&cauthor_uid=21387954


http://www.ncbi.nlm.nih.gov/pubmed/?term=Watkins%20S%5BAuthor%5D&cauthor=true&cauthor_uid=21387954



Estimates based on hospital administrative records are limited to exposures treated within the

health-care system. Cases managed at the site of exposure and not treated at a health-care facility

cannot be identified from these sources (CDC 2011).

On the other hand, there exist a possibility of overestimating the number of unintentional

poisonings: exclusion of injuries/deaths related to self-harm may not be complete due to

underreporting of self-harm (Cross Government Group on Gas Safety and Carbon Monoxide

Awareness, 2014).

Time trends observed in the data, especially increases seen in more recent years compared with

previous years, should be interpreted with caution. Although reasons are not clear, improved

reporting or better case ascertainment might account for apparent increases (Minnesota

Environmental Public Health Tracking, 2009).

There are significant constraints on the comparability of collected data. The characteristics that may

differ among data sets include:

Different sources of information on CO poisoning: media reports, data on emergency department (ED) visits or hospitalizations from hospitals or other public health databases, data on CO exposures from poison centers. Analyses of hospital admissions characterize more severe poisonings than those based on ED visits. Data from poison centers include individuals treated at a health-care facility and those who did not seek medical care. According to CDC (2011), 45% of CO exposures reported to the National Poison Data System (NPDS) in 2000-2009 were managed at the site of exposure. These would not have been identified through health care records. The sources of information on CO poisoning are described in Figure 1 (copied from Iqbal et al., 2012).

Population distribution by age and gender. Generally, there are more CO exposures and more emergency department visits among females but the rates of hospitalization and death are higher in males (Harduar-Morano and Watkins, 2011; Iqbal et al., 2012a). Reasons for these differences are unclear. Males may be exposed to higher CO levels or more vulnerable to CO than women (Fisher et al., 2014). Older individuals tend to be more frequently hospitalized for CO poisoning.

Populations of different ethnicity and/or socio-economic status differ in terms of heating and cooking practices and risk factors for CO poisoning (Ghosh et al., 2015)

Region-specific risk factors (Harduar-Morano and Watkins, 2011)

Possible inter-population differences in accuracy of diagnosis, recording and coding of morbidity and mortality data (Ghosh et al., 2015)

Analyses based on actual numbers of injuries/deaths or estimates based on a population sample (e.g., CDC, publications).

Column “Injuries” in the table may or may not include fatal cases. In some studies, fatalities are excluded from the number of injuries (e.g., BC Safety Authority, 2013; Cross Government Group on Gas Safety and Carbon Monoxide Avareness, 2014; Harduar-Morano and Watkins, 2011; CDC, 2005, 2008). In other studies, it was not possible to separate fatal









from non-fatal poisonings, and the number in the column includes both (Ghosh et al., 2015). In some cases it is unclear whether the reported numbers of hospitalizations/emergency department visits include fatal cases (e.g., Minnesota Environmental Public Health Tracking, 2009). The US National Poison Data System (NPDS) reports data on CO exposures regardless of whether or not any health effect was observed (e.g., CDC, 2011).

Figure 1. Diagram copied from Figure 2 of Iqbal et al., 2012 representing the national surveillance framework for unintentional, non-fire-related CO poisoning in the United States

4. Discussion

The summary tables show broad variation in jurisdictional safety performance. Potential reasons for this variations are discussed below. Two likely sources of variation are differences in regulatory and performance reporting requirements, as these can affect both the safety of TSSA-mandated technologies as well as the quality and transparency of safety data. This section will examine key distinctions arising in these areas, concluding with a discussion of the usefulness of benchmarking exercises in light of the potential confounding factors.

4.1 Regulatory Variation

One of the key sources of variation relates to inspection requirements for TSSA-regulated technologies. Inspection intervals, for example, are often not specified in regulatory documents, including the Technical Standards and Safety Act. This creates the potential for broad variation in the periodicity of inspection, which can impact the safety of these technologies. Some jurisdictions, such as the New York City Department of Buildings Elevator Division (2011), specify that inspections



must be performed and filed between January 1st and December 31st of each calendar year, subject to penalties and fines. It is difficult, however, to ascertain the impact of such requirements.

Further, there are certain subtle differences in some jurisdictions that are not discussed in publicly available, sector-specific regulatory documents. In New York City, for example, all wheelchair lifts in residential and/or commercial properties are required to perform annual inspection. Residential properties are not required to submit the inspection/test results to the Elevator Division, but building owners must keep and be able to produce upon request a lift maintenance log. Meanwhile, wheelchair lifts in commercial properties are required to submit to the Elevator Division the inspection/test results (New York City Department of Buildings Elevator Division, 2011, page 18). It is difficult to ascertain whether such distinctions exist in other jurisdictions as they are often not discussed.

Difficulties in comparing regulatory regimes are greater in the European Union, due to an umbrella Directive that still allows cross-jurisdictional variation. The European Lift Directive approximates the laws of the Members States and covers legal requirements for lift design, installation, and inspection. However, the Member States of the EU implement the Directive in their national laws, in some cases with subtle changes that may have important implications for lift safety. Such a possibility has yet to be explored in research.

In summary, no jurisdiction was found that had a regulatory mandate identical to that of TSSA. As a result, efforts were made to identify analogous organizations. This produced a list of organizations that were mandated to ensure the safety of at least one technology for which TSSA is responsible (elevating devices, amusement devices, or ski lifts). Further challenges relate to subtle variations in regulatory requirements which have not been sufficiently studied to allow comment on their impact. In light of such variation, it is difficult to conduct a robust benchmarking exercise, as confounding factors and uncertainty limit the confidence with which the apparent variations in safety performance can be attributed to regulatory requirements.

4.2 Performance Reporting Variation

Differences in performance reporting requirements represent another key confounding factor in this benchmarking exercise. In this regard, the TSSA tends to surpass its jurisdictional counterparts. The TSSA Chief Safety and Risk Officer is mandated to prepare an annual report, in addition to any reports that may be requested by the Board of Directors; all of these reports are made publicly available. Such requirements support regular monitoring of TSSA-mandated technology safety performance, as well as public transparency. Many analogous organizations, particularly those in South America and most of Asia, have no such requirements, which explains the absence of performance data from those countries.

Further, among those jurisdictions that do publicly report performance data, there is a wide variation in the type of data collected and how it is presented, making comparisons difficult. Norway, for example, monitors deaths from Accidental Falls and Other Accidents, but does not seem to specify how many of those injuries are due to elevating devices, ski lifts, or amusement devices. At the same time, the United States Consumer Product Safety Commission (CPSC) National Electronic Injury Surveillance System (NEISS) tracks injuries from a range of technologies, including those mandated by TSSA. However, national estimates are based on injury data from a small sample of hospitals, meaning figures are subject to uncertainty and are reliant on the need for hospitalization. The International Association of Amusement Parks and Attractions, responsible for



annual surveillance of amusement ride-related injury in the United States, does not release the outcomes of their surveillance for public scrutiny (Mikol, 2007). Further, state law regulates injury surveillance and dictates the type of information that is collected, so data collection can vary anywhere from the state to individual park level. For these reasons, it is difficult to draw conclusions regarding the implications of TSSA injury statistics in relation to other jurisdictions, as it is unknown whether they are ultimately measuring the same phenomena. An expectation that they are not measuring the same phenomena may be the best choice of a default assumption.

TSSA performance data are also more detailed than those from most other organizations. This is due to the annual surveillance, monitoring, and evaluation being conducted, as well as due to categorization of injury data into “permanent injury” and “non-permanent injury”. This allows a measure of injury severity in the case of an accident, which appears to be absent from most other jurisdictional performance reporting. The same is true for reporting on incident causality, as very few international jurisdictions participate in or publish the results of this type of analysis. Those few that do include some data on causes of injury, such as the National Ski Areas Association, often limit their reporting by concluding that the majority of incidents are the result of user error, and provide little or no information or analysis beyond this. Perhaps most important, though, is the exclusion of injuries from certain types of technologies; most notably the exclusion by some agencies of injuries arising from escalators, focusing solely on those from elevators, which are much more rare. Such a difference will contribute to lowering the apparent elevating device injury rates dramatically compared to those of TSSA, which monitors and reports injuries from both sources.

In sum, jurisdictions continue to have such a wide variety of requirements and protocols for performance monitoring, evaluation, and reporting that it is difficult to ascertain whether differences observed in the summary statistics are the result of regulatory variation or of different performance reporting practices. This key confounding variable makes it very difficult to draw meaningful conclusions about the cause of differential injury rates in various jurisdictions.

4.3 Usefulness of Performance Benchmarking

The previous discussion would suggest that there are certain challenges and confounding variables inherent in any benchmarking exercise in this field which make it very difficult to draw meaningful conclusions from the findings. There are too many regulatory variations to control for measuring the impact of one key approach, and performance-reporting protocols differ substantially across jurisdictions. Further, very few organizations keep robust, publicly available annual injury statistics, as evident by the lack of new information since the previous ASPR report. In light of this, a key recommendation arising from this report is to develop a stronger cross-jurisdictional collaboration and associated technical infrastructure in order to facilitate inter-jurisdictional communication and harmonization.



References

British Columbia Safety Authority. (2014). State of Safety Report 2013. BCSA: British Columbia.

http://www.safetyauthority.ca/sites/default/files/state_of_safety_2013_728_28may2014.pdf.

BCSA. British Columbia Safety Authority. (2014a). State of Safety Report 2014. BCSA: British Columbia.

http://safetyauthority.ca/sites/default/files/sos_2014.pdf

Centers for Disease Control and Prevention (CDC). Unintentional non-fire-related carbon monoxide

exposures--United States, 2001-2003. MMWR Morb Mortal Wkly Rep. 2005 Jan 21;54(2):36-39.

http://www.ncbi.nlm.nih.gov/pubmed/15660017

Centers for Disease Control and Prevention (CDC). Carbon monoxide--related deaths--United States,

1999-2004. MMWR Morb Mortal Wkly Rep. 2007 Dec 21;56(50):1309-1312.

http://www.ncbi.nlm.nih.gov/pubmed/18097342.

Centers for Disease Control and Prevention (CDC). Nonfatal, unintentional, non--fire-related carbon

monoxide exposures--United States, 2004-2006. MMWR Morb Mortal Wkly Rep. 2008 Aug

22;57(33):896-899. http://www.ncbi.nlm.nih.gov/pubmed/18716581

Centers for Disease Control and Prevention (CDC). Carbon monoxide exposures--United States, 2000-

2009. MMWR Morb Mortal Wkly Rep. 2011 Aug 5;60(30):1014-1017.


Chever, L. & Klien, M. (2013). The direct and indirect effect of safety regulaion on service quality: A

cautionary tale from the French Robien Law. EPPP Discussion Paper 2013-02

CO-Gas Safety. (2012). Statistics of Deaths and Injuries. Retrieved from http://www.co-

gassafety.co.uk/downloads/2013/Statistics%20Sheet%20for%20press%20pack%20page%2013%20onwa

rds%20for%20Kadee.pdf

Consumer Product Safety Commission (CPSC) NEISS. National Electronic Injury Surveillance System,

CPSC. Retrieved from www.cpsc.gov/en/Research--Statistics/NEISS-Injury-Data/.

Consumer Product Safety Commission (CPSC). NEISS Estimates Query Builder.

http://www.cpsc.gov/cgibin/NEISSQuery/Home.aspx

Consumer Product Safety Commission (CPSC). Non-Fire Carbon Monoxide Deaths Associated with the

Use of Consumer Products 2009 Annual Estimates. Report date: December 2012.

http://www.cpsc.gov/PageFiles/136146/co12.pdf

Consumer Product Safety Commission (CPSC). 2013. Incidents, Deaths, and In-Depth Investigations

Associated with Non-Fire Carbon Monoxide from Engine-Driven Generators and Other Engine-Driven

Tools, 1999–2012. http://www.cpsc.gov/Global/Research-and-Statistics/Injury-Statistics/Carbon-

Monoxide-Posioning/GeneratorsAndOEDTFatalities2013FINAL.pdf

Consumer Product Safety Commission (CPSC). 2014a. Non-Fire Carbon Monoxide Deaths Associated

with the Use of Consumer Products 2011 Annual Estimates. Report date: September 2014.

http://www.safetyauthority.ca/sites/default/files/state_of_safety_2013_728_28may2014.pdf









http://www.co-gassafety.co.uk/downloads/2013/Statistics%20Sheet%20for%20press%20pack%20page%2013%20onwards%20for%20Kadee.pdf



http://www.cpsc.gov/en/Research--Statistics/NEISS-Injury-Data/

http://www.cpsc.gov/cgibin/NEISSQuery/Home.aspx


http://www.cpsc.gov/Global/Research-and-Statistics/Injury-Statistics/Carbon-Monoxide-Posioning/GeneratorsAndOEDTFatalities2013FINAL.pdf




http://www.cpsc.gov/Global/Research-and-Statistics/Injury-Statistics/Carbon-Monoxide-

Posioning/NonFireCarbonMonoxideDeathsAssociatedwiththeUseofConsumerProducts2011AnnualEstim

atesSept2014.pdf

Consumer Product Safety Commission (CPSC). 2014b. Non-Fire Carbon Monoxide Deaths Associated

with the Use of Consumer Products 2010 Annual Estimates. Report date: January 2014.

http://www.cpsc.gov/Global/Research-and-Statistics/Injury-Statistics/Carbon-Monoxide-

Posioning/2010NonFireCODeathsFINAL.pdf

Consumer Product Safety Commission (CPSC). 2014c. Incidents, Deaths, and In-Depth Investigations

Associated with Non-Fire Carbon Monoxide from Engine-Driven Generators and Other Engine-Driven

Tools, 2004-2013. https://www.cpsc.gov/Global/Research-and-Statistics/Technical-

Reports/Home/Portable-Generators/GeneratorsandOEDTFatalities-2014-FINAL.pdf

Consumer Product Safety Commission (CPSC). Estimated Number of Injuries and Reported Deaths

Associated with Inflatable Amusements, 2003-2013. February 2015.

http://www.cpsc.gov/Global/Research-and-Statistics/Injury-Statistics/Amusement-

Rides/Inflatable_Amusements_Deaths_and_Injuries_2015.pdf

Cross Government Group on Gas Safety and Carbon Monoxide (CO) Awareness. (2012). Annual Report.

Cross-Government Group on Gas Safety and Carbon Monoxide (CO) Awareness. 2014.

http://www.hse.gov.uk/Gas/domestic/cross-government-group-1314.pdf

de Juniac A, Kreis I, Ibison J, Murray V. Epidemiology of unintentional carbon monoxide fatalities in the

UK. Int J Environ Health Res. 2012;22(3):210-219. http://www.ncbi.nlm.nih.gov/pubmed/22175228

Dianat I, Nazari J. Characteristics of unintentional carbon monoxide poisoning in Northwest Iran--Tabriz.

Int J Inj Contr Saf Promot. 2011 Dec;18(4):313-320. http://www.ncbi.nlm.nih.gov/pubmed/21827338

Directorate-General for Health & Consumer Protection. (2005). Assessment of best practices in

fairgrounds and amusement parks in relation to safety of consumers. Brussels, Belgium.

European Lift Association (ELA). (2012). The importance of accidence statistics (powerpoint). ELA:

Auderghem, Belgium.

Fisher DS, Leonardi G, Flanagan RJ. Fatal unintentional non-fire-related carbon monoxide poisoning:

England and Wales, 1979-2012. Clin Toxicol (Phila). 2014 Mar;52(3):166-170.


Graber JM, Smith AE. Results from a state-based surveillance system for carbon monoxide poisoning.

Public Health Rep. 2007 Mar-Apr;122(2):145-154. http://www.ncbi.nlm.nih.gov/pubmed/17357356

Ghosh RE, Close R, McCann LJ, Crabbe H, Garwood K, Hansell AL, Leonardi G. Analysis of hospital

admissions due to accidental non-fire-related carbon monoxide poisoning in England, between 2001 and

2010. Public Health (Oxf). 2015 Mar 9. pii: fdv026. [Epub ahead of print].


http://www.cpsc.gov/Global/Research-and-Statistics/Injury-Statistics/Carbon-Monoxide-Posioning/NonFireCarbonMonoxideDeathsAssociatedwiththeUseofConsumerProducts2011AnnualEstimatesSept2014.pdf



http://www.cpsc.gov/Global/Research-and-Statistics/Injury-Statistics/Carbon-Monoxide-Posioning/2010NonFireCODeathsFINAL.pdf


https://www.cpsc.gov/Global/Research-and-Statistics/Technical-Reports/Home/Portable-Generators/GeneratorsandOEDTFatalities-2014-FINAL.pdf


http://www.cpsc.gov/Global/Research-and-Statistics/Injury-Statistics/Amusement-Rides/Inflatable_Amusements_Deaths_and_Injuries_2015.pdf

http://www.cpsc.gov/Global/Research-and-Statistics/Injury-Statistics/Amusement-Rides/Inflatable_Amusements_Deaths_and_Injuries_2015.pdf


http://www.ncbi.nlm.nih.gov/pubmed/?term=de%20Juniac%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22175228

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kreis%20I%5BAuthor%5D&cauthor=true&cauthor_uid=22175228

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ibison%20J%5BAuthor%5D&cauthor=true&cauthor_uid=22175228

http://www.ncbi.nlm.nih.gov/pubmed/?term=Murray%20V%5BAuthor%5D&cauthor=true&cauthor_uid=22175228






Harduar-Morano L, Watkins S. Review of unintentional non-fire-related carbon monoxide poisoning

morbidity and mortality in Florida, 1999-2007. Public Health Rep. 2011 Mar-Apr;126(2):240-50.


HASS & LASS 2002. 24th (Final) Report of the Home and & Leisure Accident Surveillance System 2000,

2001 and 2002 data.

Henn SA, Bell JL, Sussell AL, Konda S. Occupational carbon monoxide fatalities in the US from

unintentional non-fire related exposures, 1992-2008. Am J Ind Med. 2013 Nov;56(11):1280-1289.


IAAPA. International Association of Amusement Parks and Attractions. Fixed-site amusement ride injury

survey, 2013 update. Report date: January 2014. http://www.iaapa.org/docs/default-source/default-

document-library/report-2013---1-26-15-final.pdf?sfvrsn=0

Iqbal S, Clower JH, King M, Bell J, Yip FY. National carbon monoxide poisoning surveillance framework

and recent estimates. Public Health Rep. 2012a Sep-Oct;127(5):486-496.


Iqbal S, Law HZ, Clower JH, Yip FY, Elixhauser A. Hospital burden of unintentional carbon monoxide

poisoning in the United States, 2007. Am J Emerg Med. 2012b Jun;30(5):657-664.


Iqbal S, Clower JH, Boehmer TK, Yip FY, Garbe P. Carbon monoxide-related hospitalizations in the U.S.:

evaluation of a web-based query system for public health surveillance. Public Health Rep. 2010 May-

Jun;125(3):423-432. http://www.ncbi.nlm.nih.gov/pubmed/20433037

Khaji A, Ghodsi SM. Trend of elevator-related accidents in Tehran. Arch Bone Jt Surg. 2014 Jun;2(2):117-

20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151445/

McCann, M., & Zaleski, N. (2006). Deaths and Injuries Involving Elevators and Escalators. (Revised) The

Center to Protect Workers’ Rights.

McCann M. CPWR. The Center for Construction Research and Training. Deaths and Injuries Involving

Elevators and Escalators. 2013.

http://www.cpwr.com/sites/default/files/publications/elevator_escalator_BLSapproved_2.pdf

McFaull SR, Keays G. Emergency department presentations for injuries associated with inflatable

amusement structures, Canada, 1990–2009. Chronic Diseases and Injuries in Canada, 33(3). 2013.

http://www.phac-aspc.gc.ca/publicat/hpcdp-pspmc/33-3/ar-03-eng.php

Michigan Department of Health and Human Services. Carbon Monoxide Poisoning. Reports (2009-2013).

http://www.michigan.gov/mdch/0,1607,7-132-54783_54784_54787---,00.html

Mikol, C. (2007). Amusement Park Injuries in School-age Children: A Mixed Methods Approach.

University of Wisconsin: Milwaukee, WI.

Minnesota Environmental Public Health Tracking. Carbon Monoxide Poisoning. Data & Measures 2000-

2007. Report date: December 2009.

http://www.health.state.mn.us/divs/hpcd/tracking/pubs/coreport.pdf


http://www.iaapa.org/docs/default-source/default-document-library/report-2013---1-26-15-final.pdf?sfvrsn=0

http://www.iaapa.org/docs/default-source/default-document-library/report-2013---1-26-15-final.pdf?sfvrsn=0

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151445/

http://www.cpwr.com/sites/default/files/publications/elevator_escalator_BLSapproved_2.pdf

http://www.phac-aspc.gc.ca/publicat/hpcdp-pspmc/33-3/ar-03-eng.php





National Safety Council, 2013. Fixed-Site Amusement Ride Injury Survey, 2011 Update Prepared for

International Association of Amusement Parks and Attractions

National Ski Areas Association. (2012). NSAA Ski Lift Safety Fact Sheet

National Ski Areas Association (2014). NSAA Ski Lift Safety Fact Sheet.

http://www.nsaa.org/media/214677/Lift_Safety_Fact_Sheet_10_31_14.pdf

Nazari J, Dianat I, Stedmon A. Unintentional carbon monoxide poisoning in Northwest Iran: a 5-year

study. J Forensic Leg Med. 2010 Oct;17(7):388-391. http://www.ncbi.nlm.nih.gov/pubmed/20851359

New York City Department of Buildings Elevator Division. (2011). Elevator rule 103-02: Operational

changes and updates.

Risk Sciences International (2013). Risk of Injuries and Deaths from TSSA-Regulated Activities in the

Context of Other Risks. Prepared for the Technical Standards and Safety Authority. Report available at

www.tssa.org.

Risk Sciences International (2014). Benchmarking Risk of Injury and Death from TSSA-Regulated

Activities Against Other Jurisdictions. Prepared for the Technical Standards and Safety Authority. Report

available at www.tssa.org.

Saferparks.org http://www.saferparks.org

(http://www.saferparks.org/database/cpsc_data/query_neiss.php)

Schminke, L., Jeger, V., Evangelopoulos, D., Zimmerman, H., & Exadaktylos, A. (2013). Riding the

elevator: how dangerous is it really? Western Journal of Emergency Medicine, 14(2), 141-5.

Smart, P. & Chalmers, D. (2010). Searching for ski-lift injury: an uphill struggle? Journal of Science and

Medicine in Sport 13, 205-9

Woodcock K. Amusement ride injury data in the United States. Safety Science. 62: 466-474. 2014

Zarikas V, Loupis M, Papanikolaou N, Kyritsi C. Statistical survey of elevator accidents in Greece. Safety

Science 59 (2013) 93–103

http://www.nsaa.org/media/214677/Lift_Safety_Fact_Sheet_10_31_14.pdf


http://www.tssa.org/



Appendix A - Relevant search terms.

Main Search Term/Phrase Partnered Search Term(s)

Elevat* device, elevator, escalator, lift And accident, death, fatal*, motalit*, morbidit*, injur*, incident,

And surveillance, data, stat*, monitor*, safety

Amusement rides, amusement parks, amusement attractions

And (as above)

Ski lift, chairlift And (as above)

Boiler, pressur* vessel* And (as above)

Fuel, carbon monoxide, gas And (as above)

Carbon monoxide poisoning/statistics and numerical data [MeSH Terms]

--



Appendix B - List of organizations with mandates similar to that of TSSA

Organization Name Jurisdiction Mandate of Interest

Consumer Product Safety Commission

United States Elevating devices and amusement rides

New York City Department of Buildings Elevator Division

New York City, USA Elevating devices

Illinois Office of the State Fire Marshal

Illinois, USA Elevating devices

European Lift Directive Members of the European Union

Elevating devices

European Lift Association Members of the European Union

Elevating devices

Lift and Escalator Industry Association

United Kingdom Elevating devices

Health and Safety Executive United Kingdom Elevating devices

Safety Assessment Federation United Kingdom Elevating devices

Japan Elevator Association Japan Elevating devices

Korean Elevator Safety Institute

South Korea Elevating devices

Lift and Elevator Contractors and Manufacturers

Association

Singapore Elevating devices

Saferparks.org United States Amusement devices

International Association of Amusement Parks and

Attractions

United States Amusement devices

Bureau of Fair Rides Inspection Florida, USA Amusement devices

Rideaccidents.com United States Amusement devices



European Union Public Health Information Network

Member States of the European Union

Amusement devices

National Ski Areas Association United States Ski lifts

Colorado Passenger Tramway Board

Colorado, USA Ski lifts



Appendix C - Population estimates for jurisdictions of relevance

Jurisdiction, Year Population Source

Ontario, 2013 13,538,000 Link

Austria, 2001 8,032,857 Link

Belgium, 2001 10,258,760 Link

Belgium, 2010 10,423,490 Link

British Columbia, 2013 4,581,978 Link

British Columbia, 2014 4,631,302 Link

British Columbia, 2009-2013 (average)

4,500,175 Link

British Columbia, 2007-2013 (average)

4,448,753 Link

Colorado, USA, 2001-2012 (average)

4,763,742 Link

Czech Republic, 2010 10,201,710 Link

Denmark, 2001 5,352,815 Link

Denmark, 2010 5,515,575 Link

Finland, 2001 5,175,783 Link

Finland, 2010 5,255,068 Link

France, 2001 59,551,230 Link

France, 2011 65,312,250 Link

Germany, 2001 83,029,540 Link

Germany, 2011 81,471,830 Link

Great Britain (England, Scotland and Wales), 2012

61,881,400 Link

Greece, 2001 10,623,840 Link

http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo02a-eng.htm

http://www.indexmundi.com/g/g.aspx?c=be&v=21

http://www.indexmundi.com/g/g.aspx?c=be&v=21

http://www.bcstats.gov.bc.ca/StatisticsBySubject/Demography/PopulationEstimates.aspx




http://www.colorado.gov/cs/Satellite/DOLA-Main/CBON/1251593346867

http://www.indexmundi.com/g/g.aspx?v=21&c=ez&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=da&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=da&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=fi&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=fi&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=fr&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=fr&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=gm&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=gm&l=en

http://www.ons.gov.uk/ons/dcp171778_320900.pdf

http://www.indexmundi.com/g/g.aspx?v=21&c=gr&l=en



Greece, 2000-2010 (average) 10,677,920 Link

Hungary, 2010 9,992,339 Link

Iran, Tabriz 1,580,000 Population estimate from the publication (Dianat and

Nazari 2011)

Iran, East Azerbaijan province 3,600,000 Population estimate from the publication (Nazari et al.,

2010)

Ireland, 2001 3,840,838 Link

Luxembourg, 2001 442,972 Link

Luxembourg, 2009 491,775 Link

Michigan, 2013 9,895,622 Link

Netherlands, 2001 15,981,470 Link

New Zealand, 2000-2005 (average)

3,928752 Link

Norway, 2011 4,691,849 Link

Portugal, 2001 10,066,250 Link

Romania, 2010 21,959,280 Link

Spain, 2001 40,038,000 Link

Switzerland, 2000-2010 (average)

7,454,048 Link

Switzerland, 2011 7,639,961 Link

Tehran, 1996 and 2006 census data (average)

7,278,182.5 Link

United Kingdom, 2001 59,647,790 Link



http://www.indexmundi.com/g/g.aspx?v=21&c=gr&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=hu&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=ei&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=lu&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=lu&l=en

http://www.michigan.gov/cgi/0,4548,7-158-54534---,00.html

http://www.indexmundi.com/g/g.aspx?v=21&c=nl&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=nz&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=no&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=po&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=ro&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=sp&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=sz&l=en

http://www.indexmundi.com/g/g.aspx?v=21&c=sz&l=en

http://www.citypopulation.de/php/iran-tehrancity.php

http://www.indexmundi.com/g/g.aspx?v=21&c=uk&l=en





United Kingdom, 2010-2011 (average)

62,523,405 Link

United Kingdom, 2000-2007 (average)

60,141,183 Link

United States, 2003 290,342,600 Link












United States, 2000-2009 (average)

292,390,920 Link


294,012,918 Link


303,828,782 Link

United States 2004-2013 305,177,401 Link

United states, 2000-2012 (average)

297,017,046 Link


298,307,194 Link



http://www.indexmundi.com/g/g.aspx?v=21&c=us&l=en










http://www.census.gov/popclock/

http://www.census.gov/popclock/










309,305,333 Tables B1-B5 at: Link

United States, 2004-2012 304,077,211 Link

Wales, 2012 3,100,000 Link



http://www.ons.gov.uk/ons/rel/pop-estimate/population-estimates-for-uk--england-and-wales--scotland-and-northern-ireland/2013/index.html


7 August 2015 32

Appendix D - Studies of injuries/deaths from carbon monoxide poisoning

Jurisdiction, Year

(Reference)

Year Reason/Circumstances

Injuries Deaths Rate (per 1M pop/yr) Source of data/Notes

British Columbia

BC Safety Authority, 2014

2013 Gas-related incidents

15 (major non-fatal) 4 Major non-fatal injuries: 3.27

Deaths: 0.87

Dara from table A-3 Gas Incidents at http://www.safetyauthority.ca/sites/default/files/state_of_safety_2013_728_28may2014.pdf

Population estimates: http://www.bcstats.gov.bc.ca/StatisticsBySubject/Demography/PopulationEstimates.aspx

Data for the 6-year period (2007-2012) were also analyzed; these data are not extracted here because they are part of the 2007-2013 data below.

British Columbia

BC Safety Authority, 2014a

2007-2013 Gas-related incidents

110 (non-fatal) 9 Non-fatal injuries: 3.53

Deaths: 0.29

See pages 31-33 and table A4-1 at http://safetyauthority.ca/sites/default/files/sos_2014.pdf

Population estimates: as above (4,448,753 averaged over 2007-2013)

“Carbon monoxide incident investigations represent 62 of the 426 gas related incidents investigated by BCSA’s safety officers.”

62 incidents 49

By source of CO50

49 One incident may involve more than one person 50 “Some investigations identified multiple appliances that may have produced CO, yet did not confirm which was most likely the CO source; therefore, the total number of appliances exceeds the number of events.”










7 August 2015 33

Jurisdiction, Year

(Reference)



Furnace: confirmed CO source-23, possible CO source – 6

Water heater: confirmed -11, possible – 5

Boiler: confirmed -11, possible -3

Fireplace: confirmed -3, possible -1

Stove or range: confirmed -1 possible-3

Heating unit: confirmed 2, possible -1

Air handling unit confirmed -2, possible -1

Refrigerator: confirmed-3

Generator: confirmed – 1

Lantern: possible -1

Investigated incidents by location

Residential: 51 (single-family-38, multi-family-10, non-primary e.g., cabin -3)

Non-residential: 11 (commercial -7, converted trailer – 2, camperized van – 1, industrial -1)

By causes and contributing factors:

Ventilation and inability to vent combustion products -20

Service, maintenance and/or equipment replacement – 11

Equipment or component failure -9

Installation issues -8

Investigations were inconclusive – 5

Unqualified persons performing regulated work – 4


7 August 2015 34

Jurisdiction, Year

(Reference)



Unsafe use of equipment -3

Poor air-gas ratio -4

Wind creating a downdraft -1

UK

Co-Gas Safety, 2013

1999/200051 Gas Mains No data 17 0.29 Data on deaths: http://www.co-gassafety.co.uk/downloads/2013/Statistics%20Sheet%20for%20press%20pack%20page%2013%20onwards%20for%20Kadee.pdf

Population estimates are available from 2000 to 2012: http://www.indexmundi.com/g/g.aspx?v=21&c=uk&l=en

Population estimates for 2000 were used to calculate rates for 1999/2000

Deaths related to CO poisoning from use of solid fuel are also reported. These numbers range from 3 in 2003-2004 to 19 in 2000-2001

As discussed by de Juniac et al., 2012 (see below), data in the Co-Gas Safety database “are primarily compiled from a ‘cuttings and media’ service and the database is an incomplete record of all deaths.”

Gas Portable No data 10 0.17

Petrol52/diesel No data 4 0.07

Oil No data 0 0

2000/01 Gas Mains No data 18 0.31


Petrol/diesel No data 3 0.05

Oil No data 0 0




Oil No data 0 0




Oil No data 0 0




Oil No data 0 0

51 Year from 1 April to 31 March 52 “Gasoline” in the U.S.








7 August 2015 35

Jurisdiction, Year

(Reference)






Oil No data 0 0




Oil No data 0 0




Oil No data 0 0




Oil No data 1 0.02




Oil No data 1 0.02




Oil No data 1 0.02



7 August 2015 36

Jurisdiction, Year

(Reference)





Oil No data 0 0




Oil No data 0 0

Great Britain (England, Scotland and Wales)

Cross Government Group on Gas Safety and Carbon Monoxide (CO) Awareness Annual Report 2013-2014

Report date: November 2014

2009/2010 Supply and use of flammable gas

292 (non-fatal) 9 4.87 non-fatal injuries/0.15 deaths

Data on CO poisoning injuries/deaths: http://www.hse.gov.uk/Gas/domestic/cross-government-group-1314.pdf

Source of information on injuries/deaths: RIDDOR - Reporting of Injuries, Diseases and Dangerous Occurrences Regulations. “The Regulations apply to events, which arise out of or in connection with work activities covered by the Health & Safety at Work etc Act 1974. The Regulations require gas conveyors and LPG suppliers to report incidents where someone has died, lost consciousness, or been taken to hospital for treatment to an injury where gas is likely to be a cause.”

2009/2010 and 2010/2011: Population estimate of Northern Ireland (approximated as 1,814, 000) was

2010/2011 368 (non-fatal) 13 6.06 injuries/0.21 deaths




53 Fewer cases than in the previous years; data may be incomplete. 54 Data may be incomplete




7 August 2015 37

Jurisdiction, Year

(Reference)



subtracted from the UK population estimates.

UK estimates: http://www.indexmundi.com/g/g.aspx?v=21&c=uk&l=en

Northern Ireland estimate: http://www.ons.gov.uk/ons/dcp171778_320900.pdf

2011/2012, 2012/2013 and 2013/2014: population estimates of Great Britain from http://www.ons.gov.uk/ons/dcp171778_320900.pdf

The mean values of the 2009-2010, 2010-2011, 2011-2012 population estimates were used to calculate rates. The population estimate for 2012 was used to calculate rates for 2012/13 and 2013/14

UK

de Juniac et al., 2012

1996 Unintentional, non-fire related

No data 74 http://www.ncbi.nlm.nih.gov/pubmed/22175228

Population estimates: http://www.indexmundi.com/g/g.aspx?v=21&c=uk&l=en

In this article, numbers of deaths obtained from Co-Gas Safety Society database are reported by year (similar to the data extracted from the Co-Gas Statistics above), month, age, type of fuel, source, housing type.

1997 No data 43

1998 No data 56

1999 No data 48

2000 No data 48 0.81

2001 No data 30 0.50

2002 No data 22 0.37

2003 No data 28 0.47

2004 No data 23 0.38

2005 No data 22 0.36












7 August 2015 38

Jurisdiction, Year

(Reference)



2006 No data 40 0.66 The study “did not attempt to estimate absolute rates, instead it focusses on patterns within the sample.”

The authors concluded:

- The number of unintentional non-fire related deaths fell between 1996 and 2000 and then stabilized.

- A ‘November spike’ in boiler-related deaths was evident between 1996 and 2000 but not in later years.

- “…while nearly 40% of fatalities came from mains gas appliances, non-gas fuel sources posed a more serious relative public health risk, with a risk of CO death about 10 times higher than that for gas-fuel appliances.

As discussed by the authors, data in the Co-Gas Safety database “are primarily compiled from a ‘cuttings and media’ service and the database is an incomplete record of all deaths.”

Bias can be introduced by inconsistency in cause of death coding.

Data “may be biased towards cases with greater media impact, such those involving the very young, the elderly, or those incidents involving multiple deaths”. This “could have caused an overrepresentation of certain appliances or sources.”

2007 No data 28 0.46

1996-2007 No data Total: 462 (100%)

By type of fuel

LPG55 76 (16.5%)

Mains gas: 177 (38.3%)

Oil: 3 (0.6%)

Paraffin 4 (0.9%) Petrol/diesel: 52 (11.3%)

Solid: 146 (31.6%)

Unknown: 4 (0.9%)

By source

Boilers: 130 (28.1%)

Heaters: 131 (28.4%)

Gas-fires: 41 (8.9%)

Cooker: 58 (12.6%)

The mean population estimate for 2000-2007 (60141182.5) was used for calculation of rates.

Average annual rates over the 12-year period

Total: 0.64

By fuel type

LPG: 0.11

Mains gas: 0.25

Oil: 0.004

Paraffin: 0.006

Petrol/diesel: 0.07

Solid: 0.2

Unknown: 0.006

By source:

Boilers: 0.18

Heaters: 0.18

Gas-fires: 0.06

Cooker: 0.08

Engine: 0.04

Other: 0.10

55 Liquefied petroleum gas


7 August 2015 39

Jurisdiction, Year

(Reference)



Engine: 30 (6.5%)

Other: 72 (15.6%)

Mean age at death: 55 years;

<15 years: 5%

>65 years: 39%

Also, “inaccuracies may not have been stable over time and could differ between UK regions.”

England and Wales

Fisher et al., 2014.

1979 Unintentional non-fire-related

No data 166 (56%)56 3.37 http://www.ncbi.nlm.nih.gov/pubmed/24533843

Rates calculated by the study authors.

Source of data for analyses by Fisher et al., 2014: mortality data provided by coroners in England and Wales.

“Despite some fluctuation from year to year, there was a steady decline in the annual number of such deaths between 1979 and 2012.”

81% and 92% of deaths in males and in females, respectively, occurred at the home address of the deceased.

Males were overrepresented in age groups 10-19, 20-39, 40-64 years with similar numbers of males and females in age groups <1, 1-9, 65-79 and 80+years

Limitations discussed by the authors:

1980 No data 118 (65%) 2.39

1981 No data 153 (66%) 3.10

1982 No data 136 (59%) 2.75

1983 No data 95 (57%) 1.92

1984 No data 73 (62%) 1.47

1985 No data 106 (60%) 2.13

1986 No data 118 (59%) 2.37

1987 No data 68 (60%) 1.36

1988 No data 83 (61%) 1.66

1989 No data 58 (59%) 1.16

1990 No data 61 (66%) 1.21

1991 No data 66 (67%) 1.31

1992 No data 65 (66%) 1.28

1993 No data 81 (65%) 1.60

1994 No data 69 (59%) 1.36

56 % male

http://www.ncbi.nlm.nih.gov/pubmed/?term=Fisher%20DS%5BAuthor%5D&cauthor=true&cauthor_uid=24533843




7 August 2015 40

Jurisdiction, Year

(Reference)



1995 No data 58 (62%) 1.14 - Detailed data on the place of death or the precise location of a death (e.g., garage, boat etc.), the source of CO (e.g., piped gas appliance, coal or wood-burning fi re, etc.) were not available.

- Deaths in a workplace could not be differentiated other than “not at a private

residential address”.

1996 No data 63 (56%) 1.23

1997 No data 53 (58%) 1.03

1998 No data 41 (71%) 0.80

1999 No data 47 (64%) 0.91

2000 No data 48 (69%) 0.92

2001 No data 59 (75%) 1.13

2002 No data 46 (78%) 0.87

2003 No data 36 (75%) 0.68

2004 No data 34 (82%) 0.64

2005 No data 22 (82%) 0.41

2006 No data 41 (68%) 0.76

2007 No data 47 (72%) 0.86

2008 No data 39 (79%) 0.71

2009 No data 39 (74%) 0.71

2010 No data 32 (84%) 0.57

2011 No data 34 (65%) 0.61

2012 No data 25 (76%) 0.44

England

Ghosh et al., 2015

2001-2010 Accidental (unintentional) non-fire-related

Hospital admissions: 2463 over 10 years; 53% were male

“HES data were not linked with mortality data so we do not know how many individuals died from CO poisoning.”

Average annual rate of hospital admissions: 4.9 (calculated by the study authors).

The rates were higher in colder winter months. There was a pattern of increasing admissions with increasing

http://jpubhealth.oxfordjournals.org/content/early/2015/03/27/pubmed.fdv026.long

Source of data: Hospital Episode Statistics (HES) inpatient data for England between 2001 and 2010

“Due to the non-specific symptoms of CO poisoning, the number of hospital admissions in HES is likely to be underestimated. In addition, many




7 August 2015 41

Jurisdiction, Year

(Reference)



deprivation. The highest rate was seen in the oldest age group (80+ years) and second highest in the youngest age group

(<10 years)57.

individuals with symptoms of non-acute CO poisoning may present first at primary care services rather than as a hospital admission leading to an underestimation of the risk of CO poisoning when using HES only.”

USA

Centers for Disease Control and Prevention (CDC), 2008

2004-2006 Unintentional, Non--Fire-Related

Non-fatal injuries

Total: 20,636

Male: 9,770

Female: 10,866

Treated and released: 18,646

Hospitalized/Transferred: 1,695

Age (years)

0-4: 2,344

5-9: 1,407

10-14: 1,577

15-24: 3,341

25-34: 4,183

35-44: 2,775

45-54: 2,229

55-64: 1,444

≥65: 1,328

Exposure status

No data ED visits

Total: 70 per 1M (95% CI: 51-88)

Male: 67 (50-84)

Female 72 (50-94)

Treated and released: 63 (95% CI: 46-80)

Hospitalized/Transferred: 6 (3-9)

Age (years)

0-4: 116 (77-154)

5-9: 72 (38-105)

10-14: 76 (33-118)

15-24: 79 (57-101)

25-34: 104 (65-143)

35-44: 63 (42-84)

45-54: 52 (34-71)

55-64: 48 (29-66)

≥65: 36 (23-49)


http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5733a2.htm#tab1

Data from the National Electronic Injury Surveillance System -- All Injury Program (NEISS-AIP) database. The database “includes data on all types and causes of injuries treated in U.S. hospital EDs”.

Estimates are based on data for ED visits to the 63 NEISS-AIP sample hospitals.

57 These data are presented in a graph.










7 August 2015 42

Jurisdiction, Year

(Reference)



CO poisoning: 14,127 (68.5%)

CO exposure: 6,320 (30.6%)

Possible CO exposure: 189 (0.9%)

Season

Winter: 8,538 (41.4%)

Spring: 4,175 (20.2%)

Summer: 3,474 (16.8%)

Fall: 4,448 (21.6%)

Location of incident

Residence: 15,030 (72.8%)

Workplace: 2,769 (13.4%)

Other: 1,162 (5.6%)

Unknown: 1,674 (8.1%)

Rates by exposure status, season and location of incident are not reported.

USA


Non-fatal exposures: 2001-2003

Deaths: 2001-2002

Unintentional, non-fire-related

Non-fatal exposures

ED visits

Total: 15,200

Male: 7,874

Total: 480

Male: 344

Female: 137

Age (years)

0-4: 9

Non-fatal exposures

ED visits

Total: 52.7 (38.3-67.2)

Male: 55.6 (40.0-71.2)

Female: 50.0 (34.0-65.9)


http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5402a2.htm











7 August 2015 43

Jurisdiction, Year

(Reference)



Female: 7,326


Hospitalized/Transferred: 1,676

Age (years)

0-4: 1,596

5-14: 2,352

15-24: 2,478

25-34: 2,750

35-44: 2,358

45-54: 1,669

55-64: 918

≥65: 1,079

Exposure status58:

Possible exposure: 6%

Exposure: 41.9%)

Poisoning: 52.1%

CO source59

Furnace (oil, gas and unspecified): 18.5%

Motor vehicle: 9.1%

5-14: 19

15-24: 58

25-34: 57

35-44: 92

45-54: 79

55-64: 53

≥65: 113

Treated and released: 45.8 (33.5-58.1)

Hospitalized/Transferred: 5.8 (2.7-9.0)

Age (years)

0-4: 81.5 (44.7-118.3)

5-14: 57.3 (36.7-78.0)

15-24: 61.1 (41.7-80.4)

25-34: 69.0 (46.9-91.1)

35-44: 52.6 (36.0-69.2)

45-54: 41.7 (25.6-57.8)

55-64: 34.5 (19.7-49.3)

≥65: not calculated

Deaths

Total over 2 years: 1.7 (1.6-1.8)

Male: 2.4 (2.3-2.6)

Female: 0.9 (0.8-1.0)

Age (years)

0-4: 0.5 (0.2-0.7)

5-14: 0.5 (0.3-0.6)

15-24: 1.4 (1.2-1.7)

25-34: 1.4 (1.2-1.7)

35-44: 2.0 (1.7-2.3)

Data on emergency department (ED) visits from the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP) and 2001--2002 death certificate data from the National Vital Statistics System (NVSS).

Data are drawn from a nationally representative subsample of 66 of 100 NEISS hospitals that were selected as a stratified probability sample of hospitals in the United States and its territories.

58 Based on 778 cases reported by NEISS-AP 59 Based on 778 cases reported by NEISS-AP


7 August 2015 44

Jurisdiction, Year

(Reference)



Stove/Gas range: 4.9%

Gas line leak: 4.9%

Gas water heater: 4.2%

Generators: 2.2%

Space heater: 1.9%

Machinery: 1.5%

Other: 9.3%

Unknown: 42.8%

45-54: 2.0 (1.7-2.3)

55-64: 2.0 (1.6-2.4)

≥65: 3.2 (2.0-3.6)

USA


1999-2004 Unintentional, non-fire-related

No data 439 (annual average number)

National 6-year average annual rate: 1.53 (95% CI: 1.47-1.59)

Males: 2.41 (95% CI: 2.30-2.52)

Females: 0.74 (95% CI: 0.68-0.79)

White, non-Hispanic: 1.54 (1.48-1.61)

Black, non-Hispanic: 1.64 (1.45-1.83)

Other, non-Hispanic: 1.01 (0.80-1.22)

Hispanic: 1.31 (1.14-1.48)



(see tables)

Mortality rates were calculated by the study authors on the basis of death certificate data obtained from the National Vital Statistics System (NVSS).

USA

Centers for Disease Control

2000-2009 Unintentional, non-fire-related CO exposures

Total of 68,316 for 2000-2009; no data by year.

Numbers of cases of CO exposure for

235 for 2000-2009; no data by year

All CO exposures: annual average 23.2; range: 19.7--25.3
















7 August 2015 45

Jurisdiction, Year

(Reference)



and Prevention (CDC), 2011

2000-2009 are reported by gender, age, region, exposure site and outcome.

CO exposures most frequently occurred between November and February (53.5%)

By gender: female (50.3%), male (44.3%)

By age (years): ≤17 (27.7%), 18-44 (20.4%), 45-64 (11.4%), ≥65 (6.2%)

By exposure cite: residence (77.65%), workplace (12.0%), public area (3.8%), school (3.0%), other (4.7%).

By outcome: death (0.3%), major effect60 (1.5%), moderate effect61 (15.1%), minor

Transported to a health-care facility: range 11.1-14.3 per year

Managed on-site: range 8.6-14.0 per year

Rates calculated by the study authors

Data from the National Poison Data System (NPDS) were used “to characterize reported unintentional, non-fire-related CO exposures, including those that were managed at the site of exposure and were not treated at a health-care facility.”

“NPDS is a near real-time, comprehensive poisoning surveillance system that collects data on calls regarding poison exposure placed to any of the U.S. poison centers.”

"Women and children are the most commonly exposed, but deaths from CO exposure more often occur among men.”

60 Definition: “Exposure symptoms were life-threatening or resulted in significant residual disability or disfigurement” 61 Definition: “Exposure symptoms were pronounced, prolonged, or systemic and usually required some form of treatment”




7 August 2015 46

Jurisdiction, Year

(Reference)



effect62 (50.1%), no effect (33.0%)

Minnesota

Minnesota Environmental Public Health Tracking

Report date: December 2009

Unintentional non-fire-related

Hospitalizations http://www.health.state.mn.us/divs/hpcd/tracking/pubs/coreport.pdf


Source of data on hospitalizations, emergency department visits and deaths: Minnesota Department of Health’s Injury and Violence Prevention Unit

Data on CO exposure calls: the Minnesota Poison Control System

“ED visits may result in treatment and release, or in hospitalization or death. ED visits that result in hospitalizations are counted as inpatient hospitalization cases and do not appear in the ED visit dataset.”

“PCC calls may represent CO exposure events that may not otherwise be captured in hospital discharge data or ED data. They may include events where CO exposure was detected but did not result in symptoms, where symptoms were mild and did not require follow-up in a healthcare facility, and where the event resulted in symptoms but the patient refused to seek medical treatment. However, PCC call data are highly reliant on the knowledge, attitudes, and practices

2000 31 6.3

2001 29 5.8

2002 29 5.8

2003 41 8.1

2004 42 8.3

2005 25 4.9

2006 39 7.6

2007 28 5.4

2003-2007 Average annual rates

By age (years)

0-17: 1.7 (95% CI: 0.9-3.1)

18-34: 6.1 (4.3-8.5)

35-64: 6.5 (5.1-8.3)

65+: 19.6 (15.0-25.2)

By gender

Male: 9.6 (7.9-11.3)

Female: 4.1 (3.1-5.4)

ED visits

2000 247 50.1

2001 249 50.0

2002 222 44.3

62 Definition: “Exposure symptoms were minimally noticeable”




7 August 2015 47

Jurisdiction, Year

(Reference)



2003 211 41.8 by local residents around the use of poison control centers.”

Some conclusions from the report:

“− Unintentional, non-fire related CO hospitalizations occur at a higher rate in older populations (65 years of age and older). In contrast, emergency department visits resulting from unintentional, non-fire related CO poisonings occur at a higher rate in younger populations (under age 65).

− Males had higher rates of unintentional, non-fire related CO hospitalizations and deaths compared with females. The emergency department visit rates were similar for males and females.

− In Minnesota, unintentional, non-fire related CO poisoning rates follow seasonal patterns, with greater hospitalizations, emergency department visits, and calls to the poison center occurring in the fall and winter months.”

2004 259 51.0

2005 242 47.4

2006 215 41.8

2007 334 64.4

2003-2007 Average annual years

By age (years):

0-17: 52.6 (95% CI: 46.9-28.2)

18-34: 70.8 (64.0-77.6)

35-64: 43.7 (39.6-47.7)

65+: 20.9 (16.2-26.7)

By gender:

Male: 51.6 (47.7-55.6)

Female: 47.1 (43.3-50.8)

Deaths

2000 16 3.2

2001 20 4.0

2002 19 3.8

2003 15 3.0

2004 14 2.8

2005 10 2.0

2006 13 2.5

2007 9 1.7

2003-2007 Annual average rates

By age (years):


7 August 2015 48

Jurisdiction, Year

(Reference)



0-17: 1.7 (0.9-3.1)

18-34: 2.4 (1.3-4.0)

35-64: 2.8 (1.9-4.1)

65+: 2.3 (0.9-4.6)

By gender:

Male: 3.9 (2.9-5.1)

Female: 0.9 (0.5-1.6)

Poison Control Center CO Exposure Calls

2002 275 54.8

2003 262 51.9

2004 303 59.7

2005 286 56.0

2006 215 41.8

2007 537 103.6

Florida

Harduar-Morano and Watkins, 2011

2005-2007 Unintentional non-fire-related

Emergency department visits: 260.3 (annual average number)

The cause and situation known for 91% of cases. Of these, 31% were “from a known source…such as generators, industrial kilns, and blast furnces; 21%

Total: 14.2 (95% CI: 13.2-15.1)

By gender

Male: 13.9 (12.5-15.3)

Female:14.4 (13.0-15.8)

By race

White: 11.9 (10.9-12.9)

Black: 24.3 (2.11-2.75)

Other: 14.4 (8.4-20.5)

By ethnicity

Non-Hispanic: 14.5 (13.4-15.7)




Morbidity data were obtained from the Florida Agency for Health Care Administration (AHCA), which collects data on all patients treated in non-federal Florida hospitals or EDs.

Death certificate data were obtained from the Florida Department of Health Bureau of Vital Statistics database.









7 August 2015 49

Jurisdiction, Year

(Reference)



from motor vehicle exhaust fumes.

There was no difference in exposure situation by race. Place recorded for 27% of cases. Of these, 50% occurred at home, 15% in industrial locations.

Hispanic: 12.0 (10.0-14.1)

By age (years):

0-14: 15.0 (12.6-17.4)

15-24: 15.7 (12.8-18.6)

25-34: 24.8 (21.0-28.6)

35-44: 19.2 (16.1-22.3)

45-54: 13.3 (10.7-15.9)

55-64: 7.2 (5.1-9.2)

65-74: 6.3 (4.0-8.6)

75-84: 5.4 (3.0-7.8)

≥85: 4.5 (0.9-8.2)

Individuals who died in the hospital or ED were excluded from motbidity analyses.

“Information related to the intent and mechanism of injury is required before an injury-related death certificate is issued, making this a more complete record for the purposes of poisoning intent and mechanisms…. ED [emergency department] and hospitalization data are medical-billings data collected for administrative purposes and often do not contain the intent or mechanism of the injury, as it is not required for reimbursement or treatment.”

“It was not possible to estimate the magnitude of the morbidity underestimation.”

The frequency of CO poisonong was highest in 2004-2005, the years in which many hurricanes and related widespread power outages occurred. However, the overall demographic pattern was similar.

A large number of poisonings occurred during winter months and during the hurricane season in the fall.

It was not possible to estimate the frequency of CO poisoning due directly to hurricanes, tropical storms, or cleanup efforts.

“Severe CO poisoning resulting in hospitalization or death in Florida affects

1999-2007 Hospitalizations: 54.8 (annual average number)

The cause and situation recorded for 88% of cases. Of these, 30% were related to motor vehicle exhaust fumes and 33% were related to a known source such as generators, industrial kilns, and blast furnaces.

White people were more likely than nonwhite people to have CO poisoning

Total: 3.2(95% CI: 2.9-3.5)

By gender

Male: 3.8 (3.3-4.2)

Female: 2.6 (2.3-3.0)

By race

White: 2.9 (2.6-3.2)

Black: 4.5 (3.7-5.3)

Other: 3.3 (1.5-5.1)

By ethnicity

Non-Hispanic: 3.3 (2.9-3.6)

Hispanic: 2.7 (2.0-3.3)

By age (years):

0-14: 2.0 (1.5-2.6)

15-24: 2.5 (1.8-3.2)


7 August 2015 50

Jurisdiction, Year

(Reference)



related to motor vehicle exhaust. Nonwhite people were more likely than white people to be exposed to CO via the burning of domestic fuels.

The place was recorded for 31% of cases. Of these, 70% occurred within the home and 9% at an industrial location.

25-34: 1.7 (1.1-2.3)

35-44: 3.7 (2.9-4.4)

45-54: 4.2 (3.3-5.1)

55-64: 3.9 (3.0-4.9)

65-74: 3.3 (2.3-4.2)

75-84: 5.6 (4.2-7.1)

≥85: 4.6 (2.3-6.8)

males more often than females, while acute CO poisoning cases (those treated in the ED) are more prevalent among females than males. The hospitalization and fatality rates are much higher for the elderly (≥75 years of age) than for other age groups. This may be because elderly patients are more likely to mistake their symptoms for other conditions, such as influenza-like illness or fatigue, leading to more severe CO poisoning cases, or because of the higher prevalence of other underlying medical conditions in this age group.

1999-2007 Fatalities: 25.6 (annual average number).

Cause and situation recorded for 82% of deaths. Of these, 35% were caused by a vehicle left running in an enclosed space; vehicle exhaust fumes were listed as the cause for an additional 34%

Total: 1.5 (1.3-1.7)

By gender

Male:1.9 (1.6-2.2)

Female: 1.1 (0.8-1.3)

By race

White: 1.6 (1.4-1.8)

Black: 0.9 (0.6-1.3)

Other: 1.5 (0.3-2.7)

By ethnicity

Non-Hispanic: 1.5 (1.3-1.7)

Hispanic: 1.3 (0.9-1.7)

By age (years):

0-14: 0.6 (0.3-0.9)


7 August 2015 51

Jurisdiction, Year

(Reference)



of deaths. Generator-related exposure: 12%; heating home with a grill, gas oven or space heater: 8%.

White people were more likely than nonwhite people to be exposed to exhaust fumes.

Place: 77% occurred in the home.

15-24: 1.0 (0.6-1.5)

25-34: 1.1 (0.7-1.6)

35-44: 1.4 (0.9-1.9)

45-54: 1.7 (1.1-2.2)

55-64: 1.14 (0.9-2.0)

65-74: 1.9 (1.1-2.6)

75-84: 3.3 (2.2-4.5)

≥85: 6.3 (3.7-8.9)

USA, Maine

Graber and Smith 2007

Outpatient and impatient: 1999-2003

ED visits: 2000-2003

Deaths: 1999-2003

Unintentional non-fire-related

Outpatient

Total: 693

Male: 380

Female: 313

Age (years)

0-17: 140

18-34: 233

35-64: 290

≥65: 30

Inpatient

Total: 47

2 deaths were identified

Outpatient

Total: 108 (95% CI: 100-116)

Male: 115 (110-134)

Female: 95 (85-106)

Age (years)

0-17: 96 (81-113)

18-34: 174 (153-198)

35-64: 108 (96-121)

≥65: 33 (23-46)

Inpatient




Morbidity data from three Maine hospital records datasets housed by the Maine Health Data Organization (MHDO): inpatient (IP), ED, and outpatient (OP)

Maine death certificate file








7 August 2015 52

Jurisdiction, Year

(Reference)



Male: 33

Female: 14

Age (years)

0-17: 0

18-34: 9

35-64: 25

≥65: 13

ED visits

Total: 442

Male: 247

Female: 195

Age (years)

0-17: 77

18-34: 151

35-64: 190

≥65: 24

Total: 7 (6-10)

Male: 14 (8-15)

Female: 4 (3-7)

Age (years)

0-17: no cases

18-34: 7 (3-13)

35-64: 9 (6-14)

≥65: 14 (8-24)

ED visits

Total: 86 (78-94)

Male: 93 (82-106)

Female: 78 (68-89)

Age (years)

0-17: 66 (51-83)

18-34: 141 (120-165)

35-64: 87 (76-101)

≥65: 32 (22-48)

USA, Michigan

Michigan Department of Health and Human Services


2009 Unintentional non-fire related

Unclear, how many injuries were fire-unrelated

17 (from a generator -7, from a vehicle -5, from a furnace or a water heater – 2, from a space heater -2, from a charcoal grill -1)

1.72

Estimated population: 9,901,591

http://www.oem.msu.edu/userfiles/file/Annual%20Reports/CarbonMonoxide/CO2009AnnualReportUpdate.pdf

Sources of information: Michigan Poison Control Center (PCC), Michigan hospitals, and death certificates.

Of 41 reported deaths, 17 were non-fire related

1,050 individuals were unintentionally poisoned by CO; it is not clear how many of










7 August 2015 53

Jurisdiction, Year

(Reference)



them were fire-related. 108 were work-related.

97 individuals with sufficient information to assign NAICS codes are listed by industry sector.

Source of exposure (occupational and non-occupational): unknown -30.6%, furnace/water heater – 26.1%, generator-4.5%, fire-8.7%, other-6.8%, portable grill -1.6%, power machinery – 4.8%, space heater – 3.2%, stove -3.7%, vehicle-8.6%, wood stove – 1.0%.

Population estimates: http://www.michigan.gov/cgi/0,4548,7-158-54534-291725--,00.html

2010 12 1.22


http://www.oem.msu.edu/userfiles/file/Annual%20Reports/CarbonMonoxide/2010CO_AnnualReport_8.22.14.pdf

Sources of information: Michigan Poison Control Center (PCC), Michigan hospitals, and death certificates.

Of 25 reported deaths, 12 were non-fire-related

Reports of unintentional CO poisoning were received on 985 individuals; it is not clear how many of them were fire-related. 118 were poisoned at work (number of fire-related is not reported).


http://www.michigan.gov/cgi/0,4548,7-158-54534-291725--,00.html

http://www.michigan.gov/cgi/0,4548,7-158-54534-291725--,00.html





7 August 2015 54

Jurisdiction, Year

(Reference)



Source of exposure (occupational and non-occupational): unknown – 27.8%; forklift -1.1%, boat – 0.8%, small engine – 1.8%, other power machinery – 3.17%, vehicle -8.6%, stove -3.3%, space heater – 3.0%, furnace/water heater – 26.3%, generator – 4.8%, portable grill/heater – 0.9%, fire -9.6%, wood stove – 1.5%, other -7.1%.

Population estimates: http://www.michigan.gov/cgi/0,4548,7-158-54534---,00.html

2011 15 (from a generator -6, from a vehicle -3, from a propane-fueled device -2 small engine-1, stove – 1, source unknown -2)

1.52



Sources of information: Michigan Poison Control Center (PCC), Michigan hospitals, and death certificates

Of 22 reported deaths, 15 were non-fire-related.

Reports of unintentional CO poisoning were received on 934 individuals; it is not clear how many of them were fire-related. 163 were exposed at work (the number of fire-related occupational cases is not reported)


Source of exposure (occupational and non-occupational): unknown – 23.6%; forklift -3%, boat – 0.3%, small engine – 0.7%,







7 August 2015 55

Jurisdiction, Year

(Reference)



other power machinery – 1.7%, vehicle -10.3%, train – 1.3%, stove -2.5%, space heater – 3.4%, furnace/water heater – 23%, generator – 10.5%, portable grill/heater – 2.5%, fire -7.1%, wood stove – 0.4%, other -9.7%.


2012 17 1.72


http://www.michigan.gov/documents/mdch/2012_report_version_8_475712_7.pdf


Of 22 reported deaths, 17 were non-fire-related.

Reports of unintentional CO poisoning were received on 765 individuals; it is not clear how many of them were fire-related.

Exposure source was known for 497 individuals. Of them: Furnace/Water Heater-22.7%, vehicle -14.9%, fire-14.5%, generator-13.7%, other-10.91%, stove -5.2%, portable grill- 4.6%, space heater -4.2%, small engine -2.2%, forklift-1.8%, woodstove -1.8%, natural gas-1.6, boat -1%, power machinery/other 0.8%.









7 August 2015 56

Jurisdiction, Year

(Reference)



2013 26 2.63


http://www.michigan.gov/documents/mdch/2013_Annual_Report_of_Carbon_Monoxide_Poisoning_in_Michigan_484733_7.pdf


Of 34 reported deaths, 26 were non-fire-related

Reports of unintentional CO poisoning were received on 823 individuals; it is not clear how many were fire-related

Exposure source was known for 465 individuals. Of them: Furnace/Water Heater -21.7%, generator -19.6%, vehicle – 14.6%, fire-12.5%, power machinery/other -8.2%, other -7.3%, space heater – 6.7%, stove- 5.2%, woodstove – 1.5%, forklift – 1.1%, portable grill- 0.9%, boat -0.4%, small engine – 0.4%


U.S.

Consumer Product Safety Commission (CPSC), 2014a

1981 Estimated non-fire carbon monoxide deaths associated with the use of consumer products

No data 311 1.355 “Non-Fire Carbon Monoxide Deaths Associated with the Use of Consumer Products 2011 Annual Estimates” at: http://www.cpsc.gov//Global/Research-and-Statistics/Injury-Statistics/Carbon-Monoxide-Posioning/NonFireCarbonMonoxideDeaths

1982 No data 340 1.402

1983 No data 323 1.338

1984 No data 275 1.247

1985 No data 284 1.119

1986 No data 240 1.049












7 August 2015 57

Jurisdiction, Year

(Reference)



Report date: September 2014

1987 No data 232 0.977 AssociatedwiththeUseofConsumerProducts2011AnnualEstimatesSept2014.pdf

“The national estimates presented in this report are based on death certificate records obtained from 50 states, the District of Columbia, and New York City directly, augmented by information collected in CPSC's In-Depth Investigations (IDis), and to a lesser extent, news articles and medical examiners' reports contained in the CPSC Injury or Potential Injury Incident (IPII) database.”

“Data collection was only partially complete for 2011, and estimates for this year may change in the future when additional data become available”.

U.S. population estimates and mortality rates are presented in tables B.1 –B5 on pp. 37 -41

More detailed information on deaths by type of consumer product and type of fuel can be found in tables 1 and 2 of the report. Only annual average numbers (2009-2011) for selected products/types of fuel are extracted into this table. Information on numbers of deaths by month of the year, age, ethnicity and other variables can be found in other tables of the report.

1988 No data 238 1.044

1989 No data 296 1.049

1990 No data 243 1.053

1991 No data 250 0.927

1992 No data 211 0.877

1993 No data 214 0.831

1994 No data 223 0.808

1995 No data 201 0.802

1996 No data 217 0.740

1997 No data 180 0.705

1998 No data 180 0.566

1999 No data 108 0.509

2000 No data 138 0.434

2001 No data 121 0.515

2002 No data 181 0.527

2003 No data 153 0.576

2004 No data 168 0.581

2005 No data 190 0.606

2006 No data 180 0.621

2007 No data 186 0.601

2008 No data 178 0.548

2009 No data 148 0.523

2010 No data 159 0.503

2011 No data 160 Not calculated




7 August 2015 58

Jurisdiction, Year

(Reference)



2001 Estimated non-fire CO deaths associated with generators

No data 20 0.095

2002 No data 42 0.129

2003 No data 49 0.152

2004 No data 41 0.20263

2005 No data 88 0.241

2006 No data 85 0.269

2007 No data 68 0.220

2008 No data 76 0.202

2009 No data 64 0.196

2010 No data 42 0.179


2001 Estimated non-fire CO deaths associated with generators and other engine-driven tools

No data 22 0.17

2002 No data 52 0.151

2003 No data 56 0.188

2004 No data 56 0.24364

2005 No data 102 0.295

2006 No data 104 0.318

2007 No data 79 0.262

2008 No data 83 0.237

2009 No data 76 0.231

2010 No data 56 0.218


63 Based on the number of deaths (41) and population estimate (293,046,000) the rate is 0.140. 64 Based on the number of deaths (56) and population estimate (293,046,000) the rate is 0.191


7 August 2015 59

Jurisdiction, Year

(Reference)



By consumer product

2009-2011 (annual average numbers)

Furnaces (incl. boilers)

No data 22 (14%65)

Of these, 11 (7%) on natural gas, 2 (1%) on liquid petroleum and 5 (3%) on unspecified gas

0.07

Average annual population estimate for 2009-2011 (tables B1-B5 of the publication): 309305333

Portable heaters No data 13 (8%). Of these, 12 8%) on liquid petroleum gas

0.04

Wall/floor furnaces

No data 4 (3%) 0.01

Room/Space heaters

No data 5 (3%) 0.02

Engine-driven tools

No data 67 (43%). Of these, 55 (35%) were generators and 12 (8%) were other engine-driven tools.

0.22

By fuel type

Natural gas No data 19 (12%)66 0.06

65 Of the total annual average of 156 66 Of the total annual average of 156


7 August 2015 60

Jurisdiction, Year

(Reference)



2009-2011 (annual average numbers)

Liquid Petroleum (LP) Gas

No data 27 (17%) 0.09

Unspecified gas No data 10 (6%) 0.03

Gasoline67-Fueled Products

No data 67 (43%) 0.22

Oil-Fueled Products

No data 2 (1%) 0.006

Diesel-Fueled Products

No data ? (<1%)

By location

Home No data 117 (75%)68 0.38

Temporary shelter

No data 17 (11%) 0.05

Vehicles (including boats)

No data 9 (6%) 0.03

By gender

Male 113 (72%) 0.37

Female 42 (27%) 0.14

U.S.

Consumer Product Safety Commission (CPSC), 2014b

Report date: January 2014

Estimates for each year from 1980-to 2010 and average annual estimates for 2008-2010

Non-Fire Carbon Monoxide Deaths Associated with the Use of Consumer Products

No data Numbers of deaths by year, by type of product and fuel are presented in way similar to the report

“Non-Fire Carbon Monoxide Deaths Associated with the Use of Consumer Products 2010 Annual Estimates” at: http://www.cpsc.gov//Global/Research-and-Statistics/Injury-Statistics/Carbon-Monoxide-Posioning/2010NonFireCODeathsFINAL.pdf

67 “Petrol” in the U.K. 68 Of the total annual average of 156






7 August 2015 61

Jurisdiction, Year

(Reference)



summarized above. Period covered: 1980-2010

This report is of similar structure and content as the one summarized above. Estimates for each year from 1980 to 2010 and annual averages for 2008-2010 are presented.

U.S.

Consumer Product Safety Commission (CPSC), 2012

December 2012

Estimates for each year from 1980-to 2009 and average annual estimates for 2007-2009

Non-Fire Carbon Monoxide Deaths Associated with the Use of Consumer Products

No data Numbers of deaths by year, by type of product and fuel are presented in way similar to the report summarized above. Period covered: 1980-2009

“Non-Fire Carbon Monoxide Deaths Associated with the Use of Consumer Products 2009 Annual Estimates” at: http://www.cpsc.gov//PageFiles/136146/co12.pdf

This report is of similar structure and content as the one summarized above. Estimates for each year from 1980 to 2009 and annual averages for 2007-2009 are presented.

U.S.

Consumer Product Safety Commission (CPSC), 2014c

Report date: June 2014

2004-201369 Engine-Driven Generators and Other Engine-Driven Tools

No data Total engine-driven tools: 808.

By product

Generators -657 (portable -650, fixed -5, welder used as a generator – 2)

Other engine-driven tools -

Total: 0.29

Generators: 0.24

Other engine-driven tools: 0.04

Include in the summary table

Multiple products: 0.02

“Incidents, Deaths, and In-Depth Investigations Associated with Non-Fire Carbon Monoxide from Engine-Driven Generators and Other Engine-Driven Tools, 2004–2013” at: https://www.cpsc.gov/Global/Research-and-Statistics/Technical-Reports/Home/Portable-Generators/GeneratorsandOEDTFatalities-2014-FINAL.pdf

69 “In this report, the two most recent years, 2012 and 2013, are identified as being incomplete because the numbers for these years most likely will increase in future reports.”









7 August 2015 62

Jurisdiction, Year

(Reference)



103 (Lawn mowers-54; power washer/sprayer11; snow blower – 10; all-terrain vehicle – 8; welder – 4; water pump – 5; concrete saw -2; air compressor – 2; one death associated with each of the following: paint sprayer, snowmobile, go-cart, tiller, small engine of unknown use, edger, stump grinder)

Multiple fuel-burning consumer products -48

By year

Detailed information by type of product, year, season, age, gender, ethnicity, location, reason for use and other variables can be found in the tables of the report

Population numbers (averaged over 2004-2012): http://www.indexmundi.com/g/g.aspx?v=21&c=us&l=en

2004 62 0.21

2005 116 0.39

2006 109 0.37




7 August 2015 63

Jurisdiction, Year

(Reference)



2007 82 0.27

2008 102 0.34

2009 76 0.25

2010 57 0.18

2011 108 0.34

2012 4970 0.16

2013 4771 0.15

U.S.

Consumer Product Safety Commission (CPSC), 2013

Report date: August 2013

1999-201272 Engine-Driven Generators and Other Engine-Driven Tools

No data Total engine-driven tools: 931 (generators- 739, other tools- 126, multiple products -66)

0.24 “Incidents, Deaths, and In-Depth Investigations Associated with Non-Fire Carbon Monoxide from Engine-Driven Generators and Other Engine-Driven Tools, 1999–2012” at: http://www.cpsc.gov/Global/Research-and-Statistics/Injury-Statistics/Carbon-Monoxide-Posioning/GeneratorsAndOEDTFatalities2013FINAL.pdf

Data by product type and year are not extracted because it is overlapping with the information from the CPSC 2014 report summarized above

Detailed information by type of product, year, season, age, gender, ethnicity, location, reason for use and other variables can be found in the tables of the report.

70 Incomplete data 71 Incomplete data 72 “In this report, the two most recent years, 2011 and 2012, are identified as being incomplete because these figures most likely will change in future reports.”







7 August 2015 64

Jurisdiction, Year

(Reference)



USA

Iqbal et al., 2012a

1993 Unintentional, non-fire-related

Hospitalizations: 15 Hospitalization rates by year from figure 3 of the publication



Public Health Rep. 2012 Sep-Oct; 127(5): 486–496

Data sources: death certificate data from the National Vital Statistics System (NVSS); emergency department visit and hospitalization data from the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample and Nationwide Inpatient Sample

Population estimate as of July 1, 2009 (307,006,550) from http://www.census.gov/popest/data/state/totals/2009/tables/NST-EST2009-01.csv See “Annual Population Estimates at: http://www.census.gov/popest/data/historical/2000s/vintage_2009/index.html

1994 Hospitalizations: 15













2007 Hospitalizations: 2,302

ED visits: 21,304

Hospitalizations: 8

ED visits: 71

2009 439 1.43

USA

Iqbal et al., 2012b

2007 Unintentional, non–fire-related

ED visits

Total: 21,304

Men: 9,879

Women: 11,426

Age (years)

0-17: 5,587

No data ED visits

Total: 71 (95% CI: 64-77)

Men: 67 (60-73)

Women: 75 (67-83)

Age (years)

0-17: 76 (66-86)


Am J Emerg Med. 2012 Jun;30(5):657-64


Data from Nationwide Inpatient Sample (NIS) and Nationwide Emergency





http://www.census.gov/popest/data/state/totals/2009/tables/NST-EST2009-01.csv

http://www.census.gov/popest/data/state/totals/2009/tables/NST-EST2009-01.csv

http://www.census.gov/popest/data/historical/2000s/vintage_2009/index.html

http://www.census.gov/popest/data/historical/2000s/vintage_2009/index.html





7 August 2015 65

Jurisdiction, Year

(Reference)



18-44: 9,879

45-64: 4,259

65-84: 1,367

≥85: 212

Place of occurrence:

Residential: 61%

Occupational: 10.8%

Recreational: 0.7%

Motor-vehicle-related: 1.5%

Public buildings: 3.9%

Other: 22.1%

Season: the highsst numbers during winter months.

Outcome


Admitted: 1,652

Transferred: 556

Died in ED: 46

Not admitted, unknown: 584

Hospitalizations

Total: 2,302

18-44: 87 (79-96)

45-64: 56 (50-62)

65-84: 42 (36-48)

≥85: 41 (28-55)

Hospitalizations

Total: 8 (6-9)

Men: 9 (6-11)

Women: 7 (5-8)

Age (years)

0-17: 3 (1-4)

18-44: 6 (4-8)

45-64: 12 (9-15)

65-84: 14 (10-18)

≥85: 18 (9-27)

Department Sample (NEDS) data from the Hospitalization Cost and Utilization Project (HCUP)

Cases were classified into confirmed, probable and suspected on the basis of ICD-9 CM codes. Only confirmed cases were analyzed.

Of 21,304 ED visits, 46 died in ED.

Data on deaths among hospitalized patients were not available.


7 August 2015 66

Jurisdiction, Year

(Reference)



Men: 1,306

Women: 992

Age (years)

0-17: 182

18-44: 664

45-64: 903

65-84: 457

≥85: 92

Place of occurrence:

Residential: 63%

Occupational: 9.5%

Recreational: 0.5%

Motor-vehicle-related: 1.3%

Public buildings: 4.1%

Other: 21.6%

Season: the highsst numbers during winter months.

Iqbal et al., 2010

2005 Hospitalizations

Total: 4,216

Male: 2,525

Female: 1,682

Age (years)

<1: no data

1-17: 341

No data Total: 14.2 (95% CI: 13.8-14.7)

Male: 17.3 (16.6-18.0)

Female: 11.2 (10.6-11.7)

Age (years)

<1: no data

1-17: 4.9 (4.4-5.4)



Public Health Rep. 2010 May-Jun;125(3):423-32.








7 August 2015 67

Jurisdiction, Year

(Reference)



18-44: 1,442

45-64: 1,499

65-84: 745

≥85: 155

18-44: 12.7 (12.1-13.4)

45-64: 20.6 (19.5-21.6)

65-84: 23.5 (21.8-25.2)

≥85: 30.4 (25.6-35.2)

Data from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS)

Cases were classified into confirmed, probable and suspected on the basis of ICD-9 CM codes. Only confirmed cases were analyzed.

USA

Henn et al., 2013

1992–2008 Occupational non fire-related carbon monoxide fatalities

No data Total: 374

By National Occupational Research Agenda (NORA) sector

Agriculture, Forestry, & Fishing: 47

Construction: 94

Health Care & Social Assistance: 6

Manufacturing: 37

Mining, Oil & Gas Extraction: 17

Services, including public safety: 114

Rates per 1M full-time equivalent workers per year (1FTE=2,000 hr worked per year)

Total: 0.17

By National Occupational Research Agenda (NORA) sector

Agriculture, Forestry, & Fishing: 0.87

Construction: 0.59

Health Care & Social Assistance: 0.02

Manufacturing: 0.11

Mining, Oil & Gas Extraction: 1.35

Services, including public safety: 0.13

Transportation,Warehousing, & Utilities: 0.16

Wholesale & Retail Trade: 0.08



Source of data on work-related fatalities due to CO poisoning:

- the Census of Fatality and Occupational Injury (CFOI) database;

- Integrated Management Information System (IMIS) of the Occupational Safety and Health Administration (OSHA)

The number of full-time equivalent workers was obtained from the Bureau of Labor Statistics (BLS) Current Population Survey (CPS) from 1992 through 2008.




7 August 2015 68

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(Reference)



Transportation,Warehousing, & Utilities: 20

Wholesale & Retail Trade: 33

Unknown: 6

Top10 Occupational CO Fatality Rates by Industry Reported in BLS’ CFOI

Fishing, hunting, and trapping: 9

Automotive repair and maintenance: 33

Mining and support activities for mining: 10

Oil and gas extraction: 7

Iron and steel mills and steel product mfg: 9

Unknown: not calculated

Top10 Occupational CO Fatality Rates by Industry Reported in BLS’ CFOI

Fishing, hunting, and trapping: 7.96

Automotive repair and maintenance: 1.51

Mining and support activities for mining: 1.35

Oil and gas extraction: 1.35

Iron and steel mills and steel product mfg: 1.17

Services to buildings and dwellings: 1.03

Crop production: 0.97

Animal production: 0.80

Investigation and security services: 0.75

Chemicals and allied products: 0.75


7 August 2015 69

Jurisdiction, Year

(Reference)



Services to buildings and dwellings: 15

Crop production: 16

Animal production: 17

Investigation and security services: 8

Chemicals and allied products: 6

Iran, Tabriz

Dianat and Nazari 2011

From 21 March 2007 to 20 March 2009 (2 years)

Unintentional, non–fire-related

Non-fatal poisonings for 2 years

Total: 1095

Male: 326

Female: 679

Age (years)

0-14: 179

15-24: 239

25-44: 414

45-64: 132

>64: 41

By type of appliances (based on 328 cases):

Fatal CO poisonings for 2 years

Total: 90

Male: 41

Female: 49

Age (years)

0-14: 12

15-24: 15

25-44: 36

45-64: 13

>64: 14

Annual average rates

Non-fatal :346

Fatal: 28

Population numbers by gender and age are not available to calculate age- and gender-specific rates.


An estimated population of Tabriz: 1.58 million

“All medical records of the patients transported by the Tabriz’s Emergency Medical Service (EMS) system in which a person received a diagnosis of unintentional CO poisoning were reviewed to identify incidents of unintentional CO-related poisoning. … All unintentional CO poisoning incidents not related to a fire were included as a case in the study. Death certificate reports related to CO poisoning confirmed by the Legal Medicine Organization (classified based on the International Classification of Diseases,




7 August 2015 70

Jurisdiction, Year

(Reference)



Water heaters: 59.2%

Heating devices: 25.3%

Boilers: 7.1%

Cookers: 2.1%

Other: 2.1%

Unknown: 4.2%

10th Revision (ICD-10) codes T58 and X47) were also reviewed…”

To identify risk factors associated with CO poisoning, telephone interviews were conducted by contacting one person from each non-fatal poisoning incident.

Iran, East Azerbaijan province

Nazari et al., 2010

From 21 March 2003 to 20 March 2008 (5 years)

Unintentional, non-fire related

Non-fatal poisonings for 5 years

Total: 3078

Male: 1176

Female: 1902

Age (years)

0-9: 344

10-19: 441

20-29: 785

30-39: 605

40-49: 362

50-59: 272

>60: 269

Fatal poisonings for 5 years

Total: 346

Male: 185

Female: 161

Age (years)

0-9: 43

10-19: 51

20-29: 76

30-39: 43

40-49: 52

50-59: 47

>60: 34

Annual average rates

Non-fatal: 171

Fatal: 19


An estimated population of 3.6 million

Sources of information: medical records of patients transported by the emergency medical service (EMS) system; death certificate reports of the Legal Medicine Organization



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