BRIEF OVERVIEW
Issues of misbranding, mislabeling, and adulteration of food and drugs concerned those who were involved in public health as well as health care providers and led to the founding of the United States Pharmacopeia (1820), the American Medical Association (1847), the American Pharmacists Association (1852), and other organizations. Concerns about food and drug safety, beginning in the 19th century, provided the impetus for the first human clinical food additive trials to demonstrate safety and efficacy in December 1902 (Hurt, 1985). These efforts led to the Pure Food and Drug Act of 1906 (Lewis, 2002). This legislation (“Wiley Act”) created the Food, Drug, and Insecticide Administration, which in 1930 became the Food and Drug Administration (FDA). The Act required approval for foods and drugs meant for human consumption. Subsequently, the federal government passed a number of laws, created regulations, and proposed other controls and management of poisoning. These efforts are summarized in Box 4-1.
In the 1930s, childhood poisoning was recognized as a significant component of pediatric practice and patient morbidity. Unfortunately, little information existed regarding the toxicity of household products and management recommendations. Jay Arena, M.D., a pediatrician at Duke University, began to systematically collect information regarding toxic hazards in the early 1930s and provided advice to physicians on poisoning cases in the surrounding area. He provided one of the first reports on the hazards of household products to children (Martin and Arena, 1939). Louis Gdalman, R.Ph., a pharmacist in Chicago, collected information during World War II. He developed a toxicological information system using index cards and eventually converted to microfiche. This system eventually covered more than 9,000 commercial and consumer products. Moreover, Gdalman established the precursor to the modern poison control center by personally taking telephone calls 24 hours per day (Botticelli and Pierpaoli, 1992; Burda and Burda, 1997).
Although recognized as a growing problem during this period, the magnitude of childhood poisoning was not appreciated until a 1949-1950 epidemiological study focusing on children under 5 years of age reported a significant number of poisoning deaths (Bain, 1954). In 1950, the American Academy of Pediatrics (AAP), which was founded in 1930, established its Accident Prevention Committee, chaired by George M. Wheatley, M.D. That committee surveyed the 3,000 members of AAP and found that 49 percent of reported “accidents” treated by AAP members involved poisoning (Wheatley, 1953).
In 1953, Edward Press, M.D., and Gdalman developed the first formal poison control center in Chicago. Their center provided professional telephone advice and included a standard data collection form (Botticelli and Pierpaoli, 1992; Burda and Burda, 1997). These centers rapidly developed, with as many as 265 by 1958 and 661 by 1978 (Scherz and Robertson, 1978).
Provision of timely information to physicians regarding drugs and the toxicity of other agents was the driving force for poison control center operations. These early leaders also recognized that effective telephone triage could avert unneeded medical visits or lead to early treatment at home. Hence, centers soon began to provide advice directly to laypersons and nonphysician care providers. This feature distinguishes poison control centers in the United States from similar centers in other countries, where the task of giving advice remains largely restricted to physicians.
In 1957, the Surgeon General established the National Clearinghouse for Poison Control Centers (NCHPCC) within the FDA. At the time, the FDA and the U.S. Department of Agriculture represented the only federal agencies related to consumers with jurisdiction over drugs and chemicals. Product ingredient information was provided and poison exposures were tracked through NCHPCC. Funding was also provided to develop the text Clinical Toxicology of Commercial Products, authored by Robert Gosselin, M.D., Harold Hodge, M.D., and Marion Gleason at the University of Rochester.
At the 1958 AAP annual meeting, the American Association of Poison Control Centers (AAPCC) was founded (Mofenson, 1975) (see Box 4-2 for the AAPCC statement of objectives). AAPCC continues to serve as the voluntary association for poison control centers. As the lead professional organization regarding poison control and management, AAPCC—along with other toxicology groups—continues to host medical toxicology scientific presentations and continuing education sessions at its annual meeting in combination with several other societies. In 1968, both the American Academy of Clinical Toxicology and the American College of Emergency Physicians were founded. One impact of both organizations was to take the focus of poisoning beyond pediatric exposures. The American Board of Medical Toxicology gave its first examination for physician toxicologists in 1974 and fellowship training programs were instituted at about the same time. Emergency medicine was recognized as a specialty in the United States in 1979 when it received conjoint status from the American Board of Medical Specialists (ABMS) and became a primary specialty 10 years later. Medical toxicology began administering examinations in 1974 and was recognized by the ABMS as a certificate of added qualification in 1994. Although AAP has remained active in the area of poisonings with its Section on Injury and Poison Prevention, founded in 1990, the organization no longer sponsors AAPCC meetings.
During the late 1970s, systems of emergency care were developed following passage of the Emergency Medical Services (EMS) Systems Act of 1973 (Pub. L. No. 93-154). The application of technology and centralized public service (communication) access points produced the opportunity for integration of poison control centers within EMS systems. Concurrent steps to enhance home safety (e.g., product labeling, smaller quantities of over-the-counter medications per package, prescription drug safety caps, childproof cabinet locks) coincided with a shift in awareness of mortality risk to include adult poisoning as a major emphasis of care. Given a growing emphasis on adult poisoning management and poisoning response with EMS services, an increasing number of leaders in medical toxicology, including the poison control center medical directors, began to come from a background in emergency medicine followed by a fellowship in clinical toxicology (see Chapter 5). Professional activities by medical toxicologists, pharmacists, and nurses also have grown dramatically in both the management and operation of poison control centers. Centers no longer use clerical personnel or sanitarians to manage exposures.
Certain aspects of poisoning prevention in the past 30 years have been independent of poison control center clinical functions. For example, the introduction by the FDA of imprint codes on tablets and capsules provided a much improved method of tablet and capsule identification. Although the system has major drawbacks (e.g., use of logos that are difficult to categorize, describe, and list), there has been faster determination of potential medication exposures (Marder et al., 2001; Symonds and Robertson, 1967).
Similarly, the use of safety caps on medications and chemical compounds has reduced the number of exposures in children and may have been the single most important reason for reduction in morbidity and mortality since the early 1970s (Anonymous, 1982; Arena, 1959; Palmisano, 1981; Rodgers, 1996; Walton, 1982). Although there have been various public campaigns to use other child safety devices, the only data that exist are related to safety caps. Child-resistant packaging was required for various prescription drugs beginning in 1974. Looking at the period from 1974 to 1992 and comparing it with a previous period, estimates show a reduction of 460 child deaths and a mortality rate reduction of 45 percent as a result of this packaging (Rodgers, 1996). Figure 4-1 from that study shows the drop in child mortality rates over the time period; Figure 4-2 shows the difference between the predicted rates with and without child-resistant packaging.
Events both before and after September 11, 2001, have heightened national concerns regarding homeland security and the threat of radiologic, biological, and chemical weapon exposure. The Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) have recognized the importance of poison control centers as a component of an all-hazards emergency planning and response system that is integrated with state health departments and supports regional and hospital-based emergency service efforts. As discussed in Chapters 5 and 9, the incorporation of poison control centers in this manner has been variable and remains underdeveloped. This new potential role—combined with substantive changes in funding and federal oversight—clearly marks a break with the past and the beginning of a new period for poison control centers.