2 figures, 1 table omitted
The four major hurricanes that struck Florida during August 13–September
25, 2004, produced electric power outages in several million homes.1 After the hurricanes, the Consumer Product Safety
Commission (CPSC) investigated six deaths in Florida attributed to carbon
monoxide (CO) poisoning (CPSC, unpublished data, 2004). The Florida Department
of Health and CDC analyzed demographic and CO exposure data from these fatal
poisoning cases and from nonfatal poisoning cases among 167 persons treated
at 10 hospitals, including two with hyperbaric oxygen (HBO2) chambers.
This report describes the results of that analysis, which determined that
misplacement of portable, gasoline-powered generators (e.g., indoors, in garages,
or outdoors near windows) was responsible for nearly all of these CO exposures.
Public health practitioners should recognize that post-hurricane environments
present challenges to the safe operation of portable generators and should
educate the public on the hazards of CO poisoning in these settings.
All medical records were reviewed from participating hospitals in which
a patient received a diagnosis of unintentional CO poisoning (International Classification of Diseases, Ninth Revision code 986)
during August 13–October 15, 2004. These dates correspond to landfall
of the first hurricane (Charley) and 3 weeks after landfall of the last hurricane
(Jeanne), when active surveillance for CO poisoning was discontinued. Nine
participating hospitals, including one with an HBO2 chamber, were
located in landfall counties and involved in post-hurricane surveillance;
a tenth participating hospital, which also had an HBO2 chamber,
was located in central Florida. Any case involving a diagnosis of unintentional
CO poisoning not related to a fire was included. All available information
about the patient’s exposure, clinical presentation, laboratory testing
(e.g., result of earliest available measurement of blood carboxyhemoglobin
[COHb] level), and medical treatment was collected. In addition, investigations
into six deaths from five exposure incidents were reviewed for basic demographic
information and details about generator location. Because the six persons
who were fatally poisoned died before arrival at a medical facility, no clinical
information was recorded for them.
A total of 167 persons had nonfatal CO poisoning diagnosed during the
study period, representing a total of 51 exposure incidents. The number of
cases and incidents peaked within 3 days after landfall of each hurricane.
The mean number of persons poisoned per incident was 3.3 (range: one to eight
persons per incident). Fifty-four (32.3%) patients were initially treated
at emergency departments (EDs) in hospitals outside the surveillance system
but were later transferred to one of the two hospitals with HBO2 chambers.
Of the 167 persons with nonfatal poisoning, 87 (52.1%) were female.
The median age was 29 years; 52 (31.1%) were aged ≤16 years, and 11 (6.6%)
were aged ≥65 years. Seventy-six (45.5%) of the persons with nonfatal poisoning
were white,* 47 (28.1%) Hispanic, 36 (21.6%) black, and six (3.6%) Asian;
the race/ethnicity of two (1.2%) persons was not known. The percentages of
those poisoned who were Hispanic and black were approximately twice the percentages
of Hispanics (14.7%) and blacks (9.1%) reported residing in the hurricane-affected
counties by the Florida 2004 Behavioral Risk Factor Surveillance System (BRFSS)
survey. Among the six persons who were fatally poisoned, all were white, and
five (83.3%) were male; the median age was 45 years (range: 30-58 years).
The most frequently reported symptoms of CO poisoning were headache
(80.0%), nausea (51.5%), dizziness (50.9%), vomiting (31.5%), shortness of
breath (16.4%), and loss of consciousness (14.5%). Among the 162 patients
for whom COHb levels were available, the mean level of COHb was 19.8% (standard
deviation: ±8.7%); median was 21.1% (range: 0.2%-45.1%). Eighty-one
(48.5%) patients were treated and released from the ED without HBO2 treatment.
Seventy-three (43.7%) patients were released after HBO2 treatment.
Thirteen (7.8%) patients were hospitalized; 11 of those were discharged after
one night. Of the 13 hospitalized patients, four received HBO2 treatment.
Overall, 77 (46.1%) persons were treated with HBO2.
The majority of nonfatal poisonings occurred overnight, with patients
waking in the early morning with symptoms. One hundred eleven (66.5%) patients
arrived at the ED during 5:00 a.m.–10:00 a.m. Medical records indicated
that patients typically used generators to power refrigerators, fans, and
air conditioners while sleeping. Similar exposure patterns and types of powered
appliances were reported among the five incidents with fatalities.
Information regarding the source of CO was available for 49 (96.1%)
of the 51 incidents with nonfatal poisonings. Use of portable, gasoline-powered
generators was implicated in 47 (96.0%) nonfatal incidents and in the five
incidents that resulted in the six fatalities. In two other nonfatal incidents,
exposure to CO was attributed to use of a gasoline-powered saw and to a vehicle
left idling in a garage. In the 47 nonfatal incidents in which a generator
was known to be involved, 16 (34.0%) generators were operated outdoors; 16
(34.0%) inside a garage; six (12.8%) inside a home; four (8.5%) on an attached
porch, deck, or patio; one (2.1%) inside a business; and one (2.1%) as part
of a recreational vehicle. Generator location was unavailable for three (6.4%)
incidents. The majority of the 16 generators placed outdoors were reportedly
located near windows or window-mounted air conditioners. Medical records for
certain patients indicated that generators were placed in homes or garages
to protect the devices from the weather or to prevent them from being stolen.
Among the five incidents with fatalities, generators were placed inside a
home in two incidents, in an office or business in two incidents, and inside
a garage in one incident. No mention was made of a home CO detector in any
of the medical records.
JC Sniffen, DO, TW Cooper, MD, Florida Hospital, Orlando; D Johnson,
MD, C Blackmore, DVM, P Patel, MD, L Harduar-Morano, MPH, Div of Environmental
Health; R Sanderson, MA, A Ourso, MPH, K Granger, MPH, Bur of Epidemiology,
Florida Dept of Health. J Schulte, DO, National Center for Health Marketing;
JM Ferdinands, PhD, RL Moolenaar, MD, K Dunn, MS, S Damon, MAIA, Div of Environmental
Hazards and Health Effects, National Center for Environmental Health; D Van
Sickle, PhD, D Chertow, MD, EIS officers, CDC.
Portable, gasoline-powered generators are a common source of unintentional
CO poisoning after power outages.2 The devices
are used increasingly to provide electricity during temporary outages resulting
from adverse weather events, but the CO produced during their operation can
be a serious health hazard. The exhaust produced by the typical 5.5 kW generator
contains as much CO as that of six idling automobiles.2,3 When
used indoors or in close proximity to residential dwellings, this exhaust
can quickly infiltrate living spaces and incapacitate occupants.2
Data from the 2004 BRFSS indicate that 17.5% of adult respondents in
Florida reported that their household used a generator for power after at
least one of the hurricanes; a substantial number of these generators were
operated inside a home or garage.4 This report
demonstrates that CO poisoning, although not perceived as an important health
problem by the public,4 represents an important
cause of morbidity and mortality in a post-hurricane environment. In this
study, portable generators were the source of CO for all fatal cases and nearly
all nonfatal cases of CO poisoning. Misplacement of portable generators indoors,
in garages, or outdoors near windows accounted for most exposures. In addition,
the majority of CO exposures occurred during overnight use of generators to
power air conditioners and appliances.
The findings in this report are subject to at least three limitations.
First, investigators used a sample of 10 hospitals to collect cases of CO
poisoning; therefore, the findings are not a complete inventory of cases of
CO poisoning in Florida during the 2004 hurricane season. Second, only cases
of CO poisoning among persons treated at hospital EDs and at two HBO2 chambers were included in the study; therefore, the results likely
reflect more severe poisonings than would occur in a general population. Finally,
because the study was limited to data documented in hospital records, the
role of previously identified risk factors (e.g., language barriers)5 was not examined in these cases of CO poisoning.
Sales of portable generators have been increasing since 2000,6 primarily because of increased affordability of the
devices and disaster preparedness campaigns. With increasing numbers of new
generator owners, public health officials can expect a decline in the mean
level of user experience with the devices. An above-normal hurricane season
was predicted for 2005, with 12-15 tropical storms (average: 10), including
seven to nine hurricanes (average: six), with three to five (average: two)
of these rated as major (category 3-5) hurricanes. The majority of the storms
were expected to form during August-October.7 However,
as of July 14, the season had already produced five tropical storms, including
two that became major hurricanes. Power outages that occur after hurricanes
create demand for alternate electricity sources to power air conditioning,
ventilation, and refrigeration. The urgent need for interim power supplies,
coupled with fear of theft and the risks of shock and electrocution posed
by using nonweatherized devices in wet conditions, create challenges to the
safe operation of portable generators in post-hurricane settings. Nonetheless,
public health campaigns should emphasize that portable generators must never
be operated indoors, in garages, or outdoors anywhere near doors, windows,
or vents of buildings that might be occupied.
This report is based, in part, on data contributed by CPSC.
*For this report, persons identified as white, black, and Asian are
all non-Hispanic. Persons identified as Hispanic might be of any race.
Carbon Monoxide Poisoning From Hurricane-Associated Use of Portable
Generators—Florida, 2004. JAMA. 2005;294(12):1482-1483. doi:10.1001/jama.294.12.1482