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Residential carbon monoxide (CO) poisoning risks: correlates of observed CO alarm use in urban households.

Introduction

Carbon monoxide carbon monoxide, chemical compound, CO, a colorless, odorless, tasteless, extremely poisonous gas that is less dense than air under ordinary conditions. It is very slightly soluble in water and burns in air with a characteristic blue flame, producing carbon dioxide;  (CO) poisoning is a significant yet preventable public health problem that is only recently gaining the necessary attention of public health and safety officials and policy makers. CO is a colorless col·or·less  
adj.
1. Lacking color.

2. Weak in color; pallid.

3. Lacking animation, variety, or distinction; dull. See Synonyms at dull.
, odorless o·dor·less  
adj.
Having no odor.



odor·less·ly adv.

o
 gas that is produced through the incomplete combustion combustion, rapid chemical reaction of two or more substances with a characteristic liberation of heat and light; it is commonly called burning. The burning of a fuel (e.g., wood, coal, oil, or natural gas) in air is a familiar example of combustion.  of hydrocarbons hydrocarbons (hīˈ·drō·kärˑ·bnz),
n.
 (Kao & Nanagas, 2005). CO sources are ubiquitous in homes, especially in heating equipment such as gas furnaces, gas and propane propane, CH3CH2CH3, colorless, gaseous alkane. It is readily liquefied by compression and cooling. It melts at −189.9°C; and boils at −42.2°C;.  heaters, clothes dryers, stoves, woodstoves, and fireplaces. Other sources of CO include motor vehicle exhaust and tobacco smoke.

CO exposure is a leading cause of poisoning death in the U.S., killing approximately 450 people annually (Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center.  [CDC See Control Data, century date change and Back Orifice.

CDC - Control Data Corporation
], 2011). Technically, CO is identified as a toxicant toxicant /tox·i·cant/ (tok´si-kant)
1. poisonous.

2. poison.


tox·i·cant
n.
1. A poison or poisonous agent.

2. An intoxicant.

adj.
, a poison that is made by humans or introduced into the environment as a function of human activity (Graber, Macdonald, Kass, Smith, & Anderson, 2007). The effects of CO exposure are often difficult to recognize because of their nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik)
1. not due to any single known cause.

2. not directed against a particular agent, but rather having a general effect.


nonspecific

1.
 nature. Early symptoms of CO exposure include headache, dizziness dizziness: see vertigo. , weakness, nausea nausea, sensation of discomfort, or queasiness, in the stomach. It may be caused by irritation of the stomach by food or drugs, unpleasant odors, overeating, fright, or psychological stress. It is usually relieved by vomiting. , confusion, and vision problems; disorientation disorientation /dis·or·i·en·ta·tion/ (-or?e-en-ta´shun) the loss of proper bearings, or a state of mental confusion as to time, place, or identity. , unconsciousness, and death may result at higher levels of CO exposure (Raub et al., 2000).

The Centers for Disease Control and Prevention (CDC) estimated that during the years 2004-2006, 20,636 nonfatal, unintentional, non-fire-related CO exposures were seen in emergency departments each year (CDC, 2008). Compared to older children, those four years of age and younger had the highest estimated rate of CO-related emergency departments visits (11.6/100,000). For adults, the rate of CO exposure was highest (10.4/100,000) among those aged 25-34 and lowest (3.6/100,000) among those 65 years and older (CDC, 2008). According to according to
prep.
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

3.
 CDC, 73% of the estimated annual CO events seen in emergency departments occur in the home (CDC, 2008).

CO alarms are one of the most important protective devices for preventing CO exposure and poisoning in homes. Given the indiscernible nature of CO itself and the nonspecific nature of symptoms from exposure to it, CO alarms serve as a warning tool to prevent prolonged pro·long  
tr.v. pro·longed, pro·long·ing, pro·longs
1. To lengthen in duration; protract.

2. To lengthen in extent.
 exposure to high levels of CO. These devices, which retail for $20 to $60, emit TO EMIT. To put out; to send forth,
     2. The tenth section of the first article of the constitution, contains various prohibitions, among which is the following: No state shall emit bills of credit.
 an audible A protected MP3 file format from the Audible.com audio download service. See Audible.com.  alarm when CO is detected at either or both an amount present or a length of exposure that would produce morbidity morbidity /mor·bid·i·ty/ (mor-bid´it-e)
1. a diseased condition or state.

2. the incidence or prevalence of a disease or of all diseases in a population.


mor·bid·i·ty
n.
 or mortality. The Consumer Product Safety Commission and other groups have long recommended CO alarms as a defense against CO poisoning (Consumer Product Safety Commission, 2012). Yoon and co-authors (1998) estimated that CO alarms could prevent at least half of non-fire unintentional CO poisoning.

As of this writing, statutes from 27 states address issues of CO alarms in certain types of residential dwellings. Many of the statutes limit CO alarms by the type of residence (e.g., rental property), when it was built (e.g., new construction only) or upon a change of ownership. Only Illinois and Massachusetts statutes mandate alarms in "every dwelling" (National Conference of State Legislatures, 2012). In Maryland, where our study was undertaken, a law was enacted in 2009 requiring CO alarms for new residential construction.

[FIGURE 1 OMITTED]

Estimates of CO alarm use in the literature are sparse sparse - A sparse matrix (or vector, or array) is one in which most of the elements are zero. If storage space is more important than access speed, it may be preferable to store a sparse matrix as a list of (index, value) pairs or use some kind of hash scheme or associative memory.  and equivocal EQUIVOCAL. What has a double sense.
     2. In the construction of contracts, it is a general rule that when an expression may be taken in two senses, that shall be preferred which gives it effect. Vide Ambiguity; Construction; Interpretation; and Dig.
. Runyan and coauthors (2005) conducted a random-digit-dial survey among a nationally representative sample that revealed that 29% of homes reported a CO alarm. More recently, Hampson and Weaver (2011) completed a computer-based survey of two sets of medical center employees in Washington and Utah and found CO alarm use reported in 51% of homes. Unfortunately both studies rely on self-reported information, which is a documented limitation (Chen, Gielen, & McDonald, 2003).

The Johns Hopkins Noun 1. Johns Hopkins - United States financier and philanthropist who left money to found the university and hospital that bear his name in Baltimore (1795-1873)
Hopkins

2.
 Home Safety Project sought to describe among an urban population the knowledge and behaviors relevant to preventing carbon monoxide poisoning Carbon Monoxide Poisoning Definition

Carbon monoxide (CO) poisoning occurs when carbon monoxide gas is inhaled. CO is a colorless, odorless, highly poisonous gas that is produced by incomplete combustion.
 as well as household risks. Specifically, our article aims to describe the prevalence of observed CO alarms prior to the enactment of a city ordinance A law, statute, or regulation enacted by a Municipal Corporation.

An ordinance is a law passed by a municipal government. A municipality, such as a city, town, village, or borough, is a political subdivision of a state within which a municipal corporation has been
 requiring CO alarms in all city residences. We also aim to identify correlates of CO alarm use.

Methods

Study Design and Sampling

A baseline survey of East Baltimore households was conducted between July and December 2009 as part of a community intervention trial, assessing the impact of an enhanced Baltimore City Fire Department (BCFD BCFD Baltimore City Fire Department (Maryland)
BCFD Baltimore County Fire Department (Maryland)
BCFD Bernalillo County Fire Department (Albuquerque, NM) 
) home visit program through which smoke alarms are installed.

Neighborhood Selection and Address Randomization randomization (ranˈ·d·m  

In preparation for a community intervention trial that would be evaluated using a two-group, quasi-experimental design, we created a sampling frame that would be comparable across important confounders of key outcomes, such as prevalence of smoke alarms and the prior success of BCFD personnel in gaining access to the premises through their program. Based on a desired final sample size of 350-400 completed baseline surveys in each community, we determined that we would need a total of 12 census tracts. We formed a sample of 10,000 paired combinations (which we called "blends") of six randomly chosen census tracts out of the 49 census tracts in East Baltimore. We then computed a summary statistic statistic,
n a value or number that describes a series of quantitative observations or measures; a value calculated from a sample.


statistic

a numerical value calculated from a number of observations in order to summarize them.
 for each blend composed as the blend's unweighted average of 1) vacancy rate; 2) number of previous BCFD home visits attempted; 3) percentage of BCFD home visits that were successful (i.e., BCFD gained entry); 4) residential fire rate; 5) percentage of dwellings built after 1984; and 6) percentage of owner-occupied properties.

The quality of matching in each pair of blends was assessed as the difference between the two blends of the raw sum of the above six indicators. The 10,000 matched scores were sorted and the study team selected candidate matches out of the top one percentile of match scores for further consideration. Members of the team, which included community representatives, drove through several of the top candidate matches to observe the neighborhoods to ensure that they had residential properties as expected and would be suitable for the intervention trial (e.g., neighborhoods had been gentrified for a large development project or new industry had come in since the time of the census).

The final selection of 12 census tracks (six paired tracts in each community) included a total of 10,333 residences. Residences that were not eligible for the BCFD installation program (i.e., public housing and city managed apartment complexes, n = 375) were excluded. From the remaining 9,958 eligible addresses, three separate samples of 1,200 addresses were randomly selected. A new random selection was done when all previously selected addresses had been resolved (i.e., enrolled, refused, deemed ineligible in·el·i·gi·ble  
adj.
1. Disqualified by law, rule, or provision: ineligible to run for office; ineligible for health benefits.

2.
, or did not respond after five attempts to contact).

Data Collection

All selected addresses received a project letter detailing the survey and contact information in case a resident wished to schedule an appointment or opt out of the survey. Data collectors, in teams of two, knocked on the doors of selected addresses, leaving a copy of the project letter at any door where there was no answer. Each house was visited on five nonconsecutive days or until an eligible resident completed the survey, refused at the door or via telephone, or was deemed ineligible by the data collectors. If unsuccessful after five attempts, the address was coded as "no answer" and not visited again unless the resident called the project office to make an appointment to complete the survey.

Eligibility criteria included both housing structure and resident characteristics. Premises deemed unsafe, vacant, or nonexistent non·ex·is·tence  
n.
1. The condition of not existing.

2. Something that does not exist.



non
 by data collectors were coded as ineligible residences. To be eligible, respondents In the context of marketing research, a representative sample drawn from a larger population of people from whom information is collected and used to develop or confirm marketing strategy.  had to be English speaking and at least 18 years old. After determining eligibility and obtaining written informed consent, data collectors, with permission, conducted the survey inside the participant's home. Surveys were conducted on small netbook computers and lasted about 30-45 minutes. Data collectors read questions aloud and recorded the respondent's answers.

Measures

Sociodemographic Characteristics Sociodemographic measures as part of the survey included self-reported race and ethnicity ethnicity Vox populi Racial status–ie, African American, Asian, Caucasian, Hispanic , education, household role, gender, age of respondent In Equity practice, the party who answers a bill or other proceeding in equity. The party against whom an appeal or motion, an application for a court order, is instituted and who is required to answer in order to protect his or her interests.  and all household members, and homeowner status. Household income was determined in two parts. First, the respondent viewed a card listing seven income ranges and selected the one that contained their household income. Per capita income Noun 1. per capita income - the total national income divided by the number of people in the nation
income - the financial gain (earned or unearned) accruing over a given period of time
 was then calculated by dividing the midpoint mid·point  
n.
1. Mathematics The point of a line segment or curvilinear arc that divides it into two parts of the same length.

2. A position midway between two extremes.
 of that income range by the total number of residents.

CO Knowledge

Eleven questions examined participant's knowledge about CO sources and poisoning risks, CO signs and symptoms, CO alarm functionality and recommendations, legal requirements for alarms, and proper evacuation evacuation /evac·u·a·tion/ (e-vak?u-a´shun)
1. an emptying.

2. catharsis; emptying of the bowels.


e·vac·u·a·tion
n.
 steps in response to an activated CO alarm. All items were created for the purpose of our study and pretesting used cognitive interviewing to improve wording and comprehension. Percentage correct scores were calculated for knowledge items.

CO Sources in Home

Participants were asked whether they had common household gas appliances (e.g., furnace furnace, enclosed space for the burning of fuel. There are many kinds of furnaces, the type depending upon the fuel and the use to which the heat produced within it is put. Most familiar are the furnaces used in the heating of buildings. , water heater, stove stove, device used for heating or for cooking food. The stove was long regarded as a cooking device supplementary to the fireplace, near which it stood; its stovepipe led into the fireplace chimney. It was not until about the middle of the 19th cent. , clothes dryer).

The total number of CO-producing appliances found in the home was tallied for each household.

CO Alarm Status

After completing the survey, which included a self-report question on whether there was a CO alarm in the home, data collectors asked all respondents to show them any CO alarms in their home. Data collectors confirmed its existence, tested whether it was working by pressing the "test" button, and recorded the result.

Data Analysis

In addition to providing frequency distributions for the variables under study, we used Chi-square tests to examine bivariate bi·var·i·ate  
adj.
Mathematics Having two variables: bivariate binomial distribution.

Adj. 1.
 relationships between having a working CO alarm and sociodemographic factors and CO knowledge. Inverse probability In probability theory, inverse probability is an obsolete term for the probability distribution of an unobserved variable. Given a probability distribution p(x|θ) for an observable quantity x  weights were used to examine the potential biases due to the study area having a higher frequency of African-American and low-income respondents than all of Baltimore. Weights were calculated based on race and income distributions obtained from the 2000 census data.

Weighted and unweighted multiple logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors.  models were then constructed to examine the relationships between the outcome, having a working CO alarm, and sociodemographic factors and CO knowledge and their results compared. Results of the unweighted versus weighted models varied by no more than 10%; therefore, results for the unweighted models are presented. The analysis was conducted using Intercooled STATA 9.2.

Results

Recruitment

From a total of 3,503 eligible addresses, we excluded 193 who refused via telephone in response to the project letter and another 39 who participated in a pilot test of the computer survey application. Data collectors attempted to visit the remaining 3,271 addresses in person and excluded another 2,659 addresses for various reasons (Figure 1). Household surveys were conducted with 612 participants, but nine had incomplete data and were removed, resulting in a final sample size of 603 completed surveys.

Demographic Characteristics

A majority of respondents were African-American (61%), female (70%), between the ages of 25 and 54 (66%), and had a high school education or less (51%). Most self-identified as the "head of the household" (81%) (Table 1). Almost three-quarters of the respondents (74%) reported a per capita income of $25,000 or less and a little more than half (52%) rented their home. Forty percent of respondents lived with children under the age of 18.

CO Sources in the Home

As shown in Table 1, most homes visited contained CO-producing appliances. In fact, 76% of the sample reported two or more items that produce CO (data not shown). The most commonly reported items were gas stoves (86%), gas furnaces (82%), and gas water heaters (79%). Less than 1% reported the use of a kerosene kerosene or kerosine, colorless, thin mineral oil whose density is between 0.75 and 0.85 grams per cubic centimeter. A mixture of hydrocarbons, it is commonly obtained in the fractional distillation of petroleum as the portion boiling off  heater (data not shown).

CO Alarm Status

A majority of respondents (54%) reported not having a working CO alarm; another 13% were unsure. One-third (33%) of respondents reporting having a CO alarm (data not shown). We were able to confirm through observation that 166 (28%) participants had at least one working CO alarm. The only sociodemographic characteristic related to having a working CO alarm was homeowner

status (Table 1). Compared to those who rented, those who owned their home or paid a mortgage were statistically significantly more likely to have a working CO alarm (62% vs. 44%, p = .00). We found no relationship between having a working CO alarm and either the presence or total number of CO-producing appliances in the home (Table 1).

CO Knowledge

As shown in Table 2, CO knowledge varied across different topics. Most respondents knew that children and teens are not the only ones at risk of CO poisoning (92%); and that CO is a gas that cannot be seen (84%). Conversely con·verse 1  
intr.v. con·versed, con·vers·ing, con·vers·es
1. To engage in a spoken exchange of thoughts, ideas, or feelings; talk. See Synonyms at speak.

2.
, few respondents were able to correctly identify symptoms of CO poisoning (17%) and the proper location for a CO alarm (18%). More than one-third (38%) of city residents knew that (at the time of the survey) CO alarms were not required by law The overall mean percentage correct knowledge score was 57%.

We found a significant relationship between having a CO alarm and overall mean percentage correct knowledge score (Table 2); respondents with higher mean percentage correct knowledge scores were more likely to have an observed CO alarm in their home compared to those with a lower knowledge score (60% vs. 55%, t = 3.16, p = .002). Individual knowledge items varied with CO alarm ownership. For instance, knowing that one cannot smell CO was significantly associated with having a CO alarm (81% vs. 65%, [chi square chi square (kī),
n a nonparametric statistic used with discrete data in the form of frequency count (nominal data) or percentages or proportions that can be reduced to frequencies.
] = 14.8, p = .00) as was knowledge of CO poisoning symptoms (22% vs. 15%, [chi square] = 4.71, p = .03). CO alarm owners, however, were less likely than those without alarms to correctly answer the question about legal requirements for CO alarms in Baltimore city (31% vs. 41%, [chi square] = 5.34, p = .02).

Predictors of CO Alarm Ownership

Results from the multiple logistic regression analysis, including odds ratio (ORs) and corresponding confidence intervals (CIs) are summarized in Table 3. The results indicate that having at least one working CO alarm is associated with owning a home or paying a mortgage (OR = 3.43; 95% CI: 1.69, 6.98; p = .0007). Two knowledge items were associated with observed CO alarms, knowing that CO cannot be smelled (OR = 2.90; 95% CI: 1.45, 5.98; p = .039) and knowing what to do when an alarm activates (OR = 2.20; 95% CI: 1.00, 4.82; p = .0495). Mistakenly thinking that CO alarms are legally required was associated with CO alarm ownership (OR = 0.25; 95% CI: 0.14, 0.45; p = .0001).

Discussion

Our results provide some of the first evidence on the extent to which residents in urban neighborhoods are aware of CO poisoning risk, are exposed to it, and are taking action to protect themselves. The findings suggest that considerable education is needed to better inform residents of the causes and symptoms of CO poisoning; the proper location, maintenance, and response to CO alarms; and the differences between smoke alarms and CO alarms. The overall mean percentage correct knowledge score was 57%, a failing grade by any test measure. The importance of these findings is underscored by the fact that almost 90% of homes had at least one source of CO and more than 50% had three or more sources. Thus, potential exposures to CO are a real threat in these urban neighborhoods and most residents are ill informed about CO.

We found shockingly low levels of self-reported CO alarm ownership, with just 33% self-reporting at least one working alarm in their home. This self-reported CO alarm possession prevalence is only slightly higher than that reported by Runyan and co-authors (2005). In their random-digit-dial telephone survey of 1,000 households designed to be representative of the entire U.S. population, 29% reported having a CO alarm. Our data differ significantly from Hampson and Weaver (2011); their computer-based survey of 1,351 individuals reported CO alarm use by 51% of their respondents.

An important strength of our study is the ability to confirm self-reported CO alarm ownership with observed data, a technique recognized to be the gold standard for reporting injury prevention behaviors. The observed prevalence of at least one working CO alarm in the home fell to 28% from 33% who self-reported alarm use. The differences between observed and reported rates in this case are not as high as those found for smoke alarm ownership by us (Chen, Gielen, & McDonald, 2003) and others (Douglas, Mallonee, & Istre, 1999). Nevertheless, the discrepancy DISCREPANCY. A difference between one thing and another, between one writing and another; a variance. (q.v.)
     2. Discrepancies are material and immaterial.
 between self-report and observed practices reminds us that we cannot rely on self-report alone to determine household safety behaviors.

The low rates of CO alarm ownership and knowledge, combined with the high rates of CO-producing sources in homes, also suggest the need for widespread campaigns to promote the use of CO alarms. Our data did not identify specific subgroups of the population least likely to have working CO alarms, which further supports the conclusion that campaigns should be targeted broadly, to homeowners, landlords, and tenants. Moreover, promotional campaigns should consider the needs of low-income communities to address the costs of and easy access to such safety devices.

Public health and safety officials should consider the lessons we have learned in our effort to promote and distribute smoke alarms and integrate these into CO alarm promotion and distribution programs. Criteria have been established to define gold standard smoke alarm campaigns including 1) working in local communities and recruiting community partners, 2) canvassing homes in high-risk areas, 3) using smoke alarms with special features (like long-lasting lithium lithium (lĭth`ēəm) [Gr.,=stone], metallic chemical element; symbol Li; at. no. 3; at. wt. 6.941; m.p. about 180.54°C;; b.p. about 1,342°C;; sp. gr. .534 at 20°C;; valence +1. Lithium is a soft, silver-white metal.  batteries and a hush feature), and 4) conducting follow up activities to ensure alarm functionality (Ballesteros, Jackson, & Martin, 2005). CO promotion campaigns while in their nascent nascent /nas·cent/ (nas´ent) (na´sent)
1. being born; just coming into existence.

2. just liberated from a chemical combination, and hence more reactive because uncombined.
 stages should be encouraged to incorporate these important lessons learned from the smoke alarm experience. Although not yet deemed a gold standard criterion, another potentially important finding from the smoke alarm experience is the concern about whether audible alarms awaken sleeping children and the call to consider voice-recording options (Smith, Splaingard, Hayes, & Xiang, 2006).

The results presented here should be interpreted in the context of several limitations. Our ability to generalize generalize /gen·er·al·ize/ (-iz)
1. to spread throughout the body, as when local disease becomes systemic.

2. to form a general principle; to reason inductively.
 results is limited to other urban populations with similar demographic characteristics to the participants in this study. The majority of our sample was African-American adults living in a predominantly pre·dom·i·nant  
adj.
1. Having greatest ascendancy, importance, influence, authority, or force. See Synonyms at dominant.

2.
 low-income, urban area, and we did not include Spanish-speaking residents. We were able to weight our sample to account for the higher frequencies of African-American and low-income residents in our study area compared to all of Baltimore and found only minor differences. Although our sampling methodology included random selection of households within census tracts specifically chosen to result in a representative sample of East Baltimore homes, our completed sample size was smaller than originally anticipated due to high rates of refusal and residents not being home. We do not have data to compare those who completed the survey to those who did not.

Conclusion

Our work recognizes and documents the need for enhanced education and promotion efforts targeted to CO poison prevention. As of March 2011 (after the completion of our data collection), all Baltimore city residences are required to have at least one working CO alarm. Legislation is a necessary but insufficient mechanism alone to ensure that all residents are safe in their homes. Implementation of the law needs to be supported with public health campaigns that address the knowledge gaps that we identified and to enhance access to and affordability of CO alarms for low-income and other special need communities.

Acknowledgements: We are grateful to the residents of Baltimore who allowed us into their homes and who completed our survey and observation. We would also like to thank Dharssi Safiyya who assisted us with a review of the literature on carbon monoxide while she was pursuing a master of public health degree at the Johns Hopkins Bloomberg School of Public Health The Johns Hopkins Bloomberg School of Public Health is part of Johns Hopkins University in Baltimore, Maryland, U.S. It was the first institution of its kind in the world.

Founded in 1916 by William H. Welch and John D.
.

Corresponding Author: Eileen M. McDonald, Associate Scientist and MSPH MSPH Mailman School of Public Health (Columbia Universty, New York City)
MSPH Master of Science in Public Health
MSPH Mrs. Potato Head (toy) 
 Program Director, Johns Hopkins Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 731, Baltimore, MD 21205. E-mail: emcdonal@jhsph.edu.

References

Ballesteros, M.F., Jackson, M.L., & Martin, M.W. (2005). Working toward the elimination of residential fire deaths: the Centers for Disease Control and Prevention's Smoke Alarm Installation and Fire Safety Education (SAIFE) program. Journal of Burn Care Rehabilitation rehabilitation: see physical therapy. , 26(5), 434-439.

Centers for Disease Control and Prevention. (2008). Nonfatal, unintentional, non-fire-related carbon monoxide exposures--United States, 2004-2006. Morbidity and Mortality Morbidity and Mortality can refer to:
  • Morbidity & Mortality, a term used in medicine
  • Morbidity and Mortality Weekly Report, a medical publication
See also
  • Morbidity, a medical term
  • Mortality, a medical term
 Weekly Reports, 57(33), 896-899.

Centers for Disease Control and Prevention. (2011). Carbon monoxide poisoning prevention clinical education webcast. Retrieved from http://www.cdc.gov/co/

Chen, L.H., Gielen, A.C., & McDonald, E.M. (2003). Validity of self reported home safety practices. Injury Prevention, 9(1), 73-75. Consumer Product Safety Commission. (2008). Carbon monoxide (CO) questions and answers. Retrieved from http://www.cpsc.gov/ cpscpub/pubs/466.html

Douglas, M.R., Mallonee, S., & Istre, G.R. (1999). Estimating the proportion of homes with functioning smoke alarms: A comparison of telephone survey and household survey results. American Journal of Public Health, 89(7), 1112-1114.

Graber, J.M., Macdonald, S.C., Kass, D.E., Smith, A.E., & Anderson, H.A. (2007). Carbon monoxide: The case for environmental public health surveillance. Public Health Reports, 122(2), 138-144.

Hampson, N.B., & Weaver, N.K. (2011). Residential carbon monoxide alarm use: Opportunities for poisoning prevention. Journal of Environmental Health, 73(6), 30-33.

Kao, L.W., & Nanagas, K.A. (2005). Carbon monoxide poisoning. Medical Clinics of North America North America, third largest continent (1990 est. pop. 365,000,000), c.9,400,000 sq mi (24,346,000 sq km), the northern of the two continents of the Western Hemisphere. , 89(6), 1161-1194.

National Conference of State Legislatures. (2011). Carbon monoxide detector laws by state. Retrieved from http://www.ncsl.org/default. aspx?tabid=13238

Raub, J.A., Mathieu-Nolf, M., Hampson, N.B., & Thom, S.R. (2000). Carbon monoxide poisoning--a public health perspective. Toxicology toxicology, study of poisons, or toxins, from the standpoint of detection, isolation, identification, and determination of their effects on the human body. Toxicology may be considered the branch of pharmacology devoted to the study of the poisonous effects of drugs. , 145(1), 1-14.

Runyan, C.W., Johnson, R.M., Yang yang (yang) [Chinese] in Chinese philosophy, the active, positive, masculine principle that is complementary to yin; see yin, under principle. , J., Waller A.E., Perkis, D., Marshall, S.W., Coyne-Beasley, T., & McGee, K.S. (2005). Risk and protective factors for fires, burns, and carbon monoxide poisoning in U.S. households. American Journal of Preventive Medicine preventive medicine, branch of medicine dealing with the prevention of disease and the maintenance of good health practices. Until recently preventive medicine was largely the domain of the U.S. , 28(1), 102-108.

Smith, G.A., Splaingard, M., Hayes, J.R., & Xiang, H. (2006). Comparison of a personalized per·son·al·ize  
tr.v. per·son·al·ized, per·son·al·iz·ing, per·son·al·iz·es
1. To take (a general remark or characterization) in a personal manner.

2. To attribute human or personal qualities to; personify.
 parent voice smoke alarm with a conventional residential tone smoke alarm for awakening children. Pediatrics, 118(4), 1623-1632.

Yoon, S.S., Macdonald, S.C., & Parrish, R.G. (1998). Deaths from unintentional carbon monoxide poisoning and potential for prevention with carbon monoxide detectors. Journal of the American Medical Association JAMA: The Journal of the American Medical Association is an international peer-reviewed general medical journal, published 48 times per year by the American Medical Association. JAMA is the most widely circulated medical journal in the world. , 279(9), 685-687.

Eileen M. McDonald, MS

Andrea C. Gielen, ScM, ScD

Wendy C. Shields, MPH

Rebecca Stepnitz, MHS (1) (Message Handling Service) An earlier messaging system from Novell that supported multiple operating systems and other messaging protocols, including SMTP, SNADS and X.400. It used the SMF-71 messaging format.  

Elizabeth Parker Elizabeth Parker may refer to:
  • Elizabeth Parker (composer), who worked at the BBC Radiophonic Workshop
  • Elizabeth Parker (journalist), Canadian journalist and co-founder of the Alpine Club of Canada
, MHS

Xia Ma, MPH

David Bishai, MPH, MD, PhD

Johns Hopkins Center for Injury

Research and Policy

Johns Hopkins Bloomberg School

of Public Health
TABLE 1

Sample Sociodemographic Characteristics, Carbon Monoxide
(CO)-Producing Appliances, and CO Alarm Ownership

Characteristics                           Pearson [chi square]
                                               (p-Value)

Gender            Male                         0.10 (.76)
                  Female
Age               18 to 24                     2.35 (.80)
                  25 to 34
                  35 to 44
                  45 to 54
                  55 to 64
                  65 and above
Householdrole     Head of household            0.23 (.63)
                  Other
Education         Less than high school        5.01 (.17)
                  diploma/GED
                  High school diploma/
                  GED
                  Some college
                  Completed college
Per capita        $5000 or less                4.40 (.22)
income            $5001 to $10000
                  $10001 to $25000
                  $25000 or more
Race              Black or African-            0.92 (.34)
                  American
                  Other
Homeowner         Rent                        15.95 (.00)
status            Own or pay mortgage
Children (<18)    Yes                          0.04 (.84)
in home           No
CO sources in     Gas furnace                  0.73 (.39)
home              No gas furnace
                  Gas water heater             2.28 (.13)
                  No gas water heater
                  Gas stove                    0.16 (.69)
                  No gas stove
                  Gas clothes dryer            0.26 (.61)
                  No gas clothes dryer
Total number      No CO equipment              2.27 (.69)
of CO sources     1 CO equipment
in home           2 CO equipment
                  3 CO equipment
                  4 CO equipment

Characteristics                               Observed CO Alarm
                                          Yes n = 166   No n = 437
                                             (28%)        (72%)

Gender            Male                      48 (29)      132 (30)
                  Female                   118 (71)      305 (70)
Age               18 to 24                  26 (16)      63 (14)
                  25 to 34                  44 (27)      123 (28)
                  35 to 44                  32 (19)      86 (20)
                  45 to 54                  26 (16)      82 (19)
                  55 to 64                  25 (15)      49 (11)
                  65 and above              13 (8)        34 (8)
Householdrole     Head of household        132 (80)      355 (81)
                  Other                     34 (21)      82 (19)
Education         Less than high school     21 (13)      58 (13)
                  diploma/GED
                  High school diploma/      57 (34)      173 (40)
                  GED
                  Some college              40 (24)      71 (16)
                  Completed college         48 (29)      133 (31)
Per capita        $5000 or less             29 (21)      100 (29)
income            $5001 to $10000           31 (22)      72 (21)
                  $10001 to $25000          42 (30)      82 (24)
                  $25000 or more            39 (28)      86 (25)
Race              Black or African-         96 (58)      263 (63)
                  American
                  Other                     69 (42)      158 (38)
Homeowner         Rent                      59 (38)      238 (57)
status            Own or pay mortgage       97 (62)      183 (44)
Children (<18)    Yes                       65 (39)      175 (40)
in home           No                       101 (61)      262 (60)
CO sources in     Gas furnace              120 (85)      286 (81)
home              No gas furnace            22 (16)      66 (19)
                  Gas water heater         118 (84)      281 (78)
                  No gas water heater       23 (16)      81 (22)
                  Gas stove                144 (87)      375 (86)
                  No gas stove              21 (13)      61 (14)
                  Gas clothes dryer         52 (33)      124 (30)
                  No gas clothes dryer     108 (68)      285 (70)
Total number      No CO equipment           15 (9)       53 (12)
of CO sources     1 CO equipment            19 (11)      60 (14)
in home           2 CO equipment            31 (19)      84 (19)
                  3 CO equipment            67 (40)      159 (36)
                  4 CO equipment            34 (21)      81 (19)

Characteristics                           Total Sample
                                           N = 603 (%)

Gender            Male                      180 (30)
                  Female                    423 (70)
Age               18 to 24                   89 (15)
                  25 to 34                  167 (28)
                  35 to 44                  118 (20)
                  45 to 54                  108 (18)
                  55 to 64                   74 (12)
                  65 and above               47 (8)
Householdrole     Head of household         487 (81)
                  Other                     116 (19)
Education         Less than high school      79 (13)
                  diploma/GED
                  High school diploma/      230 (38)
                  GED
                  Some college              111 (19)
                  Completed college         181 (30)
Per capita        $5000 or less             129 (27)
income            $5001 to $10000           103 (21)
                  $10001 to $25000          124 (26)
                  $25000 or more            125 (26)
Race              Black or African-         359 (61)
                  American
                  Other                     227 (39)
Homeowner         Rent                      297 (52)
status            Own or pay mortgage       280 (49)
Children (<18)    Yes                       240 (40)
in home           No                        363 (60)
CO sources in     Gas furnace               406 (82)
home              No gas furnace             88 (18)
                  Gas water heater          399 (79)
                  No gas water heater       104 (21)
                  Gas stove                 519 (86)
                  No gas stove               82 (14)
                  Gas clothes dryer         176 (31)
                  No gas clothes dryer      393 (69)
Total number      No CO equipment            68 (11)
of CO sources     1 CO equipment             79 (13)
in home           2 CO equipment            115 (19)
                  3 CO equipment            226 (38)
                  4 CO equipment            115 (19)

TABLE 2

Carbon Monoxide (CO) Knowledge and CO Alarm Ownership

Knowledge Items: True/False or Multiple              Pearson
Choice Options. Correct Answer Indicated           [chi square]
in Italics.                                         (p-Value)

CO is a gas that cannot be seen.                   3.19 (.074)
You can smell CO, false.                           14.77 (.00)
Electric heaters do not cause CO poisoning.         1.24 (.27)
Only children and teens are at risk for CO          1.58 (.21)
  poisoning, false.
Symptoms of CO poisoning are similar to the flu.    4.71 (.03)
Near all sleeping areas is the best place to        1.40 (.24)
  install a CO alarm in the home.
The first thing to do if your CO alarm goes off     7.15 (.01)
  is to get everyone out of the house and
  call 911.
How often should you change the battery in your     0.19 (.66)
  CO alarm, every six months.
Using a gas oven to heat your home could cause      2.49 (.11)
  CO poisoning, true.
Your smoke alarm will alert you when CO levels      2.46 (.12)
  are too high, false.
In Baltimore city, all homes are required by        5.34 (.02)
  law to have a CO alarm, false.
Overall mean percentage correct knowledge score      t = 3.16
                                                      (.002)

Knowledge Items: True/False or Multiple              Observed CO Alarm
Choice Options. Correct Answer Indicated             Yes        No
in Italics.                                        n = 166   n = 437
                                                   # (%)      # (%)
                                                   Correct   Correct

CO is a gas that cannot be seen.                   146 (88)  358 (82)
You can smell CO, false.                           135 (81)  285 (65)
Electric heaters do not cause CO poisoning.        74 (45)   173 (40)
Only children and teens are at risk for CO         157 (95)  400 (92)
  poisoning, false.
Symptoms of CO poisoning are similar to the flu.   37 (22)   65 (15)
Near all sleeping areas is the best place to       35 (21)   74 (17)
  install a CO alarm in the home.
The first thing to do if your CO alarm goes off    143 (86)  333 (76)
  is to get everyone out of the house and
  call 911.
How often should you change the battery in your    78 (47)   214 (49)
  CO alarm, every six months.
Using a gas oven to heat your home could cause     134 (81)  326 (75)
  CO poisoning, true.
Your smoke alarm will alert you when CO levels     107 (65)  251 (57)
  are too high, false.
In Baltimore city, all homes are required by       51 (31)   179 (41)
  law to have a CO alarm, false.
Overall mean percentage correct knowledge score      60%       55%

Knowledge Items: True/False or Multiple            Total Sample
Choice Options. Correct Answer Indicated             N = 603
in Italics.                                           # (%)
                                                     Correct

CO is a gas that cannot be seen.                     504 (84)
You can smell CO, false.                             420 (70)
Electric heaters do not cause CO poisoning.          247 (41)
Only children and teens are at risk for CO           557 (92)
  poisoning, false.
Symptoms of CO poisoning are similar to the flu.     102 (17)
Near all sleeping areas is the best place to         109 (18)
  install a CO alarm in the home.
The first thing to do if your CO alarm goes off      476 (79)
  is to get everyone out of the house and
  call 911.
How often should you change the battery in your      292 (48)
  CO alarm, every six months.
Using a gas oven to heat your home could cause       460 (76)
  CO poisoning, true.
Your smoke alarm will alert you when CO levels       358 (59)
  are too high, false.
In Baltimore city, all homes are required by         230 (38)
  law to have a CO alarm, false.
Overall mean percentage correct knowledge score        57%

TABLE 3

Logistic Regression Model of Sociodemographic Characteristics and
Carbon Monoxide (CO) Knowledge Correlates of CO Alarm Ownership

Sociodemographic Characteristics                       Adjusted
                                                        OR (a)

Gender                           Male                     1
                                 Female                  1.41
Age                              18 to 24                 1
                                 25 to 34                0.34
                                 35 to 44                0.25
                                 45 to 54                0.22
                                 55 and above            0.31
Household role                   Other                    1
                                 Head of household       1.41
Education                        High school/GED          1
                                 <High school/GED        1.22
                                 Some college            1.46
                                 Completed college       0.91
Per capita income                $5000 or less            1
                                 $5001 to $10000         1.40
                                 $10001 to $25000        1.24
                                 $25000 or more          1.29
Race/ethnicity                   Other                    1
                                 Black or African-       0.92
                                 American
Homeowner status                 Rent                     1
                                 Own or pay mortgage     3.43
Children (<18) in home           No                       1
                                 Yes                     1.01
Homes with CO-producing
equipment
Gas furnace                      No                       1
                                 Yes                     1.22
Gas water heater                 No                       1
                                 Yes                     1.42
Gas stove                        No                       1
                                 Yes                     0.80
Gas clothes dryer                No                       1
                                 Yes                     0.71
Knowledge question
CO is a gas that cannot be            Incorrect           1
seen.                                  Correct           1.27
You can smell CO, false.              Incorrect           1
                                       Correct           2.90
Electric heaters do not cause         Incorrect           1
CO poisoning.                          Correct           0.73
Only children and teens are           Incorrect           1
at risk for CO poisoning,              Correct           1.17
false.
Symptoms of CO poisoning are          Incorrect           1
similar to the flu.                    Correct           1.75
Near all sleeping areas is the        Incorrect           1
best place to install a CO             Correct           1.75
alarm in the home.
The first thing to do if your         Incorrect           1
CO alarm goes off is
to get everyone out of the             Correct           2.20
house and call 911.
How often should you change           Incorrect           1
the battery in your CO alarm,          Correct           0.94
every six months.
Using a gas oven to heat your         Incorrect           1
home could cause CO poisoning,         Correct           0.89
true.
Your smoke alarm will alert           Incorrect           1
you when CO levels are too             Correct           1.30
high, false.
In Baltimore city, all homes          Incorrect           1
are required by law to have a          Correct           0.25
CO alarm, false.

Sociodemographic Characteristics                          95% C/(a)

Gender                           Male
                                 Female                  0.71, 2.59
Age                              18 to 24
                                 25 to 34                0.11, 1.08
                                 35 to 44                0.08, 0.84
                                 45 to 54                0.07, 0.71
                                 55 and above            0.09, 1.05
Household role                   Other
                                 Head of household       0.60, 3.34
Education                        High school/GED
                                 <High school/GED        0.48, 3.09
                                 Some college            0.65, 3.27
                                 Completed college       0.40, 2.07
Per capita income                $5000 or less
                                 $5001 to $10000         0.60, 3.24
                                 $10001 to $25000        0.47, 3.28
                                 $25000 or more          0.43, 3.89
Race/ethnicity                   Other
                                 Black or African-       0.47, 1.77
                                 American
Homeowner status                 Rent
                                 Own or pay mortgage    1.69, 6.98 *
Children (<18) in home           No
                                 Yes                     0.53, 1.94
Homes with CO-producing
equipment
Gas furnace                      No
                                 Yes                     0.53, 2.78
Gas water heater                 No
                                 Yes                     0.63, 3.21
Gas stove                        No
                                 Yes                     0.33, 1.94
Gas clothes dryer                No
                                 Yes                     0.41, 1.25
Knowledge question
CO is a gas that cannot be            Incorrect
seen.                                  Correct           0.59, 2.70
You can smell CO, false.              Incorrect
                                       Correct          1.41, 5.98 **
Electric heaters do not cause         Incorrect
CO poisoning.                          Correct           0.40, 1.33
Only children and teens are           Incorrect
at risk for CO poisoning,              Correct           0.29, 4.73
false.
Symptoms of CO poisoning are          Incorrect
similar to the flu.                    Correct           0.88, 3.46
Near all sleeping areas is the        Incorrect
best place to install a CO             Correct           0.90, 3.40
alarm in the home.
The first thing to do if your         Incorrect
CO alarm goes off is
to get everyone out of the             Correct         1.00, 4.82 ***
house and call 911.
How often should you change           Incorrect
the battery in your CO alarm,          Correct           0.54, 1.62
every six months.
Using a gas oven to heat your         Incorrect
home could cause CO poisoning,         Correct           0.44, 1.80
true.
Your smoke alarm will alert           Incorrect
you when CO levels are too             Correct           0.70, 2.40
high, false.
In Baltimore city, all homes          Incorrect
are required by law to have a          Correct         0.14, 0.45 ****
CO alarm, false.

(a) OR = odds ratio; CI = confidence interval. * p = .0007;
** p = .0039; *** p = .0495; **** p < .0001.
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Title Annotation:ADVANCEMENT OF THE SCIENCE
Author:McDonald, Eileen M.; Gielen, Andrea C.; Shields, Wendy C.; Stepnitz, Rebecca; Parker, Elizabeth; Ma,
Publication:Journal of Environmental Health
Geographic Code:1U5MD
Date:Sep 22, 2013
Words:5718
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