Global, Regional, and National Burden of Accidental Carbon Monoxide Poisoning, 1990–2019: A Systematic Analysis for the Global Burden of Disease Study 2019

Abstract

Introduction

Health system planning requires careful assessment of accidental carbon monoxide poisoning (ACOP) epidemiology, but data of this disease are scarce or non-existent in many countries. This article investigates the global burden of ACOP based on the Global Burden of Disease Study 2019 (GBD 2019) and the World Bank database.

Materials and Methods

Numbers and age-standardized rates (ASR) of ACOP incidence, prevalence, deaths, Disability-Adjusted Life Years (DALYs), Years Lived with Disability (YLDs), and Years of Life Lost (YLLs) were analysed at global, regional, and national level. The estimated annual percentage change (EAPC) of age-standardized rates (ASR) was calculated by generalizing the linear model with a Gaussian distribution. Age, sex, and economics parameters are included to access their internal relevance.

Results

Globally, in 2019, there were approximately 0.97 million ACOP incidence cases (95% CI 0.66 million to 1.4 million), and 41,142 (95%UI 32957 to 45934) people died from it. Compared with 1990, the morbidity and mortality of ACOP in 2019 are on a downward trend. By sexes, from 1990 to 2019, females have a higher morbidity and lower mortality. This article also finds that the relevant parameters of ACOP are closely related to the economic parameters. This correlation enables us to evaluate the level and status of public health services in various countries.

Discussion

ACOP is the most common toxic disease in the world. In 2019, the number of patients who die from ACOP exceeded that of patients poisoned by all other means. In global health decision-making, especially in regions with high-middle and high SDI, more attention should be paid.

Conclusion

As the population ageing in areas with High-middle SDI and High SDI increases, the potential burden of ACOP is increasing, presenting the governments with an increasing demand for acute care, rehabilitation, and support services. The results of this study can be used by the health authorities to consider the burden of ACOP that could be addressed with preventive and therapeutic measures.

Introduction

Carbon monoxide (CO) results from the incomplete combustion of carbon-containing substances and is a colorless, odorless, and tasteless gas.[1] Exposure is most commonly from car exhaust (unleaded petrol cars produce about one-tenth the amount of CO of older cars), faulty heaters, fires, industrial accidents, and charcoal-burning suicide.[2] Moderate or serious ACOP can cause high-oxygen-demand organs injuring and disfunction, among which brain and cardiac effects dominate acute clinical features.[3, 4] Among them, more than 25% of patients will have the symptom of delayed neurologic sequelae (DNS) which is the most common sequela affecting the prognosis of patients.[5] Serious ACOP can affect the prognosis of patients and the quality of their life, meanwhile significantly increasing the burden on the family and society. In the past few years, based on several national studies, the burden of ACOP has been reported in several articles sporadically, such as the United Kingdom[6, 7], the United States of America[8, 9], New Zealand[10], and China[11]. Lippi and Mattiuzzi did a limited analysis of global ACOP data of "Global Burden of Disease Study 2017" (GBD 2017).[12] They studied the morbidity and mortality of ACOP based on age, sexes, and SDI. But detailed information has not been provided in all countries/regions.

To provide comprehensive, comparable, and up-to-date information on the burden of ACOP, this report introduces the modeled ACOP age-standardized incidence rate (ASIR), age-standardized prevalence rate (ASPR), age-standardized deaths rate (ASDR), the age-standardized rate of Disability-Adjusted Life Years (DALYs), the age-standardized rate of Years Lived with Disability (YLDs), and age-standardized rate of Years of Life Lost (YLLs) at the global, regional and national levels based on the "Global Burden of Disease Study 2019" (GBD 2019).[13] The influence of sexes, region, and economics parameters (e.g., sociodemographic index (SDI; the sum of sociodemographic factors), consumer price index (CPI), Gross Domestic Product per capita (purchasing power parity) (GDP per capita (PPP)), Gross National Income per capita (purchasing power parity) (GNI per capita (PPP))) are also included in the article.

Materials And Methods

Results

Discussion

This report provides the most up-to-date estimates of incidence, prevalence, deaths, DALYs, YLDs, and YLLs for ACOP in 204 countries and territories from 1990 to 2019. ACOP accounted for 0·97 million incident cases, 0·92 million prevalent cases, 41,142 deaths cases, 1·84 million DALYs, 82847·33 YLDs, and 1·76 million YLLs in 2019. The national-level burden of ACOP in 2019, not previously reported, has been included in this study derived from the publicly available GBD 2019 Study.

Previously, Lippi and Mattiuzzi researched ACOP based on GBD 2017[12] Their research studied the incidence and mortality rate from 1992 to 2017. And they investigated the effects of age and sexes on ACOP mortality in 2017. Most of their conclusions are consistent with our article. This article further expands the previous research conclusions.

From 1990 to 2019, the age-standardized rate of incidence, prevalence, deaths, DALYs, YLDs, and YLLs of ACOP all decreased. It is worth noting that the age-standardized rate of deaths, DALYs, YLLs, and other data all have an inflection point around 2005, especially in Low-middle SDI regions. After 2005, the probabilities of these data have dropped rapidly, and similar trends exist in regions with different economic levels. Two articles [20, 21] were published in top medical journals in the early 21st century that the application of hyperbaric oxygen can effectively cure ACOP. Based on the above, we considered that hyperbaric oxygen is one of the main reasons for the decline in ASR of deaths, DALYs, and YLLs of ACOP.

By sex, on the whole, females have a higher ASR of incidence than males. However, the ASDR of females is lower than that of males. This pattern exists in different years, regions, and ages. Previous studies[22–24] have shown that estrogen and estrogen receptors can effectively enhance the tolerance of cardiomyocytes and neurons to respond to hypoxia injury. This article appointed that the females’ ACOP mortality rate rises rapidly after the age of 60, and the increased rate exceeded that of males. However, the ACOP mortality rate of females up to the age of 80 did not match that of males. Therefore, it is still uncertain whether estrogen and estrogen receptors are the main reasons for females’ lower mortality of ACOP. For different poisoning factors, the severity of COP is often different. For different occupations, their sexes are often uneven. For example, there are more male employees than women in heavy industries such as steelmaking. What’s more, some technologies can lower the probability of ACOP in certain scenarios. For instance, many countries have seen a substantial reduction in lethal car exhaust poisoning with the rise of catalytic converters.[25, 26] This may be the reason for the different severity of COP in different sexes.

The GBD 2019 study only counts two risks of ACOP — occupational injuries and alcohol use. In terms of mortality, occupational injuries are the primary cause of deaths and disability from COP, while alcohol use is the secondary cause in most regions with different SDI level. By sexes, males are more than females. On the whole, COP is more like an occupational disease, and most COP patients are caused by occupational injuries.

Just like other reports based on the GBD database[27, 28], the correlation between disease-related parameters and SDI was investigated too. In 2019, the countries with lower SDI have lower ACOP morbidity and higher mortality. Besides, it has a strong correlation with SDI in the past 30 years in global and different SDI regions. Then we included some economic parameters, including Australia coal price, CPI-adjusted, GDP per capita (PPP), GNI per capita (PPP), and SDI. The ACOP-related parameters of most countries in the world are not related to Australia's coal price, while there is a significant linear correlation between more than 60% of countries’ parameters and GDP per capita (PPP), GNI per capita (PPP), and SDI. Within these parameters, SDI has the best correlation. Some studies[29, 30] have reported that economic development or the pollution caused by it is related to the incidence of certain diseases.

The application of fuel is closely related to economic development, and the former is also closely related to the incidence of ACOP. Therefore, we try to use SDI as a confounding factor to evaluate the trend of ACOP parameters under the non-economic influence. The influence of non-economic factors mainly stems from the promotion of medical technology, culture, domestic, and international political environment. The results show that when the economic impact is excluded, the ASIR of most countries in the world and the ASDR of nearly half of the countries are on the rise. Considering that severe CO poisoning can cause serious sequelae to patients, for these countries, the prevention, and control of carbon monoxide poisoning is still very important.

It is worth noting that some traditional developed countries such as the United Kingdom and Denmark have also appeared on the list, which seems very puzzling. On the one hand, it may be caused by errors in some data. On the other hand, taking the United Kingdom as an example, Roca-Barceló et al. [6] investigated the epidemiology of carbon monoxide poisoning in the United Kingdom. They found that the morbidity of ACOP has obvious area-level characteristics (i.e., deprivation, rurality, and ethnicity) from 2002 to 2016. The increase in morbidity may be due to the increase in the poor population, and the increase in the poor population may come from the polarization of the rich and the poor. We have tried to download the GINI coefficient from the database of the WORLD BANK, but the GINI coefficient has too many nulls for effective and reasonable analysis. This is very regrettable.

The research of this article also has certain defects. First of all, exposure to carbon monoxide by self-poisoning or undetermined intent are not included, which contrasts with most countries where suicidal poisoning (car exhaust or charcoal) is one of the leading causes of diagnosed COP. In Australia, for example, accidental poisoning accounts for less than 10% of calls about COP, and the deaths often outnumber admissions.[31] Secondly, the CPI data was predicted and filled by predictive mean matching, which will cause data distortion. For GDP and GNI data, we directly discard the null value. Although this can ensure the accuracy and authenticity of the data, it may still cause errors between the data and the real situation. Thirdly, our consideration of ACOP parameters and economic parameters is largely based on the data from the last ten years. Mainly because of the social instability in some countries in the early 1990s, and there was a strong transition in ASDRs, DALYs, and YLLs around 2005. After overall consideration, most countries around the world are in a stage of stable development from 2010 to 2019, so the data is more convincing. However, this will result in low values for the 2010–2019 group in Fig. 11.

Conclusion

In conclusion, except for a few countries and regions, the incidence of accidental carbon monoxide poisoning has shown a slow upward trend in the past 30 years, and this trend is highly correlated with economic development in most countries, which may be due to the occupational disease attribute by ACOP. We also try to evaluate the development of medical systems in different countries by multiple linear regression. Some countries must pay more attention to the development of national medical service.

Abbreviations

ACOP: accidental carbon monoxide poisoning; GBD: Global Burden of Disease; ASR: age-standardized rate; ASDR: age-standardized death rate; ASIR: age-standardized incidence rate; ASPR: age-standardized prevalence rate; DALYs: disability-adjusted life years; YLDs: lived with disability; YLLs: Years of Life Lost;

EAPC: estimated annual percentage change; SDI: socio-demographic index.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Yes, all authors consent for publication.

Availability of data and materials

Yes, all the data and materials can be asked from the author.

Competing Interests

The authors have declared that they have no competing interests.

Funding

Not applicable.

Authors' contributions

MZ designed the research. XL collected most of data. FL performed data analysis, data interpretation, and writing.

Acknowledgements

We thank Zaizai Cao and Yuanyuan Hao for assaulting some algorithm problems.

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