Fatal Fires Associated with Smoking During Long-Term Oxygen Therapy --- Maine, Massachusetts, New Hampshire, and Oklahoma, 2000--2007

Approximately 1 million persons in the United States receive long-term oxygen therapy (LTOT) annually through the Medicare program, most often for smoking-related lung disease (1,2). At 2:10 a.m. on December 14, 2007, a fire occurred in a public housing project for the elderly in Westbrook, Maine. Approximately 60 residents were evacuated; six were transported to a hospital for smoke inhalation. The fire was caused unintentionally by a woman aged 57 years who was an overnight guest of a relative who lived in the housing project. The visitor had ignited the fire while simultaneously smoking and using an oxygen concentrator.* After this incident, the Maine Department of Health and Human Services, in collaboration with three other states, attempted to determine 1) how often this type of event results in fatalities and 2) factors common to these incidents that might be amenable to prevention. This report describes the results of that study, which found that, during 2000--2007, of the 38 deaths identified in the four states, 37 occurred in private residences, and the median age of the decedents was 67 years. Prevention of this type of fatality is dependent on smoking cessation, careful assessment of the need for LTOT, and strategies to prevent injuries from fires, such as smoke alarms and sprinklers.

Three other states (Massachusetts, New Hampshire, and Oklahoma) agreed to join Maine in the study. A case was defined as a fatality resulting from a fire caused by smoking during LTOT by a resident of one of the four states during 2000--2007. In Maine, Massachusetts, and New Hampshire, cases were identified by state fire marshals, based on information provided by immediate survivors and household members and investigation of the scene by fire officials. Supplementary information for certain cases was available from medical examiners, death certificates, and newspaper accounts. In Oklahoma, cases were identified using the state burn registry, which relies on multiple data sources, including medical examiner reports, burn center medical records, fire marshal and fire department reports, and media accounts (3). Burns and smoke inhalation injuries resulting in hospitalization or death have been a reportable condition in Oklahoma since 1986 but have not been reportable in the other three states.

A total of 38 cases were identified: five in Maine, three in New Hampshire, 11 in Massachusetts, and 19 in Oklahoma. All incidents involved a single fatality except for one fire that resulted in two deaths. The overall fatality rate for the four states was 3.8 deaths per 10 million population per year. The highest fatality rate was in Oklahoma (6.7 per 10 million population), followed by Maine (4.8), New Hampshire (2.9), and Massachusetts (2.1). Decedents ranged in age from 9 to 87 years (median: 67 years); the death of a child aged 9 years was the only fatality involving a minor. Twenty-four (63%) decedents were female. Thirty-four (89%) of the decedents were on LTOT and were smoking at the time the fire began; three (8%) were household members of smokers on LTOT who survived, and one (3%) was a nonsmoker on LTOT who was unintentionally ignited by a smoker who lived in the household and survived. Twenty-two (58%) decedents died on the day of the fire, and seven (18%) died the following day. The remaining nine (24%) decedents survived a median of 15 days (range: 3--41 days).

All 38 fatalities occurred in private residences except for one in a nursing home. Ten (27%) incidents occurred in multifamily dwellings; six (16%) occurred in mobile homes. For the 27 incidents for which location in the home was known, 14 (52%) fires began in a bedroom, 11 (41%) in a living room, one (4%) in a hallway, and one (4%) in a bathroom. House fires occurred in 24 (65%) incidents; the remaining fires were confined to the person or the person's immediate surroundings (e.g., a chair or bed). No clustering of incidents by day of the week or month of the year was observed. Of 34 incidents for which time of occurrence was known, 20 (59%) occurred between 12:00 midnight and 8:00 a.m.

In addition to the 38 fatalities, these 37 incidents resulted in 16 nonfatal injuries, which included two injuries to firefighters, one injury to a police officer, and 13 injuries to civilians. Functioning smoke alarms were present in 19 (51%) incidents. Sprinklers and signage indicating that oxygen was in use were noted in one (3%) incident each.

Reported by: T Wendling, MPH, Injury Prevention Svc, Oklahoma State Dept of Health. A Pelletier, MD, Coordinating Office for Terrorism Preparedness and Emergency Response, CDC.

Editorial Note:

Fires associated with tobacco use are the leading cause of residential fire deaths in the United States (4). Although smoking should never be allowed where LTOT is used (4), a substantial percentage of persons on LTOT continue to smoke. A precise percentage is not known; however, estimates range from 10% to 43% (2,5,6,8). Medical oxygen can saturate clothing, fabric, and hair. Oxygen will not explode but will act as an accelerant. A fire, such as a lit cigarette, will burn faster and hotter in an oxygen-enriched environment.

Five case series involving patients admitted to burn centers in the United States after being injured while smoking in the presence of medical oxygen have been published previously (2,6). These case series involved a total of 79 in-patients and 15 deaths, for an overall mortality rate of 19%. In addition, one study indicated that 52% of all patients burned while smoking in the presence of medical oxygen were treated at a burn center on an outpatient basis (2). The number of fires ignited by smoking in the presence of medical oxygen in which injuries occur that do not require treatment at a burn center is unknown.

The findings in this report are subject to at least four limitations. First, electronic records maintained by state fire marshals often do not allow for the identification of this specific type of fatality (4). Therefore, case counts for Maine, Massachusetts, and New Hampshire, which relied on data from state fire marshals, might represent underestimates. Second, some of the decedents were alone at the time of the incident. Determining the exact cause of incidents without witnesses was sometimes complicated by extensive fire damage. Third, complete information was not available for all fatalities. Some of the factors described in this report, such as presence of signage, might represent minimum estimates of actual prevalence. Finally, incidents without fatalities were not examined. Focusing only on incidents with fatalities underestimates the public health impact of smoking during LTOT.

Preventing injuries resulting from smoking in the presence of medical oxygen requires a multifaceted approach. First, health-care providers should employ evidence-based guidelines for achieving smoking cessation (7,8). Quitting smoking has immediate and long-term health benefits (7) and will decrease fire risks associated with medical oxygen substantially. Second, the need for LTOT should be carefully assessed (5). In one study, 40% of patients on LTOT were found not to meet established criteria for this therapy (9). Third, strategies to prevent fire-related injuries should be emphasized. Patients and their household contacts should be thoroughly educated about the dangers of smoking in the presence of medical oxygen. The U.S. Fire Administration recommends that homes be equipped with smoke alarms on every level, including the basement, and for extra safety, both outside sleeping areas and inside bedrooms (10). Consideration should be given to installing automatic sprinkler systems, where feasible, and families should develop a fire escape plan and practice it several times a year (10).

Acknowledgments

This report is based, in part, on contributions by M Ahrens, National Fire Protection Assoc; J Dean, R Taylor, J Thomas, Maine Office of State Fire Marshal, M Greenwald, MD, Maine Office of Chief Medical Examiner, B Corkum, Maine Dept of Health and Human Svcs; D Dion, J Mieth, Massachusetts Dept of Fire Svcs; K Fallon, New Hampshire Office of Chief Medical Examiner, JW Degnan, New Hampshire State Fire Marshal; J Gofton, MD, Oklahoma Office of Chief Medical Examiner, R Doke, Office of Oklahoma State Fire Marshal, and A Bowles, Oklahoma State Dept of Health.

References

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9. Guyatt GH, McKim DA, Austin P, et al. Appropriateness of domiciliary oxygen delivery. Chest 2000;118:1303--8.
10. US Fire Administration. Smoke alarms. Available at http://www.usfa.dhs.gov/citizens/all_citizens/home_fire_prev/alarms.

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Date last reviewed: 8/6/2008