Death certificate in texas

INTRODUCTION

Inhalant abuse is well documented as a problem among young people; nationally, 20% of 8th graders, 17% of 10th graders, and 15% of 12th graders in 1999 had ever tried inhalants (1). In the 1998 Texas survey of over 158,000 secondary school students, 22% of secondary students reported ever having tried inhalants, and 8% reported past month use. Inhalants were found to be a serious problem, particularly among students in 7th and 8th grades and among those who experience academic, attendance, and disciplinary problems at school (2).

In comparison, inhalant use is lower among adults. The 1996 survey of over 8000 Texas adults (3) found that only 5% reported any lifetime use of inhalants, and only 0.3% reported use in the past year. Lifetime use was higher among young adults aged 18-24 years (9%) and those aged 25-34 years (8%) compared to those 35 years and older (3%).

The 1999 National Household Survey on Substance Use (4) reported lifetime rates of inhalant use at 9.1% for persons aged 12-17 years, 14.1% for those aged 18-25 years, and 6.5% for those aged 26 years and older.

Bowen et al. (5) reported on 39 deaths in Virginia between 1987 and 1996 from acute voluntary exposure to abused inhalants. Median age was 19 years, with 70% of the decedents under the age of 22 years.

Because both survey and death certificate data were available for Texas, this study was undertaken to compare the characteristics of Texas decedents against the survey data and against death data from the Virginia study to see if additional insight could be gained that might be used to prevent inhalant abuse and deaths.

METHOD

Between 1988 and 1998, the Texas Commission on Alcohol and Drug Abuse (TCADA) annually obtained copies of those death certificates from the Bureau of Vital Statistics of the Texas Department of Health (TDH) on which volatile or inhaled substances were mentioned as a contributing cause of death. Each year, nosologists at TDH reviewed death certificates for certain International Classification of Diseases Codes (6) * and forwarded those that met the required codes to TCADA. The certificates were then reviewed to determine appropriateness. ([dagger]) Demographic and employment information, as well as the substances involved, were then abstracted. Pearson chi-square tests using SAS software assessed the statistical significance of the findings.

Medical examiners, private physicians, and justices of the peace (who need not have medical training) all have the authority to sign a death certificate in Texas, which leads to variation in the quality of reporting. Autopsies are not required. In some instances, the certificate specified the actual product or the chemical component, while in other instances only the term "inhalant abuse" was noted. Some certificates specified the circumstances surrounding the death, such as the manner of inhalation, while others gave no information. Information on whether the case was a suicide was not uniformly included. Likewise, information as to whether the decedent was a chronic abuser was rarely provided.

Thus, the reader is cautioned that this study reflects the typical limitations of death certificate studies in terms of variations in the quality of reporting. There is no way to know whether all inhalant deaths in the state were actually reported. Yet, even with these problems of underreporting and misreporting, the data collected provided potentially useful information on those deaths that included mentions of inhalants and factors that may place certain persons at higher risk.

RESULTS

Inhalant use or abuse was mentioned on 144 death certificates in the period 1988-1998. These certificates represent between 0.004% and 0.016% of all Texas deaths each year. The total number of deaths in Texas increased from 122,731 in 1988 to 142,389 in 1998.

Ages of the decedents ranged from 8 to 62 years; the mean age was 25.6 years (SD 9.8 years). Some 28.7% were 8-17 years old, 28.7% were 18-25 years old, 22.4% were 26-34 years old, 16.7% were 35-44 years old, 2.8% were 45-54 years old, and 0.7% were 55 years or older. Figure 1 shows that, over the period of this study, the mean age of the decedents increased from 22 years in 1988 and 1989 to nearly 26 years in 1997 and 1998, and the number of deaths per year decreased from a high of 19 in 1989 to as low as 5 in 1996, with an upturn in 1997 and 1998. There is no known explanation for these fluctuations.

[FIGURE 1 OMITTED]

Most of the decedents lived in metropolitan areas: 40% of the cases were in the Dallas-Fort Worth Consolidated Metropolitan Statistical Area (CMSA), 15% were in the Houston-Galveston-Brazoria CMSA, and 10% were in the Austin-San Marcos Metropolitan Statistical Area (MSA), 3% were in the San Antonio MSA, and 1% each were in the El Paso MSA and the Brownsville-Harlingen-San Benito MSA.

While 92% of the 144 Texas decedents were male and 81% were white, the sociodemographic characteristics of the cases differed depending on the substance used, as Table 1 shows. Of the cases, 78% involved Freon *, chlorinated hydrocarbons (e.g., fabric protector, liquid paper, or carburetor cleaner), or alkylbenzenes (toluene or rubber cement). Those cases involving alkylbenzenes were older, were less likely to be male, and only half were white.

Decedents were also classified by Department of Labor occupation categories: 34% were students; 18% were mechanics, installers, and repairers; 10% were in construction trades; 8% were professionals and technicians; 7% were unemployed; 7% were in service occupations; 6% were handlers and laborers; 4% had other or unknown occupations; 2% were in marketing and sales; 1% were executives, administrators, and managers; 1% were professionals; 1% were in administrative and clerical support; and 1% were in production.

Table 2 shows the relationship of the most common occupation categories by the most common inhalant type. Of those who died from inhaling Freon, 22 were students, and 19 were classified as mechanics, installers, and repairers. Among this latter group, 95% worked as air conditioning, refrigeration, or automobile technicians, or they were involved in building maintenance.

Of those who died from inhaling chlorinated hydrocarbons, 18 were students, and 7 were in "blue collar" categories of construction trades, service occupations, handlers and laborers, and production occupations.

Of the deaths attributed to alkylbenzenes (toluene), 10 were of "blue collar" workers, of whom 7 were in construction trades, and 4 included a notation of "painter" on the death certificate.

When sociodemographic characteristics are considered together with the occupational categories, it is possible to create a profile of the inhalant abusers whose death certificates included certain categories of inhalants. Of those persons who died of chlorinated hydrocarbon inhalation, 49% were students (mean age 17.5 years, 89% male, 94% white). The other 51% came from a mix of occupations (mean age was 27.4 years, 100% were male, 74% were white, and 21% were Hispanic).

Of those persons whose death certifications included a mention of Freon, 42% were students (mean age 16.4 years, 86% white, 91% male), and another 37% were mechanics, installers, or repairers, at which jobs may have had access to Freon (mean age 33.8 years, 100% white, 100% male).

DISCUSSION

These Texas death data indicate that persons whose death certifications included a mention of inhalants do not resemble those who report use in surveys. Persons in Texas dying of inhalant use are predominately male (92%) and white (81%). In the 1998 Texas secondary school survey, there was little distinction based on gender or ethnicity: Lifetime inhalant prevalence was 23% for boys and 21% for girls. Lifetime prevalence for Hispanics was 25%, and for whites, it was 23%; among African-American students, it was 13%. In the 1996 Texas adult survey, lifetime prevalence was 8% for males and 3% for females; it was 6% for whites, 4% for Hispanics, and 2% for African-Americans.

The Texas death data also are different from those reported in the Virginia study. The Texas decedents were older than those reported in Virginia (median age 24 years in Texas vs. 19 years in Virginia). Of the Virginia decedents, 70% were under the age of 22 years (42% in Texas were under 22 years old).

Most decedents were male (92% in Texas vs. 95% in Virginia). Texas decedents were less likely to be white (81% in Texas and 95% in Virginia). However, Hispanics and African-Americans were underrepresented in the Texas data. Some 17% of the decedents were Hispanic versus 26% of the Texas population in the 1990 census, and only 1% of the decedents were African-American versus 12% of the population of the state. The lower prevalence of inhalant use among African-Americans has also been reported in other studies (7, 8).