1. WMD and All Hazards Response Jack Pittman Heather Lake Ken Hendricks

2. WMD and All Hazards Response Training Objectives: Be aware of the effects of weapons of mass destruction (WMD) and other hazardous releases Understand types of expected WMD casualties Understand impact of a HAZMAT or WMD event on public health and the environment Understand principles of agent identification using the Emergency Response Guide Understand levels of personal protection Recognize requirements for evacuation, shelter in place, decontamination, isolation, or quarantine

3. WMD and All Hazards Response Weapons of Mass Destruction: BNICE Biological, Nuclear, Incendiary, Chemical, Explosive CBRNE Chemical, Biological, Radiological, Nuclear, Explosive

4. WMD and All Hazards Response Explosive and Incendiary Threats: Favorite Terrorist weapon Mass casualty trauma: - Crushing - Fragmentation - Burns Relatively cheap High visibility High terror

5. WMD and All Hazards Response Chemical Threats: Industrial chemicals Chemical warfare agents

6. WMD and All Hazards Response Chemical Threats: Industrial chemicals FBI: Most Likely chemical terrorism event -- A Deliberate Industrial Chemical Release -- Rail -- Road -- Fixed Facility -- Pipeline

7. WMD and All Hazards Response Chemical Threats: Accidental industrial chemical releases Rail: According to the Federal Railroad Administration, there were 14,264 rail accidents in 2002 -- 59 in Florida. 704 involved cars carrying HAZMAT in the US with 13 HAZMAT accidents in Florida. In 1978, an Atlanta & St Andrews Bay Railway train derailed near Youngstown, Florida. Chlorine gas, released from a derailed car, killed 8 persons and injured 138 downwind of the accident site.

8. WMD and All Hazards Response Chemical Threats: Accidental industrial chemical releases Fixed Facility: In 1984, a release of methyl isocyanate in Bhopal, India killed 3,800 persons; 40 suffered permanent total disability; and 2,680, who lived as far as 25 miles downwind, were partially disabled. Pipeline: In May 2003, > 50 tons of anhydrous ammonia escaped after someone tapped into a pipeline in Brandon, FL. The leak sent noxious fumes into a subdivision, shutting down two schools.

9. WMD and All Hazards Response Chemical Threats: Response Except for the criminal investigation, a deliberate release of an industrial chemical would be handled as a HAZMAT event in the same way as an accidental release. Depending on the characteristics of the chemical, met conditions, etc., the event may require rapid evacuations and decontamination. First responders should be aware that terrorists may plant secondary explosives or booby traps around the scene of a chemical release incident.

10. WMD and All Hazards Response Chemical Threats: Response Recognition Isolation Protection Notification

11. WMD and All Hazards Response Chemical Threats Response Recognition The US Department of Transportation (DOT) is responsible for coordinating the national safety program for transport of hazardous materials and for accident response. DOT publishes the Emergency Response Guidebook (ERG) that provides info on identification of hazards, public safety, emergency response, and initial isolation and protective actions for over 3000 industrial chemicals.

12. WMD and All Hazards Response Chemical Threats Response Recognition – Clue 1 Occupancy and Location Fixed facilities -- specific occupancy or general area (e.g., an industrial park) Hazardous materials transportation modes –Rail, air, marine, highway and pipeline Drug lab considerations

13. WMD and All Hazards Response Chemical Threats Response Recognition – Clue 2 Container Shape and Size Classifications Fixed, portable, or in transport Pressure –Non-pressurized, low or high pressure Vapor Pressure and Storage –The higher the pressure, the greater the potential for catastrophic failure See ERG pages 18-19

14. WMD and All Hazards Response Chemical Threats Response Recognition – Clue 3 Placards and Labels Placards have limitations –Not always required –The 1000 pound rule Nine Hazard Classes subdivided into divisions. ERG Page 13 Placards and labels used for transport are based on DOT Hazard Class. ERG Pages 16-17

15. WMD and All Hazards Response Chemical Threats Response Recognition – Clue 4 Shipping Papers (ERG inside cover)

16. WMD and All Hazards Response Chemical Threats Response Recognition – Clue 4 Facility Documents Material Safety Data Sheets (MSDS) Required by the Federal Hazard Communication Standard and Florida Right-to-Know Law Provide: general information ingredients, physical and chemical characteristics, fire and explosion hazards, reactivity data, health hazards and toxicology, precautions for safe handling, first aid, control and clean up measures, transportation data, disposal data, and label data. Emergency Response Plans (ERP) Emergency Action Plans (EAP)

17. WMD and All Hazards Response Chemical Threats Response Recognition – Clue 5 Markings and Colors Container colors are not standardized National Fire Protection Association 704 Diamond Military markings

18. WMD and All Hazards Response NFPA 704 Diamond

19. WMD and All Hazards Response Chemical Threats Response Recognition – Clue 6 Human Senses SMELL SIGHT SOUND TOUCH TASTE

20. WMD and All Hazards Response Chemical Threats Response Recognition Isolation Protection Notification

21. WMD and All Hazards Response Chemical Threats Response Isolation Contain the immediate hazard Explosion Fire Contamination See ERG Yellow, Blue, and Green Sections

22. WMD and All Hazards Response Chemical Threats Response This is a Test Match the chemical with its ID number? 3065 2015 1005 What are Hazards associated with each?

23. WMD and All Hazards Response Chemical Threats Response Recognition Isolation Protection Notification

24. WMD and All Hazards Response Chemical Threats Response Protection Self Personal Protective Equipment (PPE) -- OSHA 29CFR.1910.120 Others Downwind Hazard -- ERG Green Pages Evacuate Shelter-in-place Decontamination

25. WMD and All Hazards Response Chemical Threats Response Protection: Self Portals of Entry Respiratory System Eyes Skin Ingestion System

26. WMD and All Hazards Response Chemical Threats Response Protection: Personal Protective Equipment Level A Best Respiratory and skin protection. Positive pressure SCBA, fully encapsulated chemical protective suit. For unknown skin absorptive material and high splash hazards.

27. WMD and All Hazards Response Chemical Threats Response Protection: Personal Protective Equipment Level B High level respiratory protection but less for skin protection. Positive pressure SCBA, hooded chemical resistive clothing. For areas less than 19.5% Oxygen, unidentified gas and vapor and low skin hazard.

28. WMD and All Hazards Response Chemical Threats Response Protection: Personal Protective Equipment Level C Modest skin protection. Full or half hooded APR, hooded chemical resistive clothing. For no skin hazards, no unknowns, and sufficient oxygen.

29. WMD and All Hazards Response Chemical Threats Response Protection: Personal Protective Equipment Level D No respiratory or skin protection needed. Ordinary work uniform. May include coveralls, reinforced-toe boots, and safety helmet.

30. WMD and All Hazards Response Infectious Disease Personal Protective Equipment Airborne precautions – Particles < 5 μM – Remain suspended in air, can be dispersed by air currents Recommendation: Fitted respirators meeting NIOSH N95 or better

31. WMD and All Hazards Response Chemical Threats Response Protection Self Personal Protective Equipment (PPE) Others Downwind Hazard ERG Green Pages Evacuate Shelter-in-place Decontamination

32. WMD and All Hazards Response Chemical Threats Response Protection Others Downwind Hazard ERG Green Pages Met Conditions: Lapse Cool/Warm Inversion Warm/Cool Neutral Cool/Cool

33. WMD and All Hazards Response Chemical Threats Response Protection This is a Test What is the DWHD for: Methyliodide 1005 Chlorine Compare small/large/day/ night

34. WMD and All Hazards Response Chemical Threats Response Decontamination The Hot Zone, also called the Exclusion Zone, fully encloses the Incident site -- the immediate scene of the terrorist event. The hot zone will extend downwind depending on the level of vapor hazard. All personnel must be in PPE.

35. WMD and All Hazards Response Chemical Threats Response Decontamination The Warm Zone, also called the Contamination Reduction Zone, is located upwind and preferably up gradient from the Hot Zone. Rescue, decon, and medical personnel are located here and all must be in PPE. A triage point is located near the Hot Zone exit control point for rapid assessment and further disposition of contaminated casualties.

36. WMD and All Hazards Response Chemical Threats Response Decontamination The Cold Zone, also known as the Support Zone, is located upwind and up gradient from the Warm Zone. All persons working in the Cold Zone should have respirators available in the event of a wind shift that would put them at risk for downwind vapor inhalation. A second triage point and a medical aid station may be set up here to further evaluate casualties for on-site treatment or immediate evacuation to a fully capable medical facility.

37. WMD and All Hazards Response Contagious Disease: Isolation Rooms Patients housed in rooms under negative pressure At least 6 to12 air changes/hour Air not re-circulated to other rooms

38. WMD and All Hazards Response Chemical Threats Response Recognition Isolation Protection Notification

39. WMD and All Hazards Response Chemical Threats Response Notification (Also See ERG page 384) Who ya gonna call? All major chemical releases must be reported to the State Warning Point 800-320-0519. Suspected chemical terrorism events, must also be reported to the FBI. The National Response Center maintains a one-stop point of contact site and hotline number 800-424-8802 for reporting oil and chemical spills -- to include chemical or biological terrorism releases. CHEMTREC established by the chemical industry as a public service hotline 800-424-9300 for fire fighters, law enforcement and other emergency responders to obtain information about emergency incidents involving toxic chemicals and hazardous materials.

40. WMD and All Hazards Response Chemical Threats: Commercial and industrial chemicals Chemical warfare agents

41. WMD and All Hazards Response Chemical Threats: Chemical Warfare Agents Classifications: Choking/Asphyxiation Phosgene Blister/Vesicants Mustards, Lewisite, Phosgene oxime Blood/Cytochrome oxidase inhibitors Hydrogen Cyanide, Cyanogen chloride Nerve/acetylcholine esterace inhibitors Sarin, Soman, Tabun, VX

42. WMD and All Hazards Response Chemical Threats: Chemical Warfare Agents Sarin (2810) Military Designation GB Physical State Liquid at 25 o C/77 o F Odor/color None/colorless liquid Symptoms Onset Seconds to minutes. If lethal dose is absorbed, symptoms can progress to death in 15 minutes. Vapor Toxicities in mg-min/m 3 LCt 50 100 ICt 50 75 Skin Absorption LD 50 1700 mg Eye Injury (Miosis) in mg-min/m 3 MCt 50 3

43. WMD and All Hazards Response Chemical Threats: Chemical Warfare Agents VX (2810) Military Designation VX Physical State Liquid at 25 o C/77 o F Odor/color none/colorless to amber liquid Symptoms Onset Seconds to minutes. If lethal dose is absorbed, symptoms can progress to death in 15 minutes or less. Vapor Toxicities in mg-min/m 3 LCt 50 50 ICt 50 35 Skin Absorption Toxicities Skin LD 50 10 mg Eye Injury (Miosis) MCt 50 in mg-min/m 3 < 1

44. WMD and All Hazards Response Chemical Threats: Chemical Warfare Agents Sarin (2810) Medical Management. Depending on the dissemination method and the dose received, casualties may require decon, administering of antidotes, ventilation, and supportive care. There are three therapeutic drugs used to treat nerve agent exposure: atropine, pralidoxime chloride (2-PAMCl), and anti- convulsive drugs such as diazepam. In cases of severe nerve agent exposure, ventilation has been required for up to three hours. Long term supportive care will be required for those with prolonged central nervous system effects.

45. WMD and All Hazards Response Chemical Threats: Chemical Warfare Agents Sarin Protection Because nerve agents can cause casualties from exposure to both vapors and liquid contact, full respiratory and non-permeable outer garment protection is required (Level A – Level B). Decontamination Nerve agents hydrolyze under conditions of high pH. Hot soapy water solutions can be effective in removing agent from skin, but complete hydrolysis occurs over time and run-off from decon waters may still contain sufficient agent to cause casualties among unprotected people. Skin decontamination is not needed for those who have only been exposed to vapor only; however, clothing should be removed because it may outgas trapped vapor.

46. WMD and All Hazards Response Chemical Threats: Case Study Tokyo Subway Attack After numerous failed attempts to disseminate anthrax spores and botulinum toxin, in and around Tokyo, on March 20, 1995, members of the Aum Shinrikyo cult, led by Shoko Asahara succeeded in releasing sarin in 5 trains running on three major subway lines converging in downtown Tokyo. More than 5,500 people were affected. There were 641 casualties resulting from sarin inhalation that required medical treatment and 12 deaths.

47. WMD and All Hazards Response Chemical Threats: Case Study Tokyo Subway Attack

48. WMD and All Hazards Response Chemical Threats: Case Study Tokyo Subway Attack The Tokyo Fire Department transported 688 victims to area hospitals. The remainder of the victims were transported by police vehicle, taxicabs, or self-evacuated to hospitals on their own. The nearest medical facility in central Tokyo was St. Luke’s International Hospital which treated 641 casualties on the morning of the attack with 349 follow- up cases seen during the next week.

49. WMD and All Hazards Response Chemical Threats: Case Study Tokyo Subway Attack The first EMS request was made at 8:09 a.m. Tokyo Fire Department sent 340 units and a total of 1,364 personnel to 16 stations. There was no attempt to establish decontamination. About 10% of the responding personnel (a total of 135) were among the injured after direct or indirect sarin exposure.

50. WMD and All Hazards Response Chemical Threats: Case Study Tokyo Subway Attack There were 5 patients in critical condition. 3 arrived with cardiopulmonary arrest; 2 were unconscious went into respiratory arrest soon after arrival. Three were successfully resuscitated. One patient did not respond to cardiopulmonary resuscitation and died. A second patient was resuscitated but died on day 28 after the attack due to irreversible brain damage. The other 10 deaths occurred at the attack scene. Those who died included two station employees who had tried to remove the bags of sarin.

51. WMD and All Hazards Response Chemical Threats: Case Study Tokyo Subway Attack 106 casualties (43 men and 63 women, including 4 who were pregnant) were triaged into the moderate severity category and hospitalized for overnight observation. Many complained of headache; dyspnea, nausea, vomiting, muscle weakness, coughing, agitation, and fasciculation. Hospitalized patients were treated initially with 2 mg of intravenous atropine sulfate and 2 g of pralidoxime chloride after the agent was confirmed as sarin. Intravenous diazepam was administered for fasciculation. The remaining 531 casualties had mainly with eye problems (miosis). They were treated with intravenous atropine sulfate, observed for six hours and released if no other symptoms developed.

52. WMD and All Hazards Response Chemical Threats: Case Study Tokyo Subway Attack One month after the attack, St. Luke's mailed questionnaires to 610 of those they treated. Of those responding nearly 60% reported post traumatic stress disorders. Many sought the services of psychiatrists to relieve their psychological symptoms. 32% of the victims harbored phobias related to using the subway. 29% reported insomnia. 16% still had flashbacks of scenes they witnessed on the day of the attack. 16% reported depression. 10% reported vivid nightmares.

53. WMD and All Hazards Response Chemical Threats: Case Study Tokyo Subway Attack – Lessons Learned 1. Attack Effectiveness. Although the sarin was not pure or concentrated and the dissemination method was crude, it created a mass casualty event. 2. Initially, there was no control possible at the scene. Many of those affected self-evacuated to area hospitals. Some with mild symptoms chose not to seek medical attention. 3. Although Tokyo-area hospitals had emergency and disaster plans because of the high incidents of earthquakes, they were unprepared for a mass casualty incident where all victims were exposed to the same toxic substance.

54. WMD and All Hazards Response Chemical Threats: Case Study Tokyo Subway Attack – Lessons Learned 4. There was no attempt by on scene responders to alert the hospital or communicate investigation results. 5. There was no attempt to decontaminate victims either at the scene or at the hospital. Although the major threat from sarin is vapor inhalation, some of the victims apparently contacted the liquid sarin or had pockets of vapor trapped in their outer clothing. Over 10% of first responders and 20% of the St. Luke's staff who treated victims developed nerve agent symptoms that included miosis, ocular pain, headache, sore throat, dyspnea, nausea, dizziness, and nose pain. 5. Mass psychogenic illness and post traumatic stress are factors that must be considered in the treatment of weapons of mass destruction attacks in addition to the treatment of physical symptoms.

55. WMD and All Hazards Response Chemical Threats Questions? Issues? Discussion?

56. Jack Pittman Director, Public Health Preparedness Leon CHD and NFRDSTF Heather Lake Division of Environmental Health Bioterror Threat

57. Why Bioterror is an attractive option? Spectrum of effects Dial an outcome – mild to lethal Contagion vs. contamination Covert Ops Extremely high terror and psychological consequences

58. Bioterror Threat Emerging Diseases Is mother nature the ultimate bioterrorist? HIV/AIDS WNV EEE SARS Monkeypox Malaria Antibiotic resistance Pandemic Flu Unknown unknowns

59. Bioterror Threat Bioterror Defense Education and training Intelligence Surveillance Vaccination Isolation and quarantine Stockpile Responsive logistics Research

60. Bioterror Threat Questions? Issues? Discussion?