1. PU 430 Unit 6 Chapters 4 and 9

2. Chemical Disasters Chapter Four

3. Background: Recent Chemical Warfare Agents Terrorist Events 1993 World Trade Center Bombing 1995 Aum Shinrikyo sect released Sarin vapor into Tokyo Subway

4. Basic Facts about Chemical Health Threats Chemical toxicity Response Dose Dose–response relationship

5. Chemical agents Range from warfare agents to toxic chemicals commonly used in industry. Criteria for determining priority chemical agents include ◦chemical agents already known to be used as weaponry ◦availability of chemical agents to potential terrorists ◦chemical agents likely to cause major morbidity or mortality ◦potential of agents for causing public panic and social disruption ◦agents that require special action for public health preparedness Source CDC

6. Routes of Entry Inhalation Skin/mucous membrane absorption Ingestion Injection

7. Chemical Exposure Factors The route & rate of an exposure determines the dose received. The results can include: ◦Acute poisoning - a rapid absorption resulting in an especially fast & severe response ◦Chronic poisonings - result from prolonged exposures over a longer period of time ranging from days to years There are a variety of factors that determine poisoning outcomes

8. Exposure Factors Dose Time of exposure Route of Exposure Physical characteristics of chemical substance Previous or simultaneous exposures to other chemical substances Environmental conditions Physiological characteristics of the exposed

9. CWA Characteristics Volatility ◦Tendency to evaporate from liquid to gas form ◦Greater volatility= shorter persistence Vapor Density ◦Weight of the vapor or mist relative to air ◦All CWA’s (except HCN) heavier than air Persistence ◦Most evaporate > 24 hours ◦Present increased risk for skin exposure to victims and risk to responders

10. How do we prepare public health agencies for chemical attacks

11. Globally Harmonized System (GHS) of Human Health Classes Includes 10 classes of chemical threats to human Health Is being implemented in the U.S. but requires a tremendous effort Although the implementation of this system is necessary, it will come with a substantial learning curve for nations that have firmly established practices

12. Communicating Hazards: NFPA Fire Diamond NFPA “Fire Diamond”

13. Nomenclatures: Chemical Categorization There continues to be fundamental differences in the nomenclature of various hazards CDC lists them by category: http://www.bt.cdc.gov/agent/agentlistchem-category.asp http://www.bt.cdc.gov/agent/agentlistchem-category.asp

14. Chemical Accidents versus Terrorism Chemical Terrorism The most likely chemical terrorism scenarios are also the most likely industrial accident scenarios Chemical Accidents Chemical accidents are preventable & with the knowledge, tools, & regulations that exist in the U.S., these incidents should be exceptionally rare

15. Prevention Community Prevention Activities EPCRA (“List of Lists”) - This document lists the chemicals required to be reported by industry to local & state officials LEPCs - Carry out preparedness activities at the community level SERC – Maintained by each state to appoint members & establish jurisdictional areas for each LEPC Reducing Building Vulnerability High-risk facilities need to complete a comprehensive vulnerability assessment of their AHU & ensure a detailed risk reduction plan is developed & implemented. Home Prevention Activities In the home, many household products are accumulated that individually or combined can pose a risk to residents

16. Immediate Actions Individual Response Healthcare Response Public Health Response

17. General Treatment Guidelines Nerve Agents ◦Atropine, pralidoxime chloride (2-PAMCl), or diazepam Incapacitating Agents ◦Remove to fresh air, decon w/water, 6% bicarbonate solution Pulmonary Agents ◦Supplemental oxygen, restrict physical activity, medical attention Vessicants/Blister Agents ◦Remove to fresh air, remove clothing, decontaminate skin, supplemental oxygen, hospitalization, extensive irrigation of eyes Blood Agents ◦Amyl nitrate, sodium nitrate, sodiumthiosulfate

18. Prehospital Care and Decontamination First responders: Respirators, goggles, protective clothing Self-contained breathing apparatus (SCBA) is recommended in response to any nerve agent vapor or liquid. Butyl rubber gloves (most agents are lipophilic) 20% of healthcare workers in Tokyo had mild symptoms after taking care of patients. These symptoms included nausea, eye pain, and headache.

19. Prehospital Care and Decontamination (continued) Inhalation exposure Dermal Ingestion

20. Psychological Impact Psychological impact ◦Examples  Post traumatic stress disorder  Fear and depression  Sleep disturbances

21. Recovery Actions Once a chemical emergency is over, residents of the affected area should: ◦Not reenter the area until local authorities announce that it is safe to return ◦Thoroughly ventilate the structure by opening all windows & turning the air handling systems on ◦Avoid any potentially contaminated food or water ◦Watch for household hazardous materials ◦Never smoke or initiate any open flames

22. Nuclear & Radiological Disasters Chapter Nine

23. Basic Facts about Nuclear & Radiological Threats A Nuclear Event Distinguished by a nuclear detonation or fission A Radiological Event Does not involve a fission reaction or nuclear explosion

24. Possible Scenarios Nuclear power plant incident Hidden source “Dirty bomb” Improvised nuclear device Nuclear weapon

25. Exposure vs. Contamination Exposure: irradiation of the body  absorbed dose (Gray, red) Contamination: radioactive material on patient (external) or within patient (internal)

26. Nuclear & Radiological Health Threats Acute Radiation Syndrome (ARS) It includes four stages: ◦Prodromal stage - can begin within minutes or days of the exposure & last up to several days & includes gastrointestinal symptoms such as nausea, vomiting, & diarrhea ◦Latent stage - the patient will feel fine for a period of time ranging from hours to weeks ◦Manifest stage - includes one or more of three classic syndromes ◦Final stage - either recovery or death Cutaneous radiation injury (CRI) There is usually a delay between the exposure & the onset of symptoms & the progression is in stages There is a prodromal, latent, & manifest illness stage, sometimes followed by a third wave before recovery

27. Injuries Associated with Radiological Incidents Acute Radiation Syndrome (ARS) Localized radiation injuries/ cutaneous radiation syndrome Internal or external contamination Combined radiation injuries with - Trauma - Burns Fetal effects

28. Skin Effects NUREG / CR-4214, p II-68 n Epilation n Erythema n Pigmentation n Dry desquamation n Moist desquamation that heals n Epilation n Erythema n Pigmentation n Dry desquamation n Moist desquamation that heals

29. Patient Decontamination Remove and bag the patient’s clothing and personal belongings (this typically removes 80 - 90% of contamination) Handle foreign objects with care until proven non-radioactive with survey meter Survey patient and collect samples - Survey face, hands and feet - Survey rest of body

30. Nuclear & Radiological Accidents versus Terrorism There are five distinct differences: ◦Most radiological emergency planning is focused on accidents that are much smaller events & would not include the same hazards ◦Due to the alarm systems in place, most accident scenarios will have several hours of warning before a release begins ◦Most nuclear reactors are located in rural areas where fewer people & less infrastructure will be affected by an accident ◦The management of an emergency at a nuclear facility is likely to be much better coordinated ◦The type of radiological material involved in a nuclear facility accident is likely to be different from what would be seen with the IND or RDD attack

31. Prevention Nuclear Non-Proliferation Treaty (NPT) ◦Expresses support for nonproliferation of nuclear weapons programs, disarmament, & peaceful use of nuclear technologies for energy & other peaceful applications ◦Has been signed by 189 nations over the past 30 years

32. Immediate Actions With radiological events, the principles are well understood & there are fewer unknowns: ◦The detection instrumentation is ubiquitous, dependable, & quick to use ◦The ability to predict those at risk & offer recommendations is much more straightforward than other threats There are four broad scenarios that should be considered during planning so the proper actions are incorporated into preparedness activities: ◦A transportation accident involving radiological materials ◦An accident at a nuclear facility ◦The RDD or dirty bomb with the explosion of a package or a vehicle carrying radioactive materials ◦A small IND that could appear like the September 11, 2001 attacks on the U.S. with a block or several blocks of buildings as “Ground Zero”

33. Public Health & Protective Actions The primary roles of public health agencies in the aftermath of a nuclear or radiological incident Protective Action Guides (PAGs) include recommendations for the general public & separate recommendations for first responders There are recommended initial actions for the general public for the time prior to the availability of radiological measurements & associated protective action guidance.

34. Psychological Casualties Terrorist acts perceived as very threatening Large numbers of concerned with no apparent injuries Mental health professionals should be included For more information on radiation exposure and pregnancy www.bt.cdc.gov/radiation/prenatalphysician.asp

35. Dealing With Staff Stress Preplanning  Establish information center  Train staff on radiation basics Post Event  Debrief immediately after event  Offer Counseling

36. Medical Response According to the Centers for Disease Control & Prevention, there are six areas that need to be considered by healthcare organizations as they prepare for nuclear & radiological incidents: ◦Notification & communication ◦Triage ◦Patient management ◦Healthcare worker protection ◦Surveillance ◦Community planning

37. Unique Pharmaceutical Issues The Strategic National Stockpile (SNS) has a variety of critical radiological pharmaceutical resources available to support a radiological incident response

38. Recovery The only way to minimize the chronic social impact is to manage it well from the moment it occurs, including the registration & close monitoring of those truly at risk