CDC Recommendations for Civilian Communities Near Chemical Weapons Depots: Guidelines for Medical Preparedness

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

CDC Recommendations for Civilian Communities Near Chemical

Weapons Depots: Guidelines for Medical Preparedness

AGENCY: Centers for Disease Control and Prevention (CDC), Public Health

Service, HHS.

ACTION: Request for comment.

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SUMMARY: The National Center for Environmental Health, CDC, is

recommending minimum standards for prehospital and hospital emergency

medical services' readiness in communities near the eight locations

where the U.S. stockpile of lethal chemical weapons is stored.

DATES: Comments must be received on or before August 26, 1994.

ADDRESSES: Comments may be mailed to Director, National Center for

Environmental Health, (NCEH), CDC, 4770 Buford Highway NE., Mailstop

F29, Atlanta, GA 30341-3724.

FOR FURTHER INFORMATION CONTACT: Linda W. Anderson, Chief, Special

Programs Group, NCEH, CDC, 4770 Buford Highway NE., Mailstop F29,

Atlanta, GA 30341-3724, telephone (404) 488-7071.

SUPPLEMENTARY INFORMATION: CDC Recommendations for Civilian Communities

Near Chemical Weapons Depots: Guidelines for Medical Preparedness.

I. Executive Summary

In 1985, Congress mandated that unitary chemical warfare agents be

destroyed in such a manner as to provide maximum protection for the

environment, the public, and personnel involved in destroying the

agents. The National Center for Environmental Health (NCEH), Centers

for Disease Control and Prevention (CDC), was delegated review and

oversight responsibility for any Department of the Army (DA) plans to

dispose of or transport chemical weapons (Public Law 91-121 and 91-441,

Armed Forces Appropriation Authorization of 1970 and 1971).

As part of its ongoing efforts to improve medical preparedness

within the medical sector of civilian communities surrounding chemical

agent depots, CDC has developed the following medical preparedness and

response guidelines. These guidelines represent minimum standards of

medical preparedness for civilian communities that might be exposed to

chemical warfare agents during the incineration or storage process.

These guidelines were developed in cooperation with a panel of

recognized experts in the fields of emergency medicine, disaster

preparedness, nursing, chemical warfare preparedness, and the

prehospital emergency medical system.

II. Background

In 1985, Congress mandated that unitary chemical warfare agents be

destroyed in such a manner as to provide maximum protection for the

environment, the public, and the personnel involved in destroying the

agents. This mandate was further defined in the Department of Defense

(DOD) Authorization Act of 1986, Public Law 99-145. Consistent with its

desire to promote the most environmentally safe method of destroying

chemical agents, the National Research Council determined that

incineration is the best method for disposing of the weapons(1). In

1988, The Authorization Act was amended to permit DA to set up a

prototype incineration facility on Johnston Island in the Pacific in

order to verify the safety of such an operation. To date, more than

700,000 pounds of chemical agent have been safely incinerated there.

NCEH, CDC, was delegated the responsibility of reviewing and

overseeing any DA plans to dispose of or transport chemical weapons

(Public Law 91-121 and 91-441, Armed Forces Appropriation Authorization

of 1970 and 1971). In addition, an interagency agreement between CDC

and DA requires CDC to provide technical assistance to the DA in

protecting the public health in nearby communities during the

destruction of unitary chemical agents and weapon systems.

Currently, large quantities of chemical warfare agents are stored

in eight facilities in the continental United States. These chemical

stockpiles consist primarily of nerve agents, mustard agents, or a

combination of both. In Tooele, Utah, construction of the chemical

agent incinerator is now complete, and destruction of the weapons and

chemicals in this depot is scheduled to begin in Spring of 1995. To

improve the ability of local health care personnel to handle

emergencies related to a chemical agent release, CDC has presented

medical preparedness courses to civilian medical personnel on sites

adjacent to the eight chemical weapons depots on 13 occasions.

Emergency physicians, nurses, internists, surgeons, hospital

administrators, and prehospital emergency medical responders have

attended these courses.

As part of its ongoing efforts to improve medical readiness in

civilian communities surrounding chemical agent depots, CDC developed

medical preparedness and response guidelines. These guidelines

represent minimum standards for medical preparedness in civilian

communities that might be inadvertently exposed to chemical warfare

agents during the incineration or storage process. These guidelines

were developed in cooperation with a working group of recognized

experts in the fields of emergency medicine, disaster preparedness,

nursing, chemical stockpile emergency preparedness, and prehospital

emergency medical systems. These guidelines do not supersede current

medical and public health practices and requirements (e.g., precautions

for handling bodily fluids).

The following recommendations for civilian community response to

the release of a chemical agent are divided into prehospital and

hospital. The recommendations are designed to ensure high quality

medical preparedness for chemical agent emergencies. Appendix A is a

summary of important questions to ask when evaluating medical

preparedness in the civilian prehospital and hospital environments. The

prehospital environment encompasses all areas outside both the

installation boundaries and the hospital grounds. People potentially

affected in the prehospital environment include the general public, and

first responders. First responders include police, sheriff's, and fire

department personnel, hazardous materials response teams, and medical

response teams (including emergency medical technicians, paramedics,

and any other medically-trained personnel responding to the site of

injury with the ambulance teams). The hospital environment includes

primarily the emergency department but encompasses outside areas which

might be used for triage and decontamination and other hospital

departments which might support the hospital's response.

III. Recommendations for Prehospital Medical Preparedness

Integrate all local medical emergency response plans

related to the release of a chemical agent into the overall State or

local disaster response plan.

Provide protective equipment for all members of the local

medical response team.

Train members of the local medical response team in these

measures:

--Prevention of secondary contamination from chemically exposed

patients.

--Decontamination procedures.

--Evaluation of the medical needs of chemically exposed patients.

--Treatment of large groups of patients.

--Transportation of victims to a medical facility.

1. Personal Protective Equipment (PPE)

Chemical protective clothing and respiratory protection enable

responders to care for patients exposed to chemicals while protecting

themselves from secondary contamination.

Ensure that such equipment protects the skin, eyes, and

respiratory tracts of the emergency responders.

Use DA battledress overgarments (BDOs) and portable air-

purifying respirators (PAPRs) with an organic vapor cartridge to

protect civilians from chemical warfare agents. BDOs can be used for up

to 24 hours in an agent-contaminated environment at levels of up to 10

grams of agent per square meter of surface area. Notwithstanding this

recommendation, however, civilian emergency responders should use the

equipment with which they are most familiar, providing that the

equipment used is at least as protective as the above CDC

recommendations.

Train personnel required to use personal protective

equipment when responding to chemical agent-related emergencies in

accordance with the guidelines published by the Occupational Safety and

Health Administration (OSHA).

2. First Responders

Ensure that all persons (e.g., medics, paramedics, fire

fighters, or medical personnel) designated by the State or local

disaster plans as members of the initial medical team that responds to

a chemical warfare agent release have the appropriate level of PPE and

are trained in its proper use (2).

Ensure that equipment of first responders is adequately

maintained and available at all times.

Schedule regular drills and training sessions designed to

maintain first responders' familiarity with equipment into State and

local disaster plans.

3. The Public

CDC does not recommend distributing PPE (e.g., gas masks or

protective suits) to the public. In the unlikely event that a chemical

agent release threatens the civilian population adjacent to a military

facility, CDC recommends the following graded emergency response:

Evacuate the population at risk in accordance with State

or local disaster management guidelines. If no local guidelines exist,

follow the Federal Emergency Management Agency (FEMA) and DA joint

guidelines for evacuating civilian populations threatened by chemical

warfare agents (3).

Follow FEMA and DA recommendations for sheltering the

population in place (e.g., keep people in their homes, institutions, or

places of business and seal windows and doors from an external vapor

threat) if it is not practical to evacuate the population (3).

4. Decontamination

Decontamination is the careful and systematic removal of hazardous

substances from victims, equipment, and the environment. Transporting

contaminated patients exposes emergency response personnel to chemical

warfare agents and contaminates rescue vehicles. Proper decontamination

prevents secondary contamination and chemical injury to medical and

rescue personnel. Acceptable decontamination guidelines for persons who

may possibly have been exposed to chemical warfare agents are published

by FEMA and DA (3,4).

Decontamination of patients can be achieved by

mechanically removing, diluting, absorbing, or neutralizing the

chemical agent.

Decontaminate all persons who may possibly have been

contaminated with a chemical warfare agent before they are transported

to a hospital.

Decontamination substances should be readily available.

Suitable decontamination substances include soap, water, and 5%

hypochlorite.

To protect the environment, include in State and local

disaster plans a method for containing and disposing of contaminated

runoff. CDC does not recommend establishing fixed decontamination units

in prehospital areas because of the expense and inflexibility of such

units.

5. Level of Medical Preparedness Training

At a minimum, train persons designated as prehospital

medical responders in evaluating patients exposed to chemical warfare

agents, managing patients' airways (excluding intubation), transporting

patients, and decontaminating patients.

Train prehospital responders who have been designated in

State or local disaster plans to operate in environments contaminated

by a chemical warfare agent in the proper use of PPE in accordance with

OSHA guidelines (2).

Ensure that, at a minimum, physicians who have been

designated in State and local disaster plans to provide medical

supervision for prehospital emergency responders and medical care for

victims of a chemical agent release receive specialized training

through continuing education in the emergency response areas specified

for prehospital responders.

6. Patient Triage

The basic premise of patient triage, to provide maximum

benefit to the greatest number of victims, is of utmost importance

during a mass-casualty event involving chemical agents.

Have the most experienced responder conduct triage

operations.

Base decisions regarding patient triage on local

resources, the extent of patient contamination, the type of chemical

warfare agent to which the patient is exposed, the patient's clinical

status, and the likelihood of additional traumatic injuries.

7. Public Information

Inform the public appropriately, accurately, and rapidly

about chemical agent exposures that have or may have occurred.

Establish, through the local emergency medical services

(EMS) and hospital community, a coordinated public information policy

for chemical emergencies.

Contact local and regional news media in advance to

establish an accurate and rapid way of disseminating critical

information to the public concerning a chemical agent emergency.

Ensure that hospital and EMS personnel coordinate their

plans to provide public information with the plans of those who have

overall responsibility for emergency response.

8. Communication

Medical personnel must have access to the emergency communication

network 24 hours a day. Such a network should link the chemical agent

depot, local and regional EMS, and all potential receiving hospitals.

Have medical personnel demonstrate the ability to access

the emergency communications network during any evaluation of

preparedness for a chemical warfare release into civilian communities.

Ensure that the hospitals' emergency communications system

allows hospital personnel to verify rapidly whether a chemical warfare

agent release has occurred.

9. Transporting Exposed Victims

Coordinate the transportation of chemical agent-exposed

victims with the overall disaster response plan, and include a method

for tracking transported patients during an emergency response.

Transport patients only after they have been properly

decontaminated.

Transport decontaminated patients to medical facilities

(e.g., hospitals, clinics, and urgent care centers).

Formal agreements such as memorandums of understanding

(MOUs) between organizations that transport patients and the medical

facilities that receive them must be part of the planning process.

Medical facilities designated to receive should be capable of

evaluating and managing patients exposed to chemical agents as

described later in the hospital section (Section IV) of this document.

Base decisions regarding urgent and emergency transfers of

decontaminated patients on the capabilities of the receiving

facilities, transportation resources, demand for hospital services, and

the clinical condition of the patients. Certain medical care (e.g., for

burns, pediatric emergencies, trauma, or pulmonary complications) might

require prearrangements for patients to be transferred to a tertiary

treatment center. CDC recommends that transfer and evacuation plans for

victims exposed to chemical warfare agents call for land--rather than

air--transportation.

10. Medical Evaluation and Treatment

Train medical response personnel specifically to assess

and manage patients exposed to chemical agents stored at the nearby

military depot.

Decontaminate all exposed patients as described above.

Provide medical treatment (during or after contamination),

according to accepted treatment modalities, to patients exposed to

nerve or mustard agents. If antidotes to nerve agents are used in the

field by civilian medical responders as designated in State or local

disaster plans, CDC recommends using single-dose, pre-armed

autoinjectors, unless a higher level of medical response has already

been integrated into EMS operations. Additional information on the

effects of chemical warfare agents and accepted medical protocols for

caring for patients exposed to mustard or nerve agents is available (5-

14).

IV. Recommendations for Hospital Preparedness

1. Primary Receiving Hospitals

A primary receiving hospital is a hospital that is designated by

State or local disaster plans to provide initial medical care to the

civilian population in the event of a chemical warfare agent release.

Such hospitals must have established protocols detailing evaluation,

decontamination, and treatment procedures for patients exposed to

chemical warfare agents.

Include evaluation, treatment, and decontamination

protocols in the hospitals' disaster plans.

Include chemical warfare agent scenarios in disaster

drills for hospitals that have been designated in State or local

disaster plans to receive patients exposed to chemical warfare agents.

2. Triage Considerations

Do not allow patients exposed to a chemical warfare agent

to enter the emergency department without adequate evaluation and

decontamination. Signs of mustard agent exposure, in particular, may

require 24-48 hours before they become clinically evident.

Train medical staff designated by the hospital disaster

plan to perform triage during an emergency related to chemical warfare

agents to recognize the physical signs and symptoms of patients who

have been exposed to such agents.

Base modifications to patient triage procedures on the

extent of patient contamination, the type of chemical warfare agent to

which the patient has been exposed, the patient's clinical status, and

the possibility of additional traumatic injuries. Priorities for

medical treatment of patients should be determined by the most

appropriately trained and experienced medical professional.

3. Security

Address issues related to emergency department security

during disasters in the hospital disaster plan.

Restrict access to the hospital to prevent contaminated

patients from entering the hospital. During a chemical agent release,

security personnel should direct all patients to enter the hospital

only through the triage area.

4. Decontamination

Decontaminate all persons who may have been contaminated

with a chemical warfare agent. Proper decontamination prevents

secondary contamination and chemical injury to medical and rescue

personnel. Acceptable decontamination guidelines for persons exposed to

chemical warfare agents are published by FEMA and DA (3,4).

Have decontamination substances readily available.

Suitable decontamination substances include soap, water, and 5%

hypochlorite.

In the hospital disaster plan, detail a method for

catching contaminated runoff from patients whether decontamination is

done inside or outside the hospital.

At a minimum, be capable of decontaminating at least one

nonambulatory patient.

During and after chemical agent releases that cause mass

casualties, decontaminate patients outdoors. Having indoor

decontamination facilities does not obviate a hospital's need to have

plans for decontaminating patients outdoors during mass casualty

situations.

Design hospital disaster plans, keeping in mind the

possibility of integrating local emergency response resources. Such

resources could include hazardous materials emergency response teams or

portable decontamination vehicles or facilities.

In cold weather, set up temporary shelters and heaters to

protect patients from extreme environmental conditions when undergoing

decontamination outdoors.

Have in place a method of controlling the flow of air in

the decontamination area to prevent such air from contaminating other

areas of the hospital.

Set up a system to allow medical personnel in the

decontamination area to be in continuous communication with other

medical personnel in the emergency department.

5. Personal Protective Equipment (PPE)

Chemical protective clothing and respiratory protection enable

responders to care for chemically exposed patients while protecting

themselves from secondary contamination. This equipment must protect

the skin, eyes, and respiratory tracts of the responders.

Use DA BDOs and PAPRs with organic vapor cartridges to

protect civilian personnel against chemical warfare agents. The BDO can

be used in an agent-contaminated environment for up to 24 hours at

contamination levels of up to 10 grams of agent per square meter of

surface area.

Have hospital personnel follow Environmental Protection

Agency (EPA) and National Institute for Occupational Safety and Health

(NIOSH) guidelines when managing patients exposed to unknown chemicals.

Have hospital emergency responders use the equipment with

which they are most familiar, providing that such equipment is at least

as protective as the equipment recommended by CDC.

Train response personnel to use PPE when responding to a

chemical agent emergency according to OSHA guidelines (2).

6. Level of Training

Train medical staff designated by the hospital disaster

plan to provide direct patient care during a chemical warfare agent

emergency to a level of medical preparedness that allows them to

assess, decontaminate, and manage the treatment of victims of chemical

warfare agent releases.

Medical staff who are required to wear decontamination

attire in decontamination procedures must receive training in the use

of PPE according to OSHA regulations (2-4).

7. Transportation of Patients to Other Medical Facilities

Have prearranged written agreements with those medical

facilities that agree to accept patients who are exposed to military

chemical agents.

Do not transfer patients without notifying the hospital

and having the patient accepted by a physician.

Have standardized forms available to record patient

information and management status.

8. Specific Antidotes

Have decontaminating solutions available in the emergency

department. If nerve agents are stored adjacent to the civilian

community, have atropine in multiple-dose units available in the

emergency department and in the hospital pharmacy. In addition, have

the hospital pharmacy stock atropine and pralidoxime in sufficient

quantities to cope with the anticipated number of patients who could be

managed by that facility in response to a chemical warfare agent

release. Atropine and pralidoxime should be administered intravenously

in the emergency environment.

9. Hospital Disaster Plan

Include plans for providing medical care for patients

exposed to chemical agents in the hospital's disaster plan.

Have in place a method for using the emergency

communication system so that reports of a chemical warfare agent

release can be verified rapidly. Also include provisions to coordinate

activities with State and local disaster plans for mass

decontamination.

Include in disaster drills scenarios in which patients

have become exposed to chemical warfare agents.

Use the hospital quality assurance program to review

disaster drills and decontamination procedures and to assist in

maintaining the professional skills of hospital personnel necessary to

treat the effects of exposure to a chemical warfare agent.

10. Tertiary Hospitals

A tertiary receiving hospital is a hospital that receives referrals

from primary receiving hospitals. Additional services such as burn

care, psychiatric service, and toxicologic consultation are available

at the level of care.

Ensure that tertiary hospitals designated by State or

local disaster plans to provide care for persons exposed to chemical

warfare agents have, at a minimum, emergency response capabilities

similar to those of the primary receiving hospital.

Ensure that tertiary hospitals coordinate their disaster

plans with State and local disaster plans for mass decontamination of

persons exposed to chemical warfare agents.

V. References

1. National Research Council. Disposal of Chemical Munitions and

Agents. National Academy Press, Washington, DC, 1984.

2. Occupational Health and Safety Administration--Hazardous Waste

Operations Emergency Response, Washington DC: OSHA Instruction 2-

2.59, 29 CPL 1910.120, paragraph (q), 1993.

3. Federal Emergency Management Agency and the Department of the

Army. Planning Guidance for the Chemical Stockpile Emergency

Preparedness Program. Washington, DC, November 25, 1992.

4. United States Army Medical Research Institute of Chemical

Defense. Medical Management of Chemical Casualties. Aberdeen Proving

Ground, MD, September 1992.

5. Dunn, M., Sidell, F. Progress in medical defense in nerve agents.

JAMA 1989;262:649-52.

6. Borak, J., Sidell, F. Chemical warfare agents: sulfur mustard.

Ann Emerg Med 1992;21:303-8.

7. Sidell, F., Borak, J. Chemical warfare agents: II. nerve agents.

Ann Emerg Med 1992;21:865-71.

8. Wright, P. Injuries due to chemical weapons. Br Med J

1991;302:39.

9. Sidell, F. What to do in case of an unthinkable chemical warfare

attack or accident. Postgrad Med 1990;88:70-84.

10. Moneni, A. Skin manifestations of mustard gas: a clinical study

of 535 patients exposed to mustard gas. Arch Dermatol 1992;128:775-

80.

11. Smith, W. Medical defense against blistering chemical warfare

agents. Arch Dermatol 1991;127:1207-13.

12. Tafuri, J. Organophosphate poisoning. Ann Emerg Med 1987;16:193-

202.

13. Merril, D. Prolonged toxicity of organophosphate poisoning. Crit

Care Med 1982;10:550-1.

14. Merrit, N. Malathion overdose: when one patient creates a

departmental hazard. J Emerg Nursing 1989;15:463-5.

Dated: July 21, 1994.

Joseph R. Carter,

Acting Associate Director for Management and Operations, Centers for

Disease Control and Prevention (CDC).

Appendix A Summary of Important Medical Preparedness Considerations for

Communities Surrounding Chemical Agent Stockpiles

1. Do the communities that surround chemical warfare agent depots

have a disaster plan that details the role of the prehospital and

hospital medical community during a chemical warfare agent

emergency?

2. If medical personnel are designated to treat chemical warfare

agent casualties, do they have adequate training to meet minimal

standards for evaluating, decontaminating, and treating victims of a

chemical warfare agent release?

3. Do medical personnel who are designated by State, local, and

hospital disaster plans to use PPE in response to an emergency

related to chemical warfare agents have the necessary OSHA level of

training to use these devices effectively and safely?

4. If the local disaster plan has provisions to evacuate or transfer

patients to other hospitals for further treatment and evaluation, do

existing MOUs cover the transfer of chemically contaminated

patients?

5. Do hospitals named in the State or local disaster plans have an

adequate stockpile of antidotes and decontamination solutions to

provide complete medical treatment to at least one chemically

contaminated patient?

6. Are hospitals named in the State or local disaster plans able to

decontaminate at least one nonambulatory patient exposed to chemical

warfare agent?

7. Do the disaster plans of hospitals named to receive patients by

State and local disaster plans have specific provisions which detail

how they will control access to their medical facilities during a

chemical warfare agent emergency?

8. Are all levels of the medical community that are designated by

State or local disaster plans to respond to a chemical warfare agent

emergency able to communicate via either the State or local disaster

communication network?

Appendix B

Working Group Participants

Mr. Lawrence Gallagher, Associate Director, Plant Technology and

Management, Joint Committee on Accredited Hospitals Organization

Mr. Kenneth Gray, Fire Chief, Confederate Tribes of the Umatilla

Indian Reservation

Mr. Howard Kirkwood, Jr., Chief, Emergency Response Services, Oregon

Department of Human Resources

Mr. Denzel Fisher, Emergency Preparedness Officer, Headquarters,

Department of the Army

John A. Grant, M.D., M.P.H., Health Officer, Kent County Health

Department

Deborah Kim, M.S.N., R.N., Trauma Coordinator, University of Utah

Medical Center

Ms. Laurel Lacy, Acting Chief, Chemical Stockpile Branch, Federal

Emergency Management Agency

Howard Levitin, M.D., F.A.C.E.P. Emergency Staff Physician St.

Francis Hospital

Carole A. Mays, M.S., R.N., C.E.N., Clinical Nurse, Saint Joseph

Hospital

Captain Jeff Rylee, Hazardous Materials Coordinator, Salt Lake City

Fire Department

Matthew Rice, M.D. J.D., Chief, Department of Emergency Medicine,

Madigan Army Medical Center

Mr. Allen Short, Health Department Emergency Coordinator, Utah

Department of Health

Yehuda L. Danon, M.D., Director, The Children's Medical Center of

Israel

Frederick Sidell, M.D., Commander USAMRICD

Henry J. Siegelson, M.D., F.A.C.E.P, Clinical Assistant Professor,

Emory University School of Medicine

Stephen B. Thacker, M.D., M.Sc., Acting Director, NCEH, CDC

Ms. Linda Anderson, M.P.H., Chief, Special Programs Group, NCEH, CDC

Sanford Leffingwell, M.D., M.P.H., Medical Director, Special

Programs Group, NCEH, CDC

Vernon N. Houk, M.D., Assistant Surgeon General, NCEH, CDC

Mr. Thomas E. O'Toole, M.P.H., Deputy Chief, Special Programs Group,

NCEH, CDC

Scott Lillibridge, M.D., Medical Officer, Div. of Env. Hazards and

Health Effects, NCEH, CDC

Mr. Harvey Rogers, M.S., Environmental Engineer, Special Programs

Group, NCEH, CDC

Ms. Sharon Dickerson, M.P.A., Program Specialist, Special Programs

Group, NCEH, CDC

Henry Falk, M.D., M.P.H., Director, Div. of Env. Hazards and Health

Effects, NCEH, CDC

Jose Cordero, M.D., M.P.H., Deputy Director, National Immunization

Program

Eric Noji, M.D., M.P.H., Chief, Disaster Assessment & Epi. Section,

Div. of Env. Hazards and Health Effects, NCEH, CDC

[FR Doc. 94-18274 Filed 7-26-94; 8:45 am]

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