Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents Interim Report on Current Capabilities (1998) / Chapter Skim
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2 Current Civilian Capabilities
2 Current Civilian Capabilities
Pages 15-48
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From page 15... ...
would, in most instances, be initiated by law enforcement and fire and rescue personnel, including at some point medical personnel and a hazardous materials (Hazmat) team.
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~m mmm ~m m m m m Ct .O _ O ._ m _ Ct ._ a~ ~S C: Ct C)
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In cases of suspected biological or chemical terrorism CDC itself can consult with several DoD medical research units specializing in biological or chemical defense and with experts at academic institutions and research institutes. Other DoD organizations may provide advice and assistance with bomb disposal and decontamination, and under some circumstances a new United States Marine Corps unit called the Chemical Biological Incident Response Force (CBIRF)
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DETECTION AND MEASUREMENT OF AGENTS IN THE ENVIRON1\dENT Rapid identification of the chemical or biological agents involved in any Hazmat incident is vital to both the protection of first responders and emergency medical personnel at local medical facilities and to the effective treatment of casualties. This section of the report briefly describes a number of devices that can be used for that task.
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Chemical Agents Hazmat teams are routinely equipped with a variety of chemical detectors and monitoring kits, primarily chemical-specific tests indicating only presence or absence of the suspected chemical or class of chemical (a negative test means only that a specific substance is not present in significant quantity; a positive response says nothing about the possible presence of other hazardous agents)
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Minimum levels detectable are about 100 times the ALL for the nerve agents and about 50 times the AEL for vesicants. An obvious drawback to this relative insensitivity to low concentrations is an inability to fully check the efficacy of decontamination efforts, both in the field and subsequently at treatment facilities.
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~ , PERSONAL PROTECTIVE EQUIPMENT (PPE) Chemical Agents The term PPE refers to clothing and respiratory gear designed to shield an individual from chemical, biological, and physical hazards.
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has incorporated the ASTM test battery into now widely accepted standards for protective suits for hazardous chemical emergencies. A basic rule in selecting PPE, however, is that the equipment be matched to the hazard, and none of the ASTM permeability tests employ military nerve agents or vesicants.
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From page 23... ...
. Ordinary clothing and gloves generally provide sufficient protection against cutaneous infection; intact skin itself is a formidable barrier to most biological agents, although T-2 mycotoxin is a significant exception and decontamination procedures similar to those for chemical agents should be employed if T-2 exposure is suspected (Wannamacher et al., 1991; Wannamacher and Wiener, 1997)
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METHODS FOR RECOGNIZING SIGNS AND SYMPTOMS IN VICTIMS/PATIENTS Emergency medical personnel, both at the scene of a hazardous materials incident and at hospital emergency departments, have a wide selection of reference materials to call upon for guidance in patient management. These include traditional textbooks, handbooks such as the three-volume set of medical managment guidelines prepared by the Agency for Toxic Substances and Disease Registry (United States Department of Health and Human Services, 1994a)
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From page 25... ...
This is an area where preincident intelligence could have a major impact in reducing the number of casualties. DETECTION AND 1\IEASUREMENT OF AGENT EXPOSURE IN CLINICAL SAMPLES FROM PATIENTS Chemical Agents Nerve Agents Persons exposed to high concentrations usually develop signs and symptoms within a matter of minutes after exposure.
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From page 26... ...
Biological Agents Just as with victims of chemical agents, initial treatment of those exposed to biological agents will focus on signs and symptoms. The variable and often substantial delay between exposure to a biological agent and the onset of clinical signs and symptoms, as well as the possibility of person-to-person transmission, makes rapid and accurate diagnosis important even if treatment of the earliest patients cannot be guided by laboratory findings.
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From page 27... ...
METHODS FOR RECOGNIZING COVERT EXPOSURE OF A POPULATION In the case of biological agents, because the time delay between exposure to a pathogen and the onset of symptoms may be days or weeks, effective response to a covert terrorist action will be critically dependent upon the ability of individual clinicians, perhaps widely scattered around a large metropolitan area, to identify and accurately diagnose and effectively treat an uncommon disease, a surveillance system for collecting reports of such cases, and a person or program actively monitoring the system for disease outbreaks. The CDC operates a large number of infectious disease surveillance systems.
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In addition, no federal funds are provided to state and local health departments to support this system, and the ability or willingness of the states to support infectious disease surveillance has declined in recent years (a 1993 survey, for example, indicated that 12 states had no professional position dedicated to surveillance of foodborne and waterborne diseases) (Council of State and Territorial Epidemiologists, 1993, as cited in Centers for Disease Control and Prevention, 1994a)
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From page 29... ...
The regional poison control center (PCC) serves as a surveillance system for recognizing covert poisoning with chemical agents or biological toxins, although in most of the chemical terrorism scenarios imaginable, the rapid onset of toxic effects will lead to a highly localized collection of victims in a time frame of minutes to hours.
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During a response to a covert or overt act involving chemical or biological terrorism, knowledge of the effects and treatment of nerve agents and vesicant weapons by personnel at the scene is currently likely to be highly variable, unless training and preincident information have been provided. Presently, hospital staff are likely to be familiar with triage procedures oriented to trauma rather than poisoning.
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The CBTRF and MMST have much larger shower units, capable of decontaminating dozens to hundreds of victims with hypochiorite solution, and are staffed at much higher levels than local Hazmat teams. Harsh weather, intrusive media, and the willingness of ambulatory patients to disrobe in less than private surroundings will also affect the conduct of field decontamination.
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Many communities do not have Hazmat teams readily available. In some places a hazardous materials incident may not be recognized as such until patients have already been transported.
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Treatment of considered in this report is not so time are Ames at acing collection of efficacy data and do not directly address the masscasualty situation, especially for terrorist acts involving chemical and biological agents. FDA recognized the difficulty IND status presented in potential mass-casualty situations during the Persian Gulf War and passed an interim rule waiving the requirement for the United O ~ .
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. Nerve agents act by binding to the enzyme acetylcholinesterase, thereby blocking its normal function of breaking down the neurotransmider acelylcholine following its release at neuronal synapses and neuromuscular junctions throughout the peripheral and central nervous systems.
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pesticides are widely used throughout the United States, and poisoning is not uncommon (Litovitz et al., 1997~. Treatment is identical to that for nerve agents, and as a result, many emergency medical teams and most hospital emergency departments have some familiarity with diagnosis and treatment of OP poisoning and have access to limited supplies of atropine and pralidoxime.
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From page 36... ...
Cyanide is metabolized more readily than the other chemical agents, and as a result, if the initial dose is not so large as to kill the victim within minutes, supportive therapy may be sufficient for full recovery in a matter of hours. Amyl nitrite, sodium nitrite, and sodium thiosulfate are commercially available in standard doses in the Pasadena Cyanide Antidote Kit (formerly the Eli Lilly Cyanide Antidote Kit)
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Although the stockpile is not intended for civilian use, the Department of Defense has approximately seven million doses in cold storage, one million of which are bottled and ready for use (DanIey, 19971. Postexposure Therapy Penicillin is recommended for treatment of inhalational anthrax, but tetracycline, erythromycin, and chIoramphenicoT have been used with success (Freidiander, 19971.
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Postexposure Therapy According to Franz et al.
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Postexposure Therapy The most common treatments for Q fever are tetracyclines. Macrolide antibiotics, such as erythromycin and azithromycin, are also effective.
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Regardless of route of transmission, clinical manifestations begin with fever, malaise, headache, and vomiting, and the infection is a systemic one that produced mortality rates of 20 to 30 percent in unvaccinated populations (McClain, 1997~. Preexposure Prophylaxis Individuals who were vaccinated during the WHO smallpox eradication campaign throughout the 1970s were considered to have immunity to smallpox for at least 3 years, but protection diminishes over time.
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Antimosquito precautions should also be implemented. Viral Hemorrhagic Fevers Viral hemorrhagic fever is a term indicating an acute febrile illness accompanied by circulatory abnormalities and increased vascular permeability.
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From page 42... ...
is usually adequate to prevent transmission of Ebola, Lassa, CCHF, and other hemorrhagic fevers, but isolation of the patient provides an added measure of safety and is preferred, if facilities are available. Disinfection of bedding, utensils, and excrete by heat or chemicals is recommended for all of the viral diseases under consideration.
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Postexposure Therapy Because there is no approved antitoxin, therapy is currently limited to supportive care focused on reductions of fever, vomiting, and coughing. Respiratory symptoms may follow exposure to aerosolized SEB, and mechanical ventilation may be necessary.
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Preexposure Prophylaxis Although preclinical testing in animals has encouraged the US Army to submit an TND application to the FDA for a formalin-treated toxoid immunization, no human testing has been conducted, and no vaccine is available for clinical use. Postexposure Therapy Activated charcoal ravage may be helpful immediately after ingestion of castor beans or ricin, but ricin acts rapidly and irreversibly, which makes treatment very difficult after signs and symptoms appear.
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From page 45... ...
In the case of terrorism, particularly when the aggressor is unknown, a potentially beneficial expression of anger cannot be directed at the appropriate source, producing a futile sense of helplessness, depression, demoralization, and hopelessness. At the acute stage of the aftermath of a biological or chemical terrorist attack, acute autonomic arousal and panic may result in both the victims and the emergency responders (hazmat teams, police, fire, medical)
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At the federal level, the National Disaster Medical Service (NDMS) includes Disaster Medical Assistance Teams with a focus on mental health.
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CURRENT CIVILIAN CAPABILITIES 47 determine whether these or other cities have prepared information packages of their own for use in informing the press and the public in the event of a terrorism incident, but such preparation will surely be necessary if public officials are to maintain the confidence of a community deluged with information of widely varying accuracy in the news media and, increasingly, on the internet.
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