Toxicological aspects of preparedness and aftercare for chemical-incidents

Toxicology 214 (2005) 232–248

Toxicological aspects of preparedness and aftercare for chemical-incidents Michael Schwenk ∗ , Stefan Kluge, Hanswerner Jaroni Landesgesundheitsamt, Wiederholdstr, 15, 70174 Stuttgart, Germany Available online 22 August 2005

Abstract The threat of using chemical warfare agents still exists despite the 1993 Chemical Weapons Convention. Preparedness for attacks with chemical agents has become an important issue of national security programs. It can be anticipated that toxicologists will be increasingly involved in preparedness programs of their institutions and of the government, no matter whether they work in agencies, industry or universities. Toxicologists must get prepared to give fast and reliable advice in the case of an attack, a sabotage or an accident with release of toxic chemicals. They should be familiar with the principles of hazard management and with incident command structures and cooperate with first responders of other organizations involved such as fire department and medical emergency teams already in the planning phase. In the emergency planning phase, toxicologists are expected to help identifying possible hazards. Moreover, they consult public health services with regard to toxicosurveillance and advice hospitals regarding antidotes, decontamination procedures and shelters. They may be involved in the procurement of antidotes and of protective equipment and will support qualified analytical laboratories. In the response phase, toxicologists must be ready to gain and to interpret analytical data, to support the medical care of poisoned victims and to provide repeated risk assessment reports. This requires an on-scene access to databases and registries. The aftercare phase includes the identification of exposed persons, mapping of contaminated areas, organization of decontamination measures and the release of areas. A medical study may be initiated to observe long-term health effects. Good cooperation between regulatory and clinical toxicologists, specific education of toxicologist in the field of chemical emergencies and regular trainings are essential elements of good preparedness. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Chemical warfare; Emergency planning; Preparedness; Stockpiling; Toxic agent

1. Introduction Since the end of the cold war and the subsequent reduction of civil defense measures in many countries, national and international crisis scenarios have changed (Tzihor, 1992; Fong, 2003; Moores and Moores, 2004). Terrorism and criminal activities achieved a whole

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Corresponding author at: In den Kreuz¨ackern 16/1, 72072 T¨ubingen, Germany. E-mail address: [email protected] (M. Schwenk).

new quality after incidents like the Sarin attack on the Tokyo subway in 1995, repeated assaults on the World Trade Center in New York culminating in its destruction on September 11, 2001 and the subsequent dissemination of anthrax-letters. This novel dimension of threat is well described in the 9/11 commission report (Government, 2004). At the same time, the fireworks accident at Enschede (Netherlands) and the explosion at a fertilizer plant in Toulouse (France) also made clear, that there were severe safety gaps to overcome in chemical-incident management (van Walsum et al., 2001; Commission, 2003; Dechy et al., 2004).

0300-483X/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.tox.2005.06.016

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The destructive potential of biological, nuclear or conventional incidents may exceed those of chemicalincidents (Bismuth et al., 2004). Nevertheless, the latter are also highly relevant, since highly poisonous chemicals may have a considerable impact on the health status, infrastructure and public order of a country (Moores and Moores, 2004), even if released in only limited amounts. Beside the imminent threat of chemical agents having proliferated among the terrorist or criminal field, acts of terrorism might also occur in the form of a toxic industrial chemical release (Small, 2002), e.g. when industrial plants, stocks or transports become a target of terrorist attacks. In this context, a large number of dangerous chemicals and chemical mixtures might be of relevance, including those used in agriculture and medicine. Combustion products have also to be considered. Besides, in the case of sabotage, a criminal background will often not immediately become clear. After the attack on the world trade center on 9/11, many countries became aware, that preparedness for this kind of disaster so far had been insufficient. As a consequence, there have been extensive efforts and numerous recommendations to improve disaster management structures. It also has been recognized, that experts for nuclear, biological and chemical emergencies were needed to participate in emergency teams. Thus, in case of a chemical-incident, the toxicologist will be expected to be capable of giving fast and reliable advice. His expert opinion in these situations may have far-reaching consequences not only with respect to health and safety of affected persons but also as far as the reputation of his institution is concerned. In the future, more toxicologists will be involved in crisis planning processes, no matter whether they are clinical toxicologists, research-oriented toxicologists or toxicologists who work for an agency. High priority should be put on the need for toxicologists to be trained to cooperate with the incident command structures and educated in toxicological aspects of emergencies. The present contribution focuses on these aspects of preparedness and aftercare. Much of the information on chemical weapons and preparedness was published in government reports and commission papers. Examples are the WHO guidance on public health response (WHO, 2004), the textbook of the US army (Sidell et al., 1997), the documents on public health preparedness of the US Center of Disease Control (CDC, 2002a, 2002b), the OPCW-documents and the FOA briefing book on chemical weapons (FOA, 1992) or the documents of EMEA on antidotes (EMEA, 2003), which are altogether available on the Internet. There are many valuable websites such as the official website of the

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US Department of Homeland Security and the Federal Emergency Management Agency which contain useful training material for the community emergency response teams (FEMA, 2003). Although the topic is also discussed in scientific journals, contributions herein usually are less systematic and detailed. 2. Principles of disaster management 2.1. Toxicologically relevant hazards Chemical emergencies can arise from natural disasters (e.g. volcano emissions, forest fires), technological accidents (e.g. blast of a chemical factory), major transportation accidents (e.g. chemical spill) or acts of terrorism, sabotage and crime (e.g. attack on a chemical transport). Although chemical weapons are in the focus of the present discussions, highly toxic industrial chemicals also have to be taken into account, as they might be released in the course of an accident, attack or sabotage. 2.1.1. Classification of hazards Hazards can be classified according to their threat potential in the following manner: Emergency: A situation, that requires immediate rescue operations. Accident: A sudden event due to external causes, damaging persons and/or property. Multiple casualty incidents: An emergency, resulting in a large number of injured or sick persons. The number of harmed individuals can be managed with the available human and material resources. Disaster: A natural or manmade incident that exceeds the capabilities of the local response resources. Assistance is required from surrounding communities, statewide or even across national borders. 2.1.2. Risk levels of hazardous situations Some hazards can be foreseen, such as an announced assault, while others can not at all be anticipated, e.g. a covert terror attack. In the first case, the responsible authorities will upgrade the risk response level before the incident even occurs and, at the same time, will try to prevent it and prepare for a worst case scenario. In the latter case, however, the incident will occur without early warning, which means that all response measures must be merely reduced to rescue operations. Threat analysis is a multidisciplinary activity, involving lawenforcement, intelligence and medical as well as scientific communities (WHO, 2004).

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2.1.3. Jurisdictions Depending on the national legislation, emergencies are to be regulated by different agencies: military threats are to be handled by the military forces of the country and its allies, whereas the law-enforcement institutions are in charge of all kinds of criminal threats. Civil incidents are usually managed by either the fire department or police department, which then need to cooperate with emergency medical services and units of civil defense. Terrorist attacks will be managed by all three of the above described administrative sectors, if necessary supported by the national emergency response center. 2.2. Incident command Typically, emergency management is organized in a hierarchical manner (Schools, 2003; Government, 2004) and should have a clear command structure (EPA, 2004). In case of minor events, which do not require more than one decision maker, a local incident commander will be appropriate; the command will most likely be assigned to the chief of the local fire brigade. However, with increasing severity of the incident, emergency management becomes more and more complex. In severe situations like disasters, a more elaborate command structure will be needed. Headed by political representatives of all governmental levels, who will be in charge of coordinating all responsive actions, the total supervision lies with a governor, a district administrator or a mayor. He/she is responsible for the overall success and safety of the response. This includes the emergency notification procedure (i.e. activation and termination of the emergency alert), the specification of the emergency area and the nomination of the technical head of services. He/she has the authority to make key decisions and determine when and how the public is to be informed. In fulfilling these tasks, he receives administrative support from the command staff. Also, he is advised by a safety officer and a medical officer, who have top supervisory function for human safety and health and who may even pass over the ordinary chain of command when performing their medical functions. 2.2.1. Tactical levels The command level coordinates the tasks of the tactical level, which may be split into sections such as: operation, planning, logistics and finance (Fig. 1). The tactic level also has organizational tasks such as the deployment of assigned personnel or the implementation of a communication network. In the 9/11 disaster, the leading response agency was the New York Fire Department, while all the other responding local, federal, and

Fig. 1. General command structure in emergency response (example).

state agencies acted in a supporting role (Government, 2004). Situations may arise, which require first responders and their tactical level to react and take decisions before the upper command level becomes active. In this context, they might also be confronted with contradictory information. As a result, permanent checking of the status and adaptation of the response, i.e. high flexibility and the ability to change tactics are essentials of good management. 2.2.2. Technical specialists, toxicologists Technical specialists should be integrated at all levels of the management structure. For toxicologists there are various tasks. As consultants of the medical officer and safety personnel, they may closely cooperate with the command team. As clinical toxicologists, they will be affiliated to the medical emergency team of the operation section. As experts for risk assessment, they might be integrated in the risk assessment group of the planning section or in the food, housing or transport group of the logistics section. They also might consult the financial section on important issues concerning the costs of analytics, decontamination, etc. The toxicologist should be nominated in advance, based upon his specialized knowledge. He also should regularly consult the emergency management staff even in the planning phase. Due to his expertise, he is expected to analyze a chemical hazard from his technical viewpoint, forecast the situation, analyze chances and limitations of possible countermeasures and look after the protection of the operation staff and victims. 2.2.3. Role of military experts Over the years, military experts have been gathering a unique expertise in the area of NBC-weapons. Particularly military toxicologists have been able to

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achieve profound and specific knowledge on chemical warfare agents and the respective analytics. Since chemical weapons had been banned in most countries, all scientific and practical experiences have been restricted to merely defensive aspects, focusing on the detection and destruction of these agents or on the protection and medical treatment principles in case of a chemical attack. Due to their highly specialized knowledge, technical equipment and support, military toxicologists assume a nationwide function in incidents with chemical warfare agents (Marghella, 2002), even though in some countries, their engagement in civil disasters is restricted by law. 2.2.4. Deficiencies In the past, conflicts on the command level due to divergent aims or interpretations have been frequently observed. Conflicts can also emerge on the operative work level, especially if responsibilities of representatives of the civil defense, law-enforcement, firemen, public health departments, veterinary agencies, environmental agencies, etc. are overlapping. For example it might occur, that experts of the fire department use a decontamination method, which the clinical toxicologist considers to be ineffective or to even worsen the outcome. All in all, there is general agreement on the fact, that there is a need for better harmonization and that conflicts of this kind should be reduced by conducting joint trainings, thereby moving towards a better technical preparedness. 3. Emergency planning principles 3.1. Risk reduction strategies In the course of crisis planning, different scenarios for accidents and attacks have to be worked out considering the following five phases of an anticipated crisis: prevention/mitigation, preparedness, response, recovery and aftercare (Fig. 2). Each one of these phases must be explicitly addressed within the crisis plan. The primary planning aim should be to reduce the likelihood of incidents. To achieve this aim, safety management systems have primarily been introduced to those facilities, which bear a high risk (e.g. chemical plants). A further purpose of crisis planning is the intention to be able to mitigate the consequences of an incident and to avoid insufficient emergency management in case of a disaster. Complying with these principles forms the basis for a controlled and ordered provision of the technical expert teams required within the least possible time. In general, crisis plans and emergency management structures should be developed during emergency-free periods and need to be updated in

Fig. 2. Steps of crisis management.

a continuous process. The whole process must be supervised by an assigned authority (FEMA, 2003; Schools, 2003; EPA, 2004; WHO, 2004). 3.1.1. Government plans and installation plans There are two different branches of crisis planning, the emergency planning of individual installations including public utilities and the disaster planning of the government. Emergency planning for individual installations, such as chemical plants, office buildings or schools mainly has the aim to reduce the risk of an incident within a restricted area. For this first sector, the head of the facility assumes full responsibility. Based on a prior hazard analysis, the crisis plan that has to be generated should include characteristic scenarios varying from small-scale incidents with low number of injured to large incidents, which affect the entire facility or even the neighboring community. In many countries there is a special obligation for all facilities, which produce, store or transport dangerous chemicals to provide this kind of plans. In their safety analysis, the possibility of external damage has to be taken into consideration. Guidelines concerning the communication with authorities and the public (e.g. with regard to protective measures) as well as specific rules for the reporting of accidents have to be considered too. The crisis plan should be developed in cooperation with different expert groups, including law-enforcement, fire safety, emergency medical services, toxicologists as well as health and mental health professionals. In this context, it is extremely important to become acquainted with the technical terms, command structures and background of all these different groups. In addition, the mutual recognition of each other’s spheres of competence is vital for productive work. Early warning procedures, training of first responders, organization of protective equipment

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Fig. 3. Internal and external emergency plans according to the Seveso II Directive.

and shelters as well as evacuation plans must be worked out. Generally, the internal plans of an installation (protection of the establishment) must be supplemented by corresponding external plans (protection of the public and environment) (Fig. 3), as described in the Seveso II Directive, which regulates all issues associated with chemical accident prevention, preparedness and response in the European Union (Commission, 2003). In contrast, governmental emergency planning is part of domestic preparedness, civil defense or homeland security. It has the aim to protect the national security and infrastructure at all levels, including energy, water and food supplies. Its high complexity originates from the involvement of different authorities (e.g. departments of the interior, energy, transport, environment, . . .), which often have divergent interests and regulations. This is the reason why networking with individual facility emergency planning structures is often found to be unsatisfactory. In order to decrease this conflict potential, it has been suggested to harmonize legal norms and standard procedures. Moreover, the basis for the coordination of local emergency planning of individual installations with governmental structures have to be worked out. Most importantly, there should be a clear structure in the decision making process and the flow of information. The whole planning process should be coordinated by one authority such as the Department of the Interior. Scenarios have to be developed which include chemical

attacks on densely populated areas and highly frequented places, such as railway stations, airports, sporting events, etc. As far as chemical attacks are concerned, States Parties to the Chemical Weapons Convention have access to international aid in their preparedness activities. Early and precise information of the public by the news media, such as TV and radio is essential for a smooth crisis management. Trained media professionals should be included in the process. They should coordinate their information with the command management and the specialists. 3.1.2. Role of toxicologist A toxicologist involved in the planning process should make early efforts to understand the structure of the emergency response team as a whole as well as the individual role of each one of its participating partners. He should be integrated in the crisis planning team at an early stage, and should be aware of his own responsibilities. To achieve this aim, he should participate in regular exercises, drills and training sessions. One of his primary tasks will be to help to identify and catalogue potential sources of chemical hazard and estimate the risk. Generation of suitable rescue plans which take into account the expected distribution characteristics of the chemical agents and their toxicological profiles belong to his further duties. He should also perform advisory function concerning the development of plans for stockpiling of

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Fig. 4. Tasks of the toxicologist in planning, response and aftercare.

antidotes and protective equipment. As a medical expert he should actively contact his colleagues from health departments, hospitals and related facilities in his area (Fig. 4). 4. Preparedness of health institutions and toxicologists 4.1. Preparedness of public health service The public health service is responsible for all aspects of public health protection. It monitors the health status of the population and advises other agencies with regard to public health consequences of an incident. Usually, it assumes a key role in the medical management of disasters. It should cooperate with the emergency medical services and other technical experts, such as toxicologists, microbiologists, veterinarians and epidemiologists, as well as with hospitals, pharmacies and physicians of the respective area. Within the scope of emergency planning, the public health service has to ensure its permanent readiness to coordinate the above-mentioned activities. Routine, sensitive and near-real-time disease surveillance systems are considered essential not only to detect outbreaks of infectious diseases, but also to detect effects of subacutely acting chemicals (Vries et al., 2004; Watson et al., 2004; WHO, 2004). When several persons are exposed to a chemical agent in a public place like a railway station, they will spread to different places, where they fall ill. In such cases, a toxicosurveillance system will facilitate the detection of the common cause. A summary of relevant tasks of the public health agency is provided in a checklist of the Center of Disease Control (CDC, 2002a, 2002b).

4.2. Preparedness of hospitals and treatment centers Emergency plans of hospitals have to be constantly adapted to the actual threat scenarios (Wetter et al., 2001). In order to ensure the provision of adequate medical care to chemically (as well as biologically or radiologically) injured and contaminated persons, practical care plans have to be worked out (Shapira et al., 1991; Lyons, 1999; Tur-Kaspa et al., 1999). This should be done by all hospitals in a standardized manner. Each hospital has to provide a reasonable number of intensive care beds while still leaving the option for an expansion on short notice. Their actual capacities should routinely be reported to the emergency management headquarters. Additionally, each hospital has to provide an area, where decontamination measures can take place. An adequate amount of medical assets must be stockpiled. The medical staff should regularly be trained in terms of the management of chemically contaminated and intoxicated patients and the use of personal protection equipment. Physicians and nurses must be familiar with the existing emergency response plans, too. Altogether, these preventive measures will put a considerable burden on hospitals and their medical staff. In medical emergency cases, a shortage of medical personnel may arise. It has therefore been suggested that all non-medical helpers of a hospital should acquire basic knowledge of emergency medicine, which will allow them to assist in providing basic medical care to injured persons. Furthermore, the implementation of hospital guidelines helps to better coordinate the cooperation between the medical staff and non-medical helpers. Notably, their applicability has to be tested in advance.

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4.3. Preparedness of poison centers, competence centers and networks Poison centers have the routine task to advise physicians and patients in the case of an acute intoxication. They are integrated in a WHO-managed network (IPCSINTOX) and are organized in international and national associations of clinical toxicologists and poison centers. They have immediate access to confidential information on the composition of chemical products. For this reason, poison centers have been suggested to be the agencies of choice in the management of chemical disasters (including toxin poisoning), since they are familiar with both the diagnosis and the contemporary therapy of intoxications. In addition, they are prepared to act instantaneously on the basis of a 24-h duty. Thus, poison centers may assume different important functions in the surveillance, recognition, and treatment of victims of chemical terrorist attacks as well as assisting function in the development, implementation, and procurement of pharmaceutical stocks (including antidotes) for cases of emergency (Krenzelok et al., 2000; Mrvos et al., 2003). Some governmental agencies have direct access to toxicology units, which may be subdivisions of state health departments, state laboratories or risk evaluation units. In assuming their functions, these toxicology units will often be an institutional member of the emergency operation team. An example for this kind of organizational structure can be found in the state of Baden-Wuerttemberg (South-West Germany). In connection with its anti-terror program, this state has established a so-called “health protection” competence center. This center is integrated in the State Health Department and is designated to support the local public health departments as well as other state agencies during an imminent hazard (e.g. biological or chemical terror threats). Performance of risk analyses and risk assessment belongs to its original tasks. It also gives recommendations regarding protective and therapeutic measures. The toxicology section of the competence center is part of a developing national expert network. It maintains a database on highly toxic compounds and prepares hand-outs for public health services. It is also responsible for the education and training of the state health protection teams. No matter what kind of institution the toxicologist belongs to, he needs a wide network of contacts to be able to communicate with other toxicologists. The latter will support him in developing adequate precautionary concepts or may, for example, help him to obtain immediate and specific information in case of an emergency. Altogether, the network should include toxicologists from

different fields: industrial, university or military toxicologists each might have highly specialized knowledge on the handling of specific chemicals, and sensitive means for their detection. Clinical toxicologists are trained in clinical treatment of poisonings. Agency toxicologists have special knowledge on all legal aspects and public health management procedures. These networks can be informal and may even run on informal platforms. Examples for open networks are the Promed mailing list (Diseases, 2004), internet based discussion groups as well as expert groups, which communicate in closed forums. 4.4. Research and development needs Not only because of the threat of deliberate attacks, but also because of the very high incidence of accidental poisoning especially in less industrialized countries, there is an urgent need for research and development in various areas such as antidotes, decontamination techniques for mucous membranes and open wounds, validation of analytical methods for rapid detection of toxic compounds and improvement of software to combine medical data, chemical data and spreading models. However, at present there is not much support for such activities in most countries. 4.5. Preparedness regarding toxicological information and knowledge 4.5.1. Toxicological risk assessment The toxicologist must be familiar with the common procedures of risk assessment, risk evaluation, risk management and risk communication. But his most specific task is in the performance of risk assessment. For this purpose he needs access to relevant databases, and at the same time, needs to be experienced in terms of their interpretation, especially with regard to acute clinical signs and the application of the proper guideline values. Various committees have established guideline levels for airborne compounds under the assumption of specific circumstances (AEGL-values, ERPG-values, EEI-values, MEG-values). These data are an important element of dose–response assessment in the risk assessment process. If for a certain compound no such values exist, the general toxicity data (LD50 , LC50 , etc.) will often allow to give rough estimations on acceptable exposure limits. Furthermore, physicochemical data are important to estimate the extent of incorporation into the organism as well as the environmental behavior of the agent. It is also important to be familiar with methods of estimating the spreading of hazardous compounds in the atmosphere. Exposure models (COMPAS, DISMA,

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MET) allow to predict the temporal and spatial distribution of hazardous chemicals in the atmosphere, in buildings and in the soil including meteorological and topographic influences. These kind of models are often used by experts of the fire departments. 4.5.2. Databases There are numerous useful toxicological databases in different languages. The expert needs access to a large number of databases, many of which are highly specialized and supplement each other.

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In special cases (e.g. poisonings with chemical mixtures), it can be necessary to contact poison centers that have the privilege to obtain confidential information from the producer. 4.5.3. Address lists The toxicologist should prepare and regularly update a register of names and telephone numbers of experts and institutions that he can contact for specific information and interpretations.

Important databases for rapid access to information in emergency cases Hazardous Substances Data Bank (HSDB) NIOSH Pocket Guide CEFIC Emergency Response Intervention Cards (ERICards or ERIC’s) ERG 2000 Emergency Response Guidebook [Transport Canada Canutec] Chemical Hazards Response Information System (CHRIS) [US Coast Guard] IPCS INCHEM International Chemical Safety Cards (ICSCs) [WHO, UNEP, ILO—International Program on Chemical Safety] USACHPPM; US Army Center for Health Promotion and Preventive Medicine. Fact sheets and technical guides NIOSH [US version]

http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?hsdb http://www.cdc.gov/niosh/npg/npg.html http://www.ericards.net http://www.tc.gc.ca/canutec/en/guide/guide.htm] http://www.chrismanual.com/default.htm http://www.inchem.org/pages/icsc.html http://chppm-www.apgea.army.mil/fs.htm http://www.cdc.gov/niosh/ipcs/icstart.html

Important databases for risk assessment Registry of Toxic Effects of Chemical Substances (RTECS) [MDL Information Systems, inc., USA] Integrated Risk Information System (IRIS) [US Environmental Protection Agency (EPA)]

http://mdl.com/products/predictive/rtecs/index.jsp http://www.epa.gov/iris/

Databases focussing on clinical toxicology POISINDEX [Thomson Micromedex inc., USA] IPCS Intox-data base [WHO, UNEP, ILO—International Program on Chemical Safety] Agency for Toxic Substances and Disease Registry (ATSDR) with Managing Hazardous Material Incidents (MHMI) series, Medical Management Guidelines (MMGs) for acute chemical exposures and ToxFAQsTM , toxicological profiles and interaction profiles (the latter also on CD) TOXBASE [National Poisons Information Service, UK]

http://www.mdx.com/products/poisindex/ http://www.intox.org/ http://www.atsdr.cdc.gov/atsdrhome.html

http://www.spib.axl.co.uk

Links to documents on chemical warfare agents in the internet CDC-Homepage Emergency Preparedness & Response

http://www.bt.cdc.gov/agent/agentlistchem.asp

Meta-databases ChemKnowledge® TOMES Plus® System [Thomson Micromedex] CHEMpendiumTM [Canadian Centre for Occupational Health and Safety]

http://www.mdx.com/products/chemknowledge/ http://www.mdx.com/products/tomes/ http://www.ccohs.ca/products/chempendium/

Some of these are licensed products.

Additional sources TOXNET Household Product Database

http://toxnet.nlm.nih.gov http://hpd.nlm.nih.gov

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4.5.4. Education and information An important part of preparedness is training and education (Beaton and Johnson, 2002; Kulling and Holst, 2003). This is also true for the toxicologist. Training courses for the management of chemical disasters should either be offered by the Societies of Toxicology or by specialized institutions, such as the homeland security agencies. Moreover, the toxicologist should help in educating other specialists and in informing the public. Material for rapid information can be prepared, e.g. handouts on different chemicals and compounds. Two different kinds of handouts should be available for each compound, one of them designated for the distribution among first responders and rescue teams, the other designed for the public. Both types of leaflets should leave room for modifications and amendments, which will allow to adapt the information according to the specific threat situation. Such handouts may enhance the ability of citizens, to protect themselves and their neighbors in case of an actual hazard. 4.6. Preparedness regarding detection In case of a suspected or proven release of unknown chemicals or chemical warfare agents, fast and reliable detection methods must be immediately available. The specific identification of a highly toxic compound – especially at concentrations, which exceed threshold levels – is important for the alert procedure, the selection of adequate protective measures (e.g. protective masks and clothing), the mapping of contamination, as well as for medical treatment and decontamination. All the precautions and trainings concerning effective determination of chemical agents must be met during the planning phase. The planning of this task is an extremely complicated matter, which requires support from experts who are specialized in this kind of analysis. In the past few years, there have been extensive efforts to establish new analytical methods that will allow to detect and identify unknown chemicals with high sensitivity, accuracy and velocity (Jortani et al., 2000; Hill and Martin, 2002; Hooijschuur et al., 2002; Longworth and Ong, 2002; O’Neill et al., 2002; Parshall et al., 2002; Wang et al., 2002; D’Agostino et al., 2003). There are comprehensive reviews on the analytical methods (Hill and Martin, 2002), their application in connection with chemical warfare agents (Jortani et al., 2000) and the analytical equipment for field detection (O’Hern et al., 1997). Detection devices became increasingly mobile. One future option will be, to permanently install these analytical devices in potentially endangered places in order to be able to monitor a possible release of highly

toxic chemicals or to employ them as drone-portable devices for otherwise inaccessible locations. In the case of a chemical-incident, the responsible analytical chemist should be on the spot at the earliest possible time. He must be equipped with rapid detection devices in order to be able to quickly obtain first results. These devices may raise the problem of false positive alarms because of their low selectivity. Therefore, initial results always have to be confirmed by more sophisticated methods in specialized laboratories under standard laboratory conditions in order to verify the released chemical both in the environment and in the body of exposed individuals. Hazardous chemicals can be encountered as gases, liquids or solids. Depending on both the properties of the chemical and the conditions of exposure, samples for the further instrumental analysis must be drawn from the air, from soil, from surfaces or even from human blood samples or exhaled air. The success of all further analytical procedures will largely depend on a proper sampling technique, as well as on a proper sample preparation and sample transport. Usually, airborne compounds, like gases, vapors and aerosols can easily be trapped onto adsorbing materials like tenax, sometimes only after prior heating of the contaminated surface. Sampling and shipping instructions (CDC, 2004) should be ready for use, if possible adapted to the national laws. The subsequent extraction and enrichment of chemicals with low volatility from complex matrices can be very timeconsuming. 4.6.1. On the spot analysis with detection paper Detection paper analysis is based on a comparatively old detection method. Purified chromatography paper is impregnated with reagents, which will react in the presence of warfare agents, yielding a change of color (Franke, 1976). It can be easily handled and provides immediate results on the spot. Chemical agent detection papers can detect warfare agents either on surfaces, in the air or in the water (FOA, 1992). An example is M8 detection paper, which is commercially available in polyethylene-sealed booklets (O’Hern et al., 1997). M8 paper contains three indicators. The paper is blotted on the suspected surface. Color changes can be expected within 30 s. VX turns the paper green, the G-series of agents turn the paper yellow and blister agents turn it red. However, it may give false positive results in the presence of many chemicals such as sodium hydroxide or petroleum products. Therefore, results should be verified by other methods. Detection paper has the advantage over many other methods, that it can detect even small droplets and contaminations on surfaces such as equip-

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ment, clothing or vehicles. The spot diameter and color intensity on the detection paper reflects the actual droplet size of the agent as well as the degree of contamination. 4.6.2. On the spot biosensor systems for nerve agents At present, different biosensors are being developed (Lee, 2000; Gu et al., 2004). These biosensors consist of different biomolecules (receptors or immunoreceptors), with high affinity to a specific toxic agent. If coupled with a sensitive detection system, these biosensors can be used to identify the specific toxic agent. With this principle, a more specific detection paper device for nerve agents has been developed, which consists of two different detection paper components: an enzyme (cholinesterase)impregnated paper and a substrate-impregnated paper. After the package has been opened the enzyme-paper needs to be moistened, and the substrate-containing part needs to be exposed to the suspected vapor by means of a pump. Subsequently, both parts of the detection device have to be put together for 2 min. If the enzymecontaining paper develops a weak blue color, the absence of nerve agents (cholinesterase inhibitor) in the sample can be presumed. 4.6.3. On the spot analysis with detection tubes Detection tubes have the advantage of detecting airborne chemicals with high specificity and in a quantitative manner. Detection tubes are made of glass, have break-off tips, and are filled with impregnated chemical granules for detection of chemical agents. A defined air volume is drawn through the tube with pump strokes. If the suspected chemical is present, the indicator zone changes color. Detection tubes are available for individual chemical warfare agents, but are also provided as sets of tubes mounted to an adaptor. The sets allow to detect simultaneously several different chemical agents. For example, one commercial set detects hydrocyanic acid, phosgene, lewisite, N-mustard and S-mustard. Lists of relevant limit values (e.g. AEGL-values) should be at hand, in order to estimate the health risk. 4.6.4. On the spot analysis with ion mobility spectrometer The nature of this method is to separate ions according to their size-to-charge ratio (Collins and Lee, 2002). Ion mobility spectrometers (IMS) are small and mobile and have been developed as chemical agent monitors (CAM) for field detection (Buryakov, 2004). By using a radioactive ionization source, detection of vapors of Htype vesicants or G- and V-type nerve agents with these instruments takes approximately 1 min (Hill and Martin,

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2002). However, it has a limited ability to distinguish between individual components in complex mixtures, and nonlinear signals hamper its application for quantitative detection. The resolving power is usually 1–2 orders of magnitude below that of mass spectrometers. Portable detectors of this type pose also a risk of false positive measurements. 4.6.5. Sensor-array devices Sensor array technology is based upon the simultaneous use of a combination of different chemical sensors, e.g. electrochemical cells, acoustic wave detection devices, flame photometry and ion mobility detectors (Sadik et al., 2004). When exposed to the chemical vapors, all sensors must respond rapidly and reversibly. This technology is applied in instruments, which are commonly known as electronic noses. The resulting combined signal generates a fingerprint, which will be characteristic for either a single substance or a whole group of substances, but usually will not identify it. The definitive identification of the actual compound has to be accomplished by a more specific method. 4.6.6. Mass spectrometer Gas chromatography/mass spectrometry still is the analytical technique of choice for the identification of unknown chemicals, as it can positively identify a chemical agent at very low concentrations (Capacio et al., 2004; Makas and Troshkov, 2004). However, this technique can be very time-consuming, especially if further information on the substance is lacking. Therefore, its use for the final identification of substances is increasingly replaced by faster, yet less universal and sensitive methods. 4.6.7. Infrared remote sensing Depending on background temperature, clouds of chemicals either absorb or emit a compound-specific infrared signal, which can be detected in real-time (Goillot, 1975). Applications are the detection or monitoring of airborne compounds, including chemical warfare agents (O’Hern et al., 1997), wood smoke components, fuel emissions, industrial chemical release, and chemical spills. Small lightweight instruments have been developed. 4.6.8. Differentiation between chemical agents and biological agents The “white powder attacks” in 2001 taught us, that it is extremely difficult to rapidly analyze powders of unknown composition. In such cases the toxicologist, microbiologist and physicist have to cooperate. After

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excluding the involvement of explosives, it will often be reasonable to measure radiation first, then to get first information on the chemical nature of the material (organic or inorganic, presence of protein/DNA) and to use different microscopic methods to detect crystals, bacteria or viruses. Thereafter or in parallel, the chemical and microbiological analysis has to be made with the specific methods, taking into account all the precautions to protect the involved personnel. 4.6.9. Detection of toxins As microbial toxins are macromolecules, which act, in extremely small doses, even modern chemical–analytical methods may fail to detect them. Immunoassays are available for several toxins, such as botulinal toxin A and staphylococcal enterotoxin B. If no analytical method is available to detect a suspected poison, the toxicologist must be prepared to administer the unknown materials (or extracts) in different dilutions to laboratory animals (mice). The behavior and symptoms of poisoning shown by the animals can then provide information on the type of the toxic agent, and its toxicity. 4.6.10. Quality assurance In general, laboratories must perform all their analyses according to the prevailing state-of-the-art techniques. Due to rapid advances at the analytical sector, this means the constant availability of up to date highperformance equipment. Also, the lab must have routine in analyzing unknown samples. Regularly performed internal quality controls and the additional participation in external quality controls, e.g. round robin tests are essential to maintain high quality standards. The quality of analytical results will largely depend on the expertise of the analyst. It should be strictly avoided that expensive analytical equipment will be operated by personnel without sufficient experience. Those who will apply the on the spot test kits, need sufficient training with simulator kits. 4.6.11. Organization and management Since a large number of instrumental devices and test kits are available for detection of warfare agents, the person responsible for selecting, buying and using/stocking these materials should be well informed in this particular area. The organization of lab facilities greatly differs between countries. In some countries, analyses are performed within the diagnostic routine of university research, while in others specialized state laboratories conduct all analyses related to nuclear, chemical or biological warfare agents. Usually, the military sector is

Fig. 5. Toxicologist on site network.

equipped with specialized units, which are able to provide assistance in case of a disaster. An integration of these specialized analytical teams and equipments in emergency management programs could be of advantage for obtaining fast and reproducible results (Fig. 5). In any case, a list of laboratories, which are able to analyze dangerous chemicals, should be available at the disaster management centers. 4.7. Toxicological aspects of stockpiling Medical aspects of stockpiling have to include considerations on the availability of hospital beds, chemical laboratories, decontamination materials, protective clothing and pharmaceuticals (FOA, 1992). The latter three aspects, at least in part, belong to the original tasks of the toxicologist (Fig. 6). Stocks containing sufficient amounts of wound dressing material, drugs, antidotes, and vaccines have to be built up. Experience shows, that whenever an emergency case occurred, insufficient emergency stockpiles of the above mentioned materials had been a primary problem worldwide. Since stockpiling of materials requires permanent surveillance (e.g. with regard to expiry dates, etc.), it can make sense to organize all associated tasks across district borders or even on an international level. There is a general problem concerning the availability of antidotes and other rarely used therapeutic drugs (some vaccines and antisera). Production and development of such drugs is often commercially unattractive (“orphan drugs”). This may hamper the access to such drugs and is an obstacle to the medical progress in the treatment of poisoned victims. 4.7.1. Stockpiling of decontamination equipment Management and the approach to medical care of exposed victims vary throughout the world and are based on dogmas rather than on substantial scientific data (Levitin et al., 2003). In order to prevent confusion

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among first responders and medical staff, decontamination equipment has to be immediately available and helpers need to be familiar with their use (Lepler and Lucci, 2004). Chances are that wrong decontamination efforts bring about an even larger area of contamination. Therefore, the aim of decontamination measures is to remove all poisonous substances from personnel, equipment and environment as soon as possible. The first step will often be physical removal. In many cases, especially in mass casualty situations, water is the decontaminant of choice, providing the great advantage of broad availability and complete lack in the necessity to be stocked. Soap or detergents should be added to dissolve and wash off lipophilic agents from skin and other surfaces. Organic solvents like gasoline or liquid paraffin should be available, as they can effectively solubilize highly lipophilic compounds. Polyethyleneglycol (PEG) solution is also useful for decontamination of lipophilic compounds and used broadly in clinical toxicology. It should be noted that disposal of large volumes of contaminated fluids may cause a problem. Sodium phenolate or sodium cresolate in alcoholic solution can be used, in particular, for the decontamination of nerve agents. Absorbent powders, such as bentonite (“Fuller’s Earth”), should be stocked for all cases, in which an application of liquid decontaminants is contra-indicated. Flour is also an effective dry decontaminant. Chloramine solutions also should be kept in store, because they are able to break down various substances and even more importantly are mild enough to be applied to the skin. These solutions also show good results when being used for the treatment of injuries caused by mustard and V-agents but are ineffective if used against G-type nerve agents (sarin, soman, tabun). An aqueous solution of soda rapidly inactivates nerve agents of the G-type, but if being used in connection with Vagents, it produces an end product, which is almost as toxic as the original substance. Detergents, which contain perborates, are particularly effective in destroying nerve agents. Chlorinated lime powder (sludge) can be used as a decontaminant which destroys chemicals by the release of active chlorine. Plastic foils and heavy-duty garbage bags should be kept in store in case it will become necessary to cover contaminated areas. In the absence of any covering material, contaminated surfaces or soil may simply be covered with clean soil or gravel. During a chemical attack, contaminated individuals requesting to enter a shelter or treatment facility will pose a serious problem. If exposed to persistent chemical war-

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fare agents, these persons first need to be decontaminated and the success of decontamination has to be checked before they can be allowed to pass. Decontamination is very time-consuming and will require large amounts of personnel. 4.7.2. Stockpiling of protective equipment Personal protective equipment has the purpose to prevent the entry of all airborne, liquid or solid chemical agents into the body. It not only has to be stocked for professionals such as the personnel of civil protection units, fire departments, medical emergency services and other helpers but also for civilians and victims including children of various ages as well as disabled persons. Equipment, which helps to shield an exposed individual from further exposure or recontamination during rescue operations has to be included (USACHPPM, 2003). 4.7.3. Body protection For highly contaminated areas impermeable full protective gears with integral hood, gloves, overshoes, and self-contained oxygen supply should be kept in store. In minor cases or for the protection of secondline helpers, droplet resistant semi-permeable protective over garment and full protective masks, mounted with passive or motor blower filter units may be adequate. 4.7.4. Respiratory protection Full-face protective masks provide good protection for both the respiratory tract and the eyes. They should be equipped with a large field of vision and a speakingdevice. Leakage should not exceed 0.001%. A semiprotective mask (facelet) is more comfortable to wear but provides less protection than a fully protective mask or self-contained breathing apparatus. Respiratory protective masks also should be stocked in different sizes. Suitable filters must be held in store. They consist of an outer aerosol filter and an inner gas filter, which usually contains activated carbon, which might be impregnated with additional compounds to improve filter-performance. Protective masks equipped with such kind of filters have a limited spectrum of protection and are not appropriate in the case of threat by unknown toxic chemicals, especially in fire where also oxygen deprivation may occur. Also, small children are not able to overcome the breathing resistance of the filter and need motor supported ventilation.

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Fig. 6. Three classes of drugs, which have to be stockpiled.

4.7.5. Gloves and overshoes Chemical protective gloves are composed of an outer glove for chemical protection (e.g. butyl rubber) and an inner glove for the absorption of perspiration water (cotton). They are available in various thickness for use in low and high precision tasks. Thin gloves will provide protection for about 6 h after a contamination has occurred. It has also to be kept in mind, that similar to gloves, overshoes, which are used to protect footwear against contamination have to be stockpiled in various sizes, including children. 4.8. Stockpiling of drugs and antidotes The quantity of emergency drugs to be kept in store has to be adapted to the anticipated demand in case of a hazard and should be sufficient even for incidents with larger numbers of casualties. Stockpiling has to be thoroughly planned in advance of an imminent threat (Burda and Sigg, 2001; Plataki et al., 2001; Mrvos et al., 2003). The stocked pharmaceuticals have to be immediately available at any time, i.e. the access and the distance to the potential place where they will be needed have to be considered. Stocks should include antidotes, antibiotics, antitoxins, vaccines and other drugs, as well as disinfectants. Preparedness in terms of a stockpiling of pharmaceuticals has to take into account all different kinds of scenarios such as chemical injuries, intoxications, traumatic injuries, burns and frostbites, radiation injuries, infections, epidemics, mental stress and dis-

eases. The following types of drugs should be considered for storage (Fig. 6). 4.8.1. General emergency drugs Medical emergency service requires a stock of all common emergency pharmaceuticals for the immediate use on scene, as well as for the application during transport or early in the hospital. These pharmaceuticals have to be stored in amounts sufficient for mass casualties. 4.8.2. Antidotes for poisonings Since antidotes and antisera can be lifesaving in case of a poisoning, their stockpiling is an important issue for toxicologists. Overviews are given by EMEA/CPM Guidance Document/1255/03 (EMEA, 2003), ATSDR medical management guidelines (ATSDR, 2005), and WHO ICPS INTOX Consensus Documents on treatment, antidotes and poisons (INTOX, 2004). 4.8.3. Standard drugs In case of mass casualties, the necessity of treating many patients at a time may lead to an early exhaustion of the common stockpiles of local hospitals, pharmacies and drug stores. In these cases, further reserves have to be available within 6–24 h. The assortment also has to be adapted to the needs of specifically sensitive patients. For example, stress situations may provoke an early birth, or the aggravation of persistent chronic diseases such as asthma, angina pectoris or high blood pressure. As a consequence, further reserves of important drugs, e.g.

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for the treatment of high blood pressure, heart and respiratory diseases, diabetes, epilepsy, as well as vaccines, antibiotics and disinfectants must be available within a period of 24–48 h. 4.8.4. Size of drug stockpiles Depending on the area, which has to be supplied a stock of one complete unit of drugs for every 1000–10,000 inhabitants may be recommended. During the planning period, the following questions may arise: in what amounts will each drug be needed? Who is going to pay for it? Where should drugs be stored? Who should be put in charge of taking care of these stocks? How should transports be organized? Depending on the geographic, financial and political conditions, the answers to all these questions might vary to a great extent. 4.8.5. Logistics in drug stocking There may be different stocks of drugs for immediate use, short-term use (6–24 h), and intermediate-term use (24–48 h). Ideally, antidots should be available on the spot at any time. Stocks, that are far away, will often be useless. The toxicologist must be informed about the exact location of all stockpiles and also should have immediate access to required drugs in case of an emergency. High costs partly due to the limited stability of drugs are a major problem of stocking. Since drugs have to be replaced from time to time, expensive and highly specific drugs, such as additional antidotes and antisera against toxins, are often being centrally stored. 4.8.6. Location of stockpiles Local depositories (communal/municipal, district) are appropriate to immediately supply medical services and hospitals. However, during a crisis, these services might be fully occupied with fulfilling their basic tasks, e.g. the delivery of pharmaceuticals to patients in the hospitals. As an alternative, stocks could be built up in regional depositories, which could belong to either a poison center, a hospital pharmacy, a wholesale pharmacy or the producer himself. Solely relying on the normal reserves of the latter institutions would be inadequate. Altogether, a balanced mix of local, regional, supraregional and national or even international supplies should be established. Permanent updates of databases will be required to guarantee exact information concerning the size and location of stockpiles in decentralized reserves and allow for their effective organization.

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4.8.7. Twenty-four-hour duty In emergency planning, the term readiness implies, that all members of an emergency response team have to be involved in a common alert system and should be ready to react either as first responders or as part of the command structure immediately and at all times. Usually, all staff members can be contacted on the basis of a 24-h duty. In addition, alerts can be announced through the media. Since communication systems tend to break down in emergency situations, a specific and safe communication network should be established already during the planning phase. For the involved toxicologist the term readiness means, that he should have all his toxicological databases, stocked materials and registers of contact persons and institutions at his immediate disposal at all times. 5. Aspects of aftercare and recovery As soon as the acute response phase of a chemicalincident has passed, concerns about possible long-term effects on health and the environment need to be considered. These central topics of aftercare are often managed by the public health services in cooperation with the environmental agencies. The questionnaires and information leaflets, which are required in the aftercareperiod, should already be prepared in the planning phase. 5.1. Risk assessment and biomonitoring After an incident occurred, one of the main objectives will be to perform a risk assessment for exposed persons. Quantifying a person’s individual risk can be a challenging task because estimates on exposure levels will vary extremely, depending on the assumptions made. Comparatively stable results can be obtained either by applying worst-case assumptions or by using probabilistic approaches. Nevertheless, results often will be a matter of discussion. In order to obtain reliable results on the exposure of humans, individual human biomonitoring-methods (e.g. in plasma, urine) should be applied whenever reasonable (Heinrich-Ramm et al., 2004; May et al., 2004; Stokstad, 2004). This is the straightest method for an individual risk assessment, provided that a sensitive method is available and exposure levels are within the limits of analytical detection. Samples of an unexposed control group should be measures simultaneously in order to avoid wrong interpretations of the obtained results. This procedure is often appropriate for compounds, which

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are taken up systemically, but usually does not detect irritants. 5.2. Long-term studies The subsequent observation of the health status in an exposed population is of importance for the detection of possible long-term effects. For this purpose, a long-term survey project should be launched early after the incident, which should be aimed at comparing the health situation of the exposed population with that of a matched yet unexposed group. Establishing a disease registry can support this aim. 5.3. Release of contaminated areas Areas, which have been exposed to highly toxic agents, must be considered contaminated until the opposite is proven. Different aspects relating to human health have to be explored before the area can be released. Important aspects are: where are the hot spots of contamination? Has the drinking water and groundwater been contaminated? Have crops or animals been affected? Have any buildings or air-conditioning systems been contaminated? Is it necessary to decontaminate, and if so, what measures have to be taken? Is there a need to consider any sensitive population groups? Can the existing toxicological guideline levels be applied, or is it appropriate that these levels may be exceeded for a restricted period of time? All of these questions have to be discussed in detail in an expert team consisting of analysts, toxicologists, environmental chemists and other experts. Conclusions should be proposed to the regulatory agencies, and the population has to be involved in the risk communication process as well. Decontamination campaigns should be followed by a reevaluation of the risk. It is of utmost importance that allowable exposure levels of chemicals are fixed in regulations as early as possible in order to prevent discussions during the incident and thereby unnecessary fears in the population (e.g. for release of food and water). 5.4. Operational reports provide a basis for future planning Incidents with hazardous chemicals have always been a major source of knowledge in human toxicology. Analyzing an incident will not only be of interest to the affected area but also to toxicology as a science (Dhara and Dhara, 2002; Dechy et al., 2004; Gersons et al., 2004). Reports should include all relevant information

on the chemical agents properties, exposure levels and health effects on humans, animals and plants. Moreover, the quality of all conducted incident management procedures should be evaluated. The expert-team should critically reflect its experiences and identify further chances to improve its skills in the fields of preparedness, response and aftercare. The resulting report should be made available to the scientific community.

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