[Federal Register Volume 59, Number 143 (Wednesday, July 27, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-18274]
[[Page Unknown]]
[Federal Register: July 27, 1994]
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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]
BILLING CODE 4163-18-P