[Federal Register Volume 59, Number 143 (Wednesday, July 27, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Printing 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