National Toxic Substance Incidents Program: Assessment of Chemical Exposures Investigations

1. National Toxic Substance Incidents Program: Assessment of Chemical Exposures Investigations Mary Anne Duncan, DVM, MPH United States Public Health Service Division of Health Studies Agency for Toxic Substances and Disease Registry

2. The findings and conclusions in this presentation have not been formally disseminated by the Agency for Toxic Substances and Disease Registry and should not be construed to represent any agency determination or policy.

3. National Toxic Substance Incidents Program (NTSIP) • Partnership between ATSDR and multiple stakeholders such as state agencies, other government agencies, and industry • Expands on work of Hazardous Substances Emergency Events Surveillance (HSEES) program • Comprehensive approach to toxic substance surveillance, prevention, and response

4. Development of a Body of Knowledge • Preparedness training • Targeted prevention activities • Identification of health effects of chemical exposures

5. Three Components • State-based Surveillance • Incident Investigations • National Surveillance

6. Part I: State-based Surveillance

7. State-based Surveillance • Participating state health departments collect detailed incident data • Seven state health departments currently have cooperative agreements with ATSDR to participate in NTSIP: • Louisiana, New York, North Carolina, Oregon Tennessee, Utah, Wisconsin

8. State-based Surveillance • Enter data into ATSDR’s hazardous substance incidents surveillance system • Collect information on hazardous substance use and transport • Map location and movement of hazardous substances throughout communities • Identify and prioritize vulnerable areas for targeted prevention activities

9. State Outreach Programs • Determine where hazard reduction principles or green chemistry can be applied • Promote hazard reduction through inherently safer technologies • Enhance preparedness and response capabilities

10. Part II: Incident Investigations — Assessment of Chemical Exposures (ACE)

11. ACE Investigations • Provide assistance to state and local health agencies to: • Register persons exposed to large-scale acute chemical incidents • Characterize exposure and acute health effects • Incidents in which at least 100 persons are exposed to a toxic substance at levels that could produce acute health effects

12. ACE Investigations • ATSDR team can deploy within 1–2 days of receiving a request for assistance from a state • Four possible components of the assessments: • Rapid Response Registry (RRR) • Community Survey • Biological Sampling • Environmental Sampling

13. Rapid Response Registry • States register exposed persons before ATSDR team arrives • RRR is quick survey form: 38 questions / 5–6 minutes • Can ask just the four “critical” questions: name, sex, home address, phone numbers / 1–1.5 minutes

14. Community Survey • Use GIS to map area, possibly some plume modeling • Interview all potentially exposed persons or sample of exposed persons • Participants in community survey: • Community members • Local business employees • Responders • Hospital personnel • Others in the area

15. Community Survey • Exposure history • Symptoms • Health services use • Demographics • Medical history • Other potential exposures • Needs resulting from the release • Communication effectiveness • Impact on pets

16. Biological and Environmental Sampling • Biological • If available • Blood • Urine • Environmental Sampling • When applicable • Air • Water • Soil • Surfaces

17. Benefits of Assessments after Chemical Releases • Community members • Know impact on community • May benefit from aid resulting from assessment • Receive results of biological testing • Local and state health department • Reassure community by action • Know impact on community • Better direct aid to the affected community • Identify issues to address on emergency plans • Improve community preparedness

18. Benefits of Assessments after Chemical Releases • Emergency Responders • Identify issues to address on emergency plans • Identify best methods of communication • Assess shelter-in-place efficacy • Federal Agencies • Describe acute health effects of chemical exposures • Identify recurring issues to be addressed in mass casualty plans • Identify cohorts that may be followed for persistent health effects of acute exposures

19. Part III: National Surveillance

20. National Database of Toxic Substance Incidents • Use the Department of Transportation (DOT) Hazmat Intelligence Portal (HIP) • Combine data from existing databases • National Response Center Incident Reporting Information System (IRIS) • DOT Hazardous Materials Incident System (HMIS) • NTSIP Data (Part 1) • Supplement with information from news media and other databases

21. National Database of Toxic Substance Incidents • Operational early 2010 • For use by: • Federal agencies • Responders • Public health officials • Public

22. National Database of Toxic Substance Incidents • Use for: • Coordination among federal agencies • Situational awareness • Alerts of hazardous situations • Trending and planning • Access by public for information

23. Assessment of Chlorine Exposure and Health Consequences Following Graniteville Train Derailment

26. Timeline: Day 1 • 2:40 am Train derailment • 3:00 am First patients arrive at hospital • 6:42 am Reverse 911 call to community • 12:00 pm Emergency declaration • 4:20 pm Evacuation order (~5400 people evacuated)

27. Objectives • Extent and location of exposure • Morbidity • Use of health services • Risk factors for severe outcomes • Persons at risk for long-term sequelae

28. Case Definition • Death or illness • Chlorine exposure • January 6 – February 17, 2005 • Area of Graniteville, SC

29. Case Finding • Review of hospital emergency department logs • Health advisory • Mandatory reporting by physicians

30. Methods • Questionnaire • Level of chlorine exposure • Scale of 1 to 5 • High exposure level = 4 or 5 • Based on duration and proximity • Severe medical outcome • Death • Hospitalization 3+ nights

31. Total Cases Deaths Hospitalizations Outpatients 605 9 72 525 Results

32. Demographics 36 (<1 – 85)

33. 1 3 5 7 9 11 13 15 17 19 21 23 25 Epidemic Curve (n=569) Cases by Day of Presentation 280 260 ED Visit, Not Admitted Admitted to Hospital Deceased 100 Cases 80 60 40 20 0 Day(s) Since Accident

34. Patients Treated at Emergency Departments within 24 Hours

35. Method of Transport to Medical Facility – First 24 Hours

36. Decontamination • Three sites • Four hospitals • Wet decontamination • 107 (38%) decontaminated • Secondary exposures

37. Symptoms Reported

38. Reported Impact to Pets • Dogs: 7 died, 10 sick, 2 missing • Cats: 10 died, 1 missing • Fish: died in 2 aquariums and 1 pond • Rabbit: 1 sick • Rooster: 1 died • Frog: 1 died • Total: 132 pets with no visible effects / 22 died / 12 sick / 3 missing

39. Limitations • Unable to contact half of the patients for interview • Self report of symptoms • Legal concerns

40. Conclusions • More than half of the patients treated within 24 hours went to hospitals in Georgia • Two-thirds of the patients treated within 24 hours arrived in privately owned vehicles • Patients often not decontaminated • Exposure classification predictive of severe outcome

41. Recommendations • Improve emergency preparedness and response in • Facility-specific mass casualty plans to address symptomatic patients who arrive in privately owned vehicles • Regional mass casualty plans to include inter-state issues

42. Impact of the Assessment • Provide information for decision-making and policy development • Respond to the needs of those affected: • Referrals for medical care, counseling, and assistance of social worker • Referrals for decontamination of vehicles • Free influenza vaccines • Information on the health impact of the incident • Obtain funding for future interventions • Add to the knowledge base to lessen impact of future incidents

43. Acknowledgements • SC DHEC • Jerry Gibson • Dan Drociuk • Amy Belflower • Claire Youngblood • Erik Svendsen • Veleta Rudnick • Lena Bretous • David Whisenant • Shirley Jankelevich • Drew Gerald • CDC • David Van Sickle • Vuong Nguyen • Randolph Daley • Richard Taylor • David Callahan • ATSDR • Robin Lee • Kris Bisgard • Photographs by DHEC and Aiken County Emergency Management • Properties and effects of chlorine from lecture by Peter Chase, MD, PhD, University of Arizona