Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities

1 2 Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities i Federal Points of Contact Susan M. Cibulsky, PhD Medical Countermeasure Strategy and Requirements Division Office of Policy and Planning Office of the Assistant Secretary for Preparedness and Response US Department of Health and Human Services [email protected] Mark A. Kirk, MD Program Director, Chemical Defense Health Threats Resilience Division, Office of Health Affairs US Department of Homeland Security [email protected] Primary Authors Susan M. Cibulsky, PhD Medical Countermeasure Strategy and Requirements Division Office of Policy and Planning Office of the Assistant Secretary for Preparedness and Response US Department of Health and Human Services Mark A. Kirk, MD Program Director, Chemical Defense Health Threats Resilience Division, Office of Health Affairs US Department of Homeland Security Joselito S. Ignacio, MA, MPH, CIH, CSP, REHS Captain, US Public Health Service Deputy Program Director, Chemical Defense Health Threats Resilience Division, Office of Health Affairs US Department of Homeland Security Adam D. Leary, MA, MS Medical Countermeasure Strategy and Requirements Division Office of Policy and Planning Office of the Assistant Secretary for Preparedness and Response US Department of Health and Human Services Michael D. Schwartz, MD Commander, US Public Health Service Office of Environmental Health Emergencies National Center for Environmental Health Centers for Disease Control and Prevention US Department of Health and Human Services December 2014 US Department of Homeland Security US Department of Health and Human Services Washington, DC 1 Executive Summary Introduction Each day, substantial quantities of hazardous chemicals are produced, transported, stored, and used for industrial or household purposes. Stockpiles of chemical weapons around the world, while currently being destroyed, still exist. Various terrorist organizations and non-state actors have shown interest in procuring or developing and using chemicals in terrorist attacks. In each instance, these chemicals pose significant risk to public health due to the potential for accidental or intentional release that could harm large numbers of people. Civilian first responders (e.g., fire, hazardous materials (HAZMAT), and emergency medical service) and first receivers (e.g., health care facility-based and other clinical personnel), along with emergency managers, public health practitioners, law enforcement officials, and risk communication experts, must be prepared to respond to such incidents. The potential for a large-scale chemical release resulting in the need to decontaminate an overwhelming number of people has garnered wide interest among policy makers and emergency planners. Guidance and best practice documents have been published and specialized equipment has been purchased. However, decontamination practices have evolved based on sparse evidence. Limited research has been conducted on decontaminating civilians. Patient decontamination, like other aspects of disaster response, medicine, and public health, could benefit from an assessment of the body of evidence, enhanced incorporation of the evidence into planning and practice, and additional study to generate needed evidence. Furthermore, many current guidance and best practice documents do not address the full spectrum of issues that a community may face when large-scale patient decontamination is necessary in a mass chemical exposure incident. The need for examination of current patient decontamination practices was identified by experts in the emergency response and medical communities. The White House National Security Council (NSC) staff followed with a request for evidence-based national planning guidance for mass patient decontamination in a large-scale chemical release. Efforts to enhance preparedness for patient decontamination in a mass exposure incident may also benefit the care that is provided to individual contaminated patients in other circumstances. Audience, scope, and intent The intended audience includes senior leaders, planners, incident commanders, emergency management personnel, and trainers of local response organizations and health care facilities. Though the guidance was developed with this specific audience in mind, it may be of value to other audiences, including first responders and first receivers, community leaders, scientific researchers, as well as others from the response and emergency management fields. A basic assumption of this document is that mass patient decontamination takes place at the level of the local affected community. Due to the need for chemically- contaminated patients to be decontaminated as soon as possible, the federal government will likely not be able to participate directly in the decontamination response. Therefore, this guidance is directed primarily at local organizations. The subject matter considered here is limited to external contamination of living people (henceforth defined as “patients”; see Appendix B: Lexicon) with toxic industrial chemicals (TICs), toxic industrial materials (TIMs), or chemical warfare agents (CWAs) in a mass casualty incident resulting from an accidental or intentional release. This guidance attempts to address the full spectrum of the decontamination response operation, from initial assessment and decision making through evaluation of decontamination effectiveness. Further, the entire affected community is considered, with emphasis on coordination between on-scene and health care facility-based response activities and communication on multiple levels. 2 Patient decontamination principles are set forth here from a strategic perspective, rather than a tactical one. The principles are meant to guide, but not specify, operational practices. The guidance is evidence- based to the extent possible and the supporting evidence is documented and briefly discussed. The approach in this guidance is flexible and scalable according to the resource and capability limitations of the community. The recommendations should be adapted as each unique community sees fit according to their own hazard and risk assessment. Examples of how the guidance might be used include: • Planners: incorporate current evidence-based recommendations during development or revision of an organization’s response plans. • Community leaders, public health officials: enhance system-wide coordination and develop plans for communicating with patients and the whole community. • Trainers: develop, improve, or augment training of response personnel for patient decontamination operations, using current evidence-based recommendations. • Emergency managers: generate policy and plans to address issues related to system-wide coordination, the whole community response, and crisis and risk communications, as well as other overarching issues. • Hospital emergency managers: incorporate evidence-based recommendations into the hospital response plan and training program addressing the hospital’s unique challenges, and enhance coordination of the hospital response with those of the rest of the community through effective interagency planning and communication. • Researchers: identify knowledge gaps and conduct research to investigate them. Guidance statement format and quick reference guide In Section III, each of the guidance statements is described in full along with associated information in the following format: Functional Area The guidance statements are organized by six functional areas, each broadly describing a key element of the response Guidance Statement Full text of the guidance statement (GS) Considerations Additional factors that should be considered when implementing the guidance statement LOC Level of Confidence rating (described in Appendix D) for the evidence on which the guidance statement is based Discussion Briefly describes the evidence applicable to the guidance statement, from reviews of the scientific literature, current practices, and subject matter expert opinion and experience 3 Quick Reference Guide Page Functional Area GS# Description # The decision to decontaminate should take into account a combination of key indicators, including (but not limited to): • Signs and symptoms of exposure displayed by the patient; • Visible evidence of contamination on the patient’s skin or clothing; • Proximity of the patient to the location of the release; 1.1 • Contamination detected on the patient using appropriate 24 detection technology; • The chemical identity (if known), physical state, characteristics, and behavior; and • Request by the patient for decontamination, even if Determining the contamination is unlikely Need for Patient Decontamination Decontamination should be performed if the potential contamination on a patient requiring transport to, or care in, a health care facility poses a reasonable risk of exposure to first 1.2 27 responders, first receivers, other patients, or contamination of critical infrastructure. If the likelihood of adverse consequences from water-based decontamination methods outweighs the likely health outcome 1.3 gains, then patient decontamination should be performed 29 using alternative practices. A risk-based approach should be employed by a responding or receiving organization to determine the appropriate response 2.1 level and associated strategies and tactics, including PPE, 31 medical interventions, and decontamination. A tiered approach to patient decontamination allows responders and

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