National Toxic Substance Incidents Program:

Assessment of Chemical Exposures Investigations

Mary Anne Duncan, DVM, MPHUnited States Public Health Service

Division of Health StudiesAgency for Toxic Substances and Disease Registry

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.

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

• Preparedness training

• Targeted prevention activities

• Identification of health effects of chemical exposures

Development of a Body of Knowledge

Three Components

1. State-based Surveillance

2. Incident Investigations

3. National Surveillance

Part I: State-based Surveillance

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

• 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

State-based Surveillance

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

Part II: Incident Investigations — Assessment of Chemical

Exposures (ACE)

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

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

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

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

Community Survey

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

Biological and Environmental Sampling

• Biological – If available – Blood– Urine

• Environmental Sampling– When applicable– Air– Water– Soil– Surfaces

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

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

Part III: National Surveillance

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

National Database of Toxic Substance Incidents

• Operational early 2010

• For use by:

– Federal agencies

– Responders

– Public health officials

– Public

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

Assessment of Chlorine Exposure and Health

Consequences Following Graniteville

Train Derailment

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)

Objectives

• Extent and location of exposure

• Morbidity

• Use of health services

• Risk factors for severe outcomes

• Persons at risk for long-term sequelae

Case Definition

• Death or illness

• Chlorine exposure

• January 6 – February 17, 2005

• Area of Graniteville, SC

Case Finding

• Review of hospital emergency department logs

• Health advisory

• Mandatory reporting by physicians

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

Results

Total Cases

Deaths

Hospitalizations

Outpatients

605

9

72

525

No. %

Male 332 (59)

WhiteBlackHispanicOther

255 150

1110

(60)(35)

(3)(2)

Mean Age (Range)

Demographics

36 (<1 – 85)

Epidemic Curve (n=569) Cases by Day of Presentation

0

20

40

60

80

100

260

280

1 3 5 7 9 11 13 15 17 19 21 23 25

ED Visit, Not Admitted

Admitted to Hospital

Deceased

Day(s) Since Accident

Cases

Facility (n=263) No. %

Aiken Regional Medical Center 109 (41)

Other SC hospitals 8 (3)

Augusta, GA hospitals 146 (56)

Patients Treated at Emergency Departments within 24 Hours

Method of transport (n=150) No. %

Privately owned vehicle 94 (63)

Emergency medical services 51 (34)

Other (police, company vehicle) 5 (3)

Method of Transport to Medical Facility – First 24 Hours

Decontamination

• Three sites

• Four hospitals

• Wet decontamination

• 107 (38%) decontaminated

• Secondary exposures

Symptoms Reported

Symptom (n=280) No. %

Coughing 219 (81)

Eye burning 204 (76)

Shortness of breath 137 (73)

Nose burning 199 (52)

Vomiting 90 (34)

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

Limitations

• Unable to contact half of the patients for interview

• Self report of symptoms

• Legal concerns

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

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

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

AcknowledgementsSC 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