This current climate reminds me of what Winston Churchill once said about the survival and triumph of Great Britain after the bombing of London during World War II. Churchill referred to this victory, as Britain's finest hour when he said, "Never was so much owed by so many to so few". HazMat has now been thrust into the limelight because of the biological threat and it is enjoying the well-deserved attention. In many municipal fire departments hazmat programs are thought of as the unwanted red-haired step child, but no longer. Response to biological threats will most likely be a reality for Americans for some time and hazmat response teams will play a significant role in protecting the public. Right now, this is indeed hazmat's finest hour!
Visionaries
Two decades ago, John Naisbitt and his staff recognized emerging trends in both our country and the world in terms of economics, culture, and even scientific endeavors. Consequently, Naisbitt wrote a book in 1982 citing these trends called "Megatrends". This book discussed one identifiable trend of our society moving from the scientific focus of chemistry to one of physics or nuclear power eventually to a biological focus. It is easy to see that Naisbitt was right on the mark; biological research has been in the news often especially with research with stem cells, DNA, and even pharmaceuticals. Unfortunately, biology also represents a sinister element when it comes to weapons of mass destruction (WMD).
The Threat
That brings us to our current circumstances. Anthrax (bacillus anthracis) has been delivered through the mail to several locations across the country resulting in numerous exposures. While a few people have died from anthrax exposure due to inhalation several people have contracted anthrax from dermal exposure. Hoaxes involving powders and solids have also been numerous with many large cities reporting hundreds of calls per day. These types of responses demand our vigilance, as we have to respect the threat. It is also important to realize that these unknown powders have potential for being other biological hazards such as botulism, tularemia, or small pox. Additionally, these powders could be chemical in nature to include cyanides, arsenics, or organophosphate pesticides.
Much has been written about anthrax (and other biologicals), its hazards, its medical complications, and medical treatment, but little has been written addressing response guidelines for first responders or fire departments. There have been numerous training sessions conducted across the country by the Department of Defense, the International Association of Fire Fighters (IAFF), and other groups and institutions on the subject of terrorism. There has also been many first responder guidebooks issued for WMD incidents in addition to the Department of Transportation (DOT) Emergency Response Guidebook (ERG) yet many first responders feel very vulnerable. In a recent firehouse.com poll over 80% of respondents said they were unprepared to handle a WMD incident. In another poll at the same website 54.7% of respondents had recently responded to an anthrax threat. It is for these reasons that this column will concentrate on strategies or protocols for responses to unknown powder threats. Especially timely is the fact that on October 25, 2001 a clear and concise guideline was issued by the Centers for Disease Control (CDC) in response to the anthrax threat for first responders. The CDC guideline will also be included in this column.
General Guidelines
Recently, there have been issued response guidelines by the CDC and other agencies for general audiences on how to handle anthrax and other unknown powder threats. Many of these guidelines can be accessed on the web at the sites listed in the resource section of this column. As a general overview these guidelines include;
How to handle situations with threat letters;
bag the envelope or package without excessive movement (if no container is available just cover the material without disturbing it)
Additionally, the CDC has recently issued public health advisories to state health departments with the following information;
Double bag letter using zip-lock clear, plastic bagsBut these guidelines may not be specific or informative enough for your locale. It may be prudent to issue additional information such as;
Discouraging the public from opening envelopes and then blowing into them to gain access to a letter. This highly risky habit needs to be reconsidered.
First Reponder General Guidelines
All first responders should remember that responses to unknown powder releases fall under hazardous material response guidelines. All previous training for hazmat response still applies. Most agencies use some type of plan or general guideline for hazmat response. If not, there are many such guidelines to adhere to such as;
- APIE by the International Association of Fire Fighters (IAFF)
- DECIDE by Ludwig Benner
- Eight Step Process by Michael Hildebrand and Gregory Noll
- GEDAPER by David Lesak
The point here is to find a process you feel comfortable with, train your personnel, and use it on all hazmat and unknown powder releases.
HazMat Response Team General Guidelines
Some general guidelines also exist for hazmat response teams for anthrax and other biological or unknown powder releases.
Remember, anthrax is a spore. It is not a true spore such as that of a puffball mushroom spore which is genetically designed for airborne dispersion. Anthrax is a bacterium, which develops a spore casing so it can survive in soil or water. While it is difficult for anthrax to become airborne if a sufficient amount of spores are in the air they present an inhalation (8,000 - 10,000 spores) or dermal exposure hazard, but this would usually require sufficient energy through some type of dissemination device to project a lethal concentration. If these conditions exist the following are some response considerations.
Site Control or Scene ManagementTriage the Scene - Who was exposed? Patients who have product on them, touched the product or walked though a visible airborne concentration, are considered to be exposed. Other people who merely stepped into a room that contained a suspected contaminate, were in the room and did not have contact with the product, did not have contact with visible airborne concentrations, or significant contact (cross contamination) with other exposed people are at little risk and should be considered for release.Isolate the Scene - Evacuate only what is necessary! A work area or a room is generally adequate, unless there has been a visible airborne release in which securing the ventilation system may be a consideration. Only in extraordinary cases should an entire occupancy be evacuated. Remember, Anthrax is not genetically engineered for airborne dispersion!
Establish Safe Refuge Areas - Establish a safe refuge area to keep exposed patients until they can be evaluated, decontaminated, and processed for medical transport. Preferably keep them indoors, but away from the exposure area. This will limit the possibility of cross contamination and it will also prevent environmental conditions such as wind, from sending particles airborne. An indoor safe refuge area will also significantly simplify modesty concerns associated with patient decontamination.
Decontamination
If no visible product is present- The only concern is patient(s) that have had direct contact with the suspected letter or package. Have patient(s) wash hands, face, and exposed skin with soapy water or anti-microbial solution. No transport or treatment advised. Obtain name, address, and phone for follow-up.
If there is a visible product but no airborne release- Have patient(s) wash hands, face, and exposed skin with soapy water or anti-microbial solution. Transport may be advised if dermal exposure to open wounds is suspected.
If there is a visible airborne release with dermal and inhalation exposures- Have patient(s) wash hands, face, and exposed skin with soapy water or anti-microbial solutions. As soon as possible, mist down the patient(s) with water in spray bottle to eliminate inhalation and cross contamination hazard. Have the patient(s) remove outer clothing and provide TyvekR coveralls or even hospital scrubs for re-dressing. Provide for modesty. Have hazmat personnel package contaminated personal effects such as wallets, purses, jewelry, etc in clear, zip-lock bags and give to the patient. In most instances, these items will not be contaminated and do not require packaging.
For gross product contamination- A shower may be indicated in extreme cases and a garden hose or fixed shower at the facility may be adequate. Time is not critical! Take your time and make good sound decisions.
Sample Responses
Another good idea to see if your response guidelines are prudent is to find out what other responders are doing in response to similar problems. A quick check with fire departments around the country found that responses to unknown powder releases vary greatly. For instance;
Akron is sending a hazmat battalion chief initially to these incidents to assess the situation and then make appropriate decisions as to what is needed for mitigation. If it is a mail problem the post office officials handle or remove the problem after the hazmat team stabilizes the situation. If it is a substantial threat or package with a threat the hazmat team works with local law enforcement and explosive ordinance disposal (EOD) teams, and the FBI to safely mitigate.
Boston is sending 5 man response teams to these types of incidents with 2 entry, 1 safety, 1 Team Leader, and 1 Communications person. The entry personnel are wearing Level C protection with TyvekR suits (double suiting with credible threats), TyvekR booties, double gloves, and air-purifying respirators (APR's). All material gets triple bagged and taken to the public health laboratory for analysis. Boston has also adapted the concept of large, clean plastic glove bags that are used for asbestos removal to drape over packages. This concept encapsulates the package and minimizes airborne releases when the package is opened.
Honolulu is sending both hazmat units separately to their unknown powder incidents. They are considering utilizing rapid action teams to initially assess the situation. These teams would consist of two technicians with Level B protection (TyvekR suits and self-contained breathing apparatus (SCBA)) and decontamination equipment. Health department and EOD would also respond as needed. Honolulu is also using glove bags for package opening but first the package is screened for radiation and x-rayed for explosives by the local Explosive Ordinance Disposal (EOD) team.
Miami-Dade has added an additional hazmat response unit just to deal with the increased call volume for these incidents. Their hazmat units are responding to over 100 calls per day at this time.
Milwaukee is responding to these incidents with TyvekR suits and cartridge respirators.
Phoenix is using Level B protection for anthrax/unknown powder releases.
It is dangerous if your own department has been all over the board regarding these unknown powder responses because there is no consistency. Inconsistent responses make for responder injuries and possible lawsuits. To correct these types of responses the following response guidelines may assist you. They have been developed with safety, efficiency, consistency, and reasonability in mind.
Response Considerations
Consider a terrorist event to be any event that was intended to do harm to life, the environment, or property. This includes both physical harm and disruption of normal activities.
At any intentional event, responders must be concerned about secondary devices, the risk of being assaulted by the perpetrator, or the possibility that the perpetrator will in some way interfere with efforts to aid the original target. In addition, responders must be more concerned with preserving evidence than they would be at an accidental event.
Accidental Event or Terrorist Attack?
Responders need to determine whether or not there is a credible threat present at every incident. The following are general indications that should raise suspicions of a possible terrorist event.
Unexpected/Suspicious packages and letters
