GOOD

Hello and welcome to "Recognition of Illness Associated With Chemical
Exposure".

I'm Cynthia Good, your moderator for this program which is originating
from the Centers for Disease Control and Prevention in Atlanta, Georgia.

This program is sponsored by the National Center for Environmental
Health/Agency for Toxic Substances and Disease Registry and the Public
Health Training Network.

The goal of today's program is to increase the likelihood that
physicians and public health professionals will recognize
chemical-release-related illness so that public health authorities can
implement the appropriate emergency response and public health actions.

Upon successful completion of the program, participants will be able to
describe:

Epidemiologic clues that might suggest the covert release of a chemical
agent and . . .

the importance of reporting and surveillance in recognizing outbreaks of
illness resulting from exposure to chemicals and toxins.

If you'd like to register and evaluate this program, you can do so from
August 5^th^ through September 4^th^, 2004 at
[www.phppo.cdc.gov/phtnonline](http://www.phppo.cdc.gov/phtnonline).

The Webcast and Web on Demand registration and evaluation begins
September 5^th^, 2004. The course numbers are WC0061 for the webcast and
WD0049 for Web on Demand.

If you have any questions about registration please call 1-800-41-TRAIN
or you can

e-mail us at ce@cdc.gov

And though your evaluation is appreciated, it is not required.

Now it\'s my great pleasure to introduce our two distinguished
panelists. They are:

Dr. Manish Patel, Medical Toxicologist, Division of Environmental
Hazards and Health Effects, National Center for Environmental Health,
CDC and . . .

Dr. Martin Belson, Medical Toxicologist, Division of Environmental
Hazards and Health Effects, National Center for Environmental Health,
CDC

Welcome, gentlemen.

Since the September 11, 2001 attacks, there is increasing concern in the
United States about other potential terrorist attacks such as those
involving the use of chemical agents.

September 11^th^ was an obvious or an overt attack but future terrorist
attacks may not be so obvious and may be more covert.

Martin, can you distinguish between covert and overt events and how they
relate to chemical terrorism, commonly referred to as a CT event?

BELSON

Thank you, Cynthia. We would first like to give a very brief background
on the two types of chemical events.

The intentional release of a chemical agent into the environment may be
an overt or covert event. An overt event, which receives most of the
national focus, is one in which the nature of the event reveals itself.

Examples of an overt event include a large explosion of a chemical
container or a release of a nerve agent in a subway, such as the Tokyo
sarin attacks in the 1990s.

PATEL

And as Martin mentioned, terrorism also can be covert, that is, an
unrecognized release in which the presentation of sick patients might be
the first sign of an exposure, such as deliberate contamination of food,
water, or a consumer product.

An example of a recent covert event would include the ricin incidents
where castor beans were ground up and ricin was extracted and put into
the mail system with the specific intent of harming individuals.

BELSON

Previous events, some very recent, involving intentional or inadvertent
contamination of food or product tampering with chemicals have
highlighted the need for physicians and public health officials to be at
heightened alert for patients in their communities who have signs and
symptoms consistent with chemical exposures.

PATEL

Let's begin with our first example of how the presence of ill people
might be the first sign of a deliberate contamination or a terrorist
event.

In January 2003, 18 people from four families became ill after eating
ground beef that was purchased either on Dec 31st or Jan 1st. Symptoms
included nausea, vomiting and a burning sensation in the mouth; one
person developed atrial fibrillation. None of the patients required
hospitalization.

Since ground beef was the only commonality, the supermarket, in
conjunction with the Michigan Department of Agriculture and the USDA
issued a recall of approximately 1700 pounds of ground beef. 120 people
returned the recalled product and 36 more people reported being ill.
Company officials submitted samples of ground beef provided by the ill
families to a private lab where they found high concentrations of
nicotine in the beef.

The supermarket issued multiple press releases and recall notices. It
was eventually discovered that the product was contaminated at a single
store rather than at the processing plant. The local health department
alerted hospital EDs and local medical practices in the area. In all, 92
people had an illness consistent with nicotine poisoning after eating
the contaminated beef.

An employee of the supermarket intentionally poisoned 200 pounds of beef
with a nicotine containing insecticide. He was subsequently arrested and
indicted for this event.

BELSON

Prevention of potential future events, such as the example given by
Manish, are a real challenge because of the large number of toxins and
chemical agents and the infinite combination of agents and dissemination
scenarios.

Despite some difficulties in recognizing illness from a covert exposure,
there are ways to overcome the challenges. We will focus on what health
care workers and public health professionals can do to improve
recognition of covert illness from intentional contamination through
food, water, or medications. We will offer epidemiologic clues and
clinical signs or patterns of illness that might suggest covert release
of a chemical agent. Early recognition of illness associated with these
types of exposures is vital because early detection of an outbreak has
the greatest potential for limiting the scope of the illness.

PATEL

We will also discuss public health strategies for responding to
intentional chemical releases and emphasize the importance of reporting
and surveillance so that public health authorities can implement the
appropriate emergency response and public health actions.

GOOD

Okay Manish, why don't you start us off with a discussion of why a
covert release of a chemical agent might be difficult to identify?

PATEL

I will be glad to. The way we see it, there are six obstacles that might
delay the recognition of a chemical-related illness. We will discuss
each one of these in detail.

These obstacles include the potential for delayed health effects that
might occur with certain chemicals; the outbreak may occur over an
extended period of time with gradual presentation of cases following
certain exposures; in a terrorist scenario, there also is a potential
for exposure to multiple agents; some chemicals are also notorious for
causing non-specific illness resembling other common natural illnesses;
and lastly, many chemical-related illnesses are not encountered that
often and this lack of familiarity may make it difficult to recognize
and treat these illnesses.

Let's discuss our first obstacle. Chemicals do not always cause acute
and obvious health effects. Immediate symptoms of chemical exposures
might be nonexistent or mild despite the risk for long-term effects.
Because of this lag time, it may be difficult for us to recognize the
exposure source leading to the illness.

BELSON

Some examples include pharmaceutical agents such as digitalis, which can
cause toxic effects at very small doses and symptoms may not be evident
for up to several hours.

Depending on the dose and the chronicity of exposure, symptoms from
heavy metal poisoning such as dimethylmercury or lead poisoning may not
be evident for weeks to months.

Warfare agents such as phosgene may result in pulmonary edema up to 48
hours after exposure.

Carcinogens such as aflatoxin may not result in a detectable illness for
years.

Reproductive toxins such as isotretinoin or Accutane are also examples
of agents leading to delayed health effects.

Chemical toxicity also depends on dose-gradient or dose-response. In
other words, those further away from a source, inhalational for example,
or those who consumed less of a contaminated product will be affected
less.

Physicians and public health professionals will need to try innovative
approaches and think outside the box to detect these illnesses and
prevent further morbidity and mortality.

PATEL

That's right, Martin.

As you can see in this graphic,

the second possible obstacle to recognition could be from contamination
of food, water, or consumer products, especially at a location such as a
distribution facility. Unless detected early, the ongoing community-wide
exposure may continue through the distribution chain. This might result
in reports of illness to physicians over a long period and in various
locations, such as grocery stores and pharmacies, through the city,
state, or possibly across the country.

GOOD

What are your thoughts on that, Martin?

Can you give us an example to demonstrate that point?

BELSON

Yes, Cynthia, I do have a good example of an incident involving the
adulteration of medication that caused illness over a couple of days in
different areas of a city.

In 1983, seven sudden deaths occurred over a two-day period in several
different suburbs of Chicago. Three of these deaths occurred in one
family and one death involved a 12-year-old child.

At first, the deaths appeared to be unrelated as the first patient was
initially believed to die of a stroke and the second appeared to have
suffered a massive heart attack. But an astute physician at a Chicago
area hospital grew suspicious when two family members of the first
victim were admitted to the hospital with severe hypotension and
unexplained acidosis.

The physician reported the cases to the regional poison control center
and based on the signs and symptoms, cyanide was suspected and
subsequently confirmed. Also, an investigation into these deaths
progressed when two observant off-duty firefighters made the connection
of the deaths to Tylenol.

Subsequent investigation by law enforcement and public health agencies
revealed that eight bottles of Extra-Strength Tylenol had been removed
from six different Chicago area stores over a period of weeks to months,
and placed back on the shelves of five different Chicago area stores, as
shown on the map. Five Tylenol bottles involved in the seven deaths were
purchased at these five stores.

Two lots of Extra-Strength Tylenol were recalled from the market when
the link was made. This recall involved over 250,000 bottles. FDA issued
a national warning not to take any Extra-Strength Tylenol. As you would
expect, there was nationwide concern.

Within days FDA had inspected more than a million Tylenol capsules from
across the nation and fortunately no additional cyanide-laced capsules
were found outside of the Chicago area.

A priority in the investigation was to determine the location of the
tampering. Was it during the manufacturing process, during shipping, or
at the retail level?

Because the cyanide-laced Tylenol was discovered in shipments from more
than one plant and had only turned up near Chicago, investigators
concluded that any tampering occurred at the retail level. To this day,
the perpetrator has not been identified.

For years following this incident, a wave of copycat tamperings with
cyanide occurred in the United States including Lipton Cup-A-Soup in
1986, Excedrin and Tylenol in 1986, and Sudafed in 1991.

GOOD

That's a frightening story. Manish, what are some other obstacles in
recognizing a chemical-related illness?

PATEL

Another obstacle that could lead to difficulty in recognition might be
exposure to multiple chemical agents.

For instance, simultaneous exposure to a nerve agent and arsenic would
result in obvious clinical effects that would likely resemble a
cholinergic syndrome . . . in other words, patients are likely to have
excessive salivation, lacrimation, sweating, vomiting, diarrhea, and
pulmonary secretions.

In the setting of a chemical terrorism event, the likely diagnosis will
be nerve agent poisoning and providers will institute the appropriate
therapy . . . atropine and pralidoxime. However, in this scenario,
arsenic is likely to be overlooked. Arsenic most likely will cause
vomiting and diarrhea but will not result in an obvious toxidrome
leading to a rapid diagnosis in this setting.

BELSON

So Manish, as a physician if it is already difficult for me to recognize
an illness related to a single covert exposure, how do I recognize an
exposure that potentially involves more than one chemical agent?

PATEL

Good question Martin. We are often taught the principle of Occam's
Razor, which states that even things which seemingly do not fit together
well can be explained by ONE unifying theory, or in other words, one
cause typically explains the entire clinical picture. Although this may
be true with a naturally occurring disease, with a malicious event keep
in mind that more than one agent may be introduced into the environment.

So, in answer to your question, initially, I would recommend treating
the patient's signs and symptoms at hand, however, for admitting
physicians and public health officials, it may be prudent to consider a
wider differential and make use of available environmental & biological
screening tests to rule out other reasonable causes of illness.

BELSON

Thanks, Manish. That really makes sense.

You know, chemical poisoning also is notorious for resulting in
nonspecific signs or symptoms that resemble other common diseases.

For instance, arsenic is very likely to resemble viral gastroenteritis.

Inhalation of ricin will result in a non-specific illness with
generalized fatigue, malaise, and constitutional symptoms.

Acute lead poisoning may lead to neurologic emergencies such as
status-epilepticus or encephalopathy that may be misdiagnosed initially
as meningitis.

Cyanide, a potent cellular poison, will lead to shock and acidosis which
could easily be mistaken for more common causes of shock such as acute
cardiac failure and sepsis.

PATEL

Finally, physicians might be less familiar with recognition and
treatment of illness related to chemical agents simply because illness
from most chemicals is just not that common or at least not recognized
as often as it occurs.

Take for example:

Paraquat . . . a toxic herbicide still available across the world;

cyanide . . . another commonly found potent poison;

and then there is ricin. There are very few clinicians in this world,
much less this country, who have ever seen a case of ricin poisoning.
However, ricin is a potential agent of chemical terrorism.

Poisoning from metals such as thallium, mercury and arsenic also is not
commonly seen.

BELSON

And one last obstacle I should mention is that some chemicals and toxins
such as ricin, present unique advantages for deliberate contamination
because they tend to be odorless, colorless, and tasteless.

PATEL

Let me give you an example that nicely illustrates the non-specific
illness caused by certain chemicals and the difficulties encountered
even after these illnesses are recognized.

On a Sunday afternoon during the spring of 2003, there was a church bake
sale in the small town of New Sweden, Maine, which has a population of
less than a thousand.

During the church function, sixteen adults became acutely ill with
gastroenteritis like symptoms. Most people had vomiting, some had
diarrhea, and a few became hypotensive. After these patients arrived at
the local ED, a relatively small facility, the staff immediately
recognized the cluster of illness and called the hospital infection
control nurse. Rightfully so, the initial concern was that this cluster
was an infectious or a typical food borne illness.

The regional poison control center was also called. At this point one
person was in the ICU with the diagnosis of sepsis and five patients
were hypotensive. The PCC staff and toxicologist immediately recognized
the unusual nature of the clinical course for people with typical food
borne gastroenteritis. They suggested a chemical as the cause of the
illness.

Preliminary epidemiology suggested coffee as the source of illness. The
state laboratory was immediately prepared for wide-screen testing of
chemicals and biologic agents. The following morning, on Monday,
biological samples were couriered to the state lab, maintaining chain of
custody. Samples arrived at the state lab at 5:00 PM and were analyzed
within two to three hours.

High levels of arsenic were identified in the coffee and the biologic
samples within 24 hours of patients' presentation to the ED.

By any standard, this was a phenomenal response by the health care
workers, public health and law enforcement agencies of Maine.

GOOD

Manish, I know you are an emergency physician, but were there any
ongoing treatment issues or follow-up considerations for these patients?

PATEL

Yes Cynthia, but recognition was only part of the battle.

As we discussed, lack of familiarity with treatment of illness related
to chemical agents is also likely to be a problem, simply because we do
not see these outbreaks frequently. Beyond recognition, there were many
difficulties with regards to the appropriate treatment of arsenic
poisoning, the availability and shipment of antidotes, how long to
observe patients, how long to pursue cardiac monitoring, the frequency
of laboratory analysis, and the expected prognosis of the patients.

In addition, illness from chemical exposures is typically thought to be
short-lived; in other words, a misperception might be that patients
usually survive without complications or die shortly after a chemical
exposure.

However, arsenic is a perfect example of how certain chemicals are also
notorious for causing long-term complications such as skin cancer and
cardiac arrhythmias.

GOOD

All of this really sounds overwhelming and fatalistic. But are there
ways to prepare ourselves for the challenges posed by these chemicals?

Martin, what can we do to recognize these potentially covert events?

BELSON

That is exactly what we are going to spend the remainder of the hour on
. . . specific strategies to recognize illness associated with the
covert release of a chemical agent into the environment.

Despite some difficulties in recognizing illness from a covert exposure,
there are ways to overcome the challenges. Ultimately, it involves
familiarity with the epidemiologic clues and the syndromic presentations
of chemical agents exposures.

First, let's discuss the epidemiologic clues that might suggest the
covert release of a chemical agent. The first clue is an unusual
increase in the number of patients seeking medical care. These patients
may seek care in clusters all in the same day, or may be spread out over
time, such as over a period of weeks.

An excellent example of an increased number of patients seeking medical
care is the arsenic poisoning outbreak in Maine, which involved 16
people. Reporting of such a large number of illnesses to the proper
authorities is important for a number of reasons but there is one I
would like to emphasize now.

This event was detected by national poison control center surveillance
because astute health care workers recognized the event as a possible
noninfectious poisoning and reported the cases to their regional poison
control center.

The poisoning surveillance system detected an increase in the number of
poison exposures for the hour that the cases were called into the
Northern New England PCC. Based on the surveillance methods, the
expected number of poisoning calls for this center between 6 to 7 PM is
13. On the day of the church poisonings, 17 calls took place to the
poison center during this one-hour period. This resulted in an alert at
the national level.

Obviously, the regional poison center was aware of this cluster and
helped manage the patients involved;

however, it's important to not only recognize this on the local level
but also on a national level in order to identify trends or patterns of
illness at other locations throughout the country. This would be crucial
in a potential widespread terrorist act.

Another very useful epidemiologic clue is the cluster of illness in
people who have a common exposure, such as drinking water or eating food
from the same source:

PATEL

The Michigan ground beef incident we discussed earlier is a perfect
example. In this outbreak, there were four families with 18 people that
initially became ill over a two-day period.

As it turned out, all of the ill people ate beef purchased from the same
store prior to becoming ill.

GOOD

Martin, it appears that a detailed historical evaluation is crucial in
this type of circumstance.

BELSON

Yes Cynthia, you are correct. This really points out the importance of
what we have all been taught early in our training . . . to ask and
record the food and beverages consumed by the patient prior to a GI
illness.

Another epidemiologic clue is the rapid onset of symptoms after an
exposure to a potentially contaminated medium.

PATEL

Both the Michigan beef outbreak and the Maine arsenic event are perfect
examples. In the arsenic outbreak, there were many reports of a "funny"
taste to the coffee, and the onset of illness was within an hour of
drinking the coffee.

Again, this points out the importance of a detailed epidemiologic
investigation.

BELSON

Unexplained death of plants, fish, or animals, either domestic or wild,
is an additional epidemiologic clue that might suggest the covert
release of a chemical agent.

PATEL

Absolutely! For example, just this past spring CDC and state and local
health officials investigated the death of several dogs shortly after
the dogs swam in a lake in Nebraska. Their deaths were attributed to a
toxin released from Microcystins, a blue-green algae, found on autopsy
and in the lake water.

Fortunately, no significant illness occurred in humans living around the
lake, but the death of the dogs alerted public health officials to a
potential human health threat.

BELSON

Lastly, unexplained deaths among young or healthy people may alert you
to a covert

Chemical illness.

PATEL

I have an example that nicely illustrates your point. During a six-month
period between November of 1995 and July of 1996, 109 previously healthy
children were admitted to the University hospital in Port-au-Prince,
Haiti, with acute renal failure. 99 of the 109 children died. At this
hospital, no children had been admitted with this diagnosis in the
preceding five years.

Members of multiple international agencies collaborated with the
hospital and the Ministry of Health of Haiti to determine the cause of
the outbreak, institute control measures, and evaluate their
effectiveness. The epidemiologic investigation revealed that a locally
manufactured acetaminophen syrup was highly associated with the illness.

Subsequent laboratory analysis of the product revealed high
concentrations of diethylene glycol, a known human toxicant. Traceback
investigation revealed that DEG contaminated a shipment of glycerin
imported to Haiti from China.

Withdrawal of the glycerin-containing products from the market resulted
in an abrupt cessation of cases.

GOOD

Thanks Manish, for your description of that unfortunate, but
educational, outbreak. Martin, I believe you have some information about
the recognition of a chemical event.

BELSON

Yes, Cynthia. I would like to turn our attention to toxicologic
syndromes, another useful tool in the recognition of a chemical event.

A toxic syndrome can be defined as a constellation of clinical signs and
symptoms typical for a given chemical exposure.

The photos seen here represent the clinical syndrome for a vesicant, or
blistering agent, exposure, in which large bullae are present along with
eyelid edema and conjunctivitis.

Many chemical agents could be used as covert weapons, and the actual
clinical syndrome will vary depending on the type of agent, the amount
and concentration of the chemical, and the route of the exposure.

Also, some syndromes can be caused by many different agents. For
example, caustics and corrosive chemicals can also cause a syndrome
similar to the vesicants syndrome shown in the previous graphic.

In general, treating exposed people by clinical syndrome rather than by
specific agent probably is the most pragmatic approach to the treatment
of illness caused by chemical exposures.

PATEL

As Martin mentioned, the list of chemical agents is exhaustive. The
bright side, however, is that because many agents have similar chemical
properties, there are a limited number of clinical syndromes. Certain of
these clinical syndromes are more likely to occur than others based on
factors such as high toxicity and ease of availability and dispersal of
certain chemicals.

In recognizing covert CT events, the KEY message to remember is that, it
will really involve recognition of patterns rather than individual cases
. . . the pattern to recognize will involve a combination of
epidemiologic clues and clinical syndromes.

One classic example of a clinical syndrome that we should be aware of is
cellular hypoxia. When we talk of agents that cause cellular hypoxia, we
are talking about chemicals that impair the ability of our body's cells
to utilize oxygen. Signs and symptoms are typically nonspecific and,
depending on the dose, may be mild, such as nausea, vomiting, and
headache, or severe such as delirium, dyspnea, hypotension, seizures,
and metabolic acidosis.

The hallmark of toxicity in this syndrome is acidosis, particularly
unexplained acidosis.

Again, an isolated case of unexplained acidosis is not something that
would tip off clinicians; however, if combined with the epidemiologic
patterns we discussed earlier, a CT event should be considered.

BELSON

Manish, let me mention here that one reason that the cyanide outbreak in
Chicago was detected early was because an astute clinician recognized
the unusual pattern of unexplained acidosis in two family members.

PATEL

Thanks Martin.

Toxins causing cellular hypoxia include:

Cyanide, the most likely CT agent in this group;

carbon monoxide,

hydrogen sulfide,

sodium monofluoroacetate, which is an agent used as a rat poison in the
past;

and sodium azide, an industrial chemical.

Another clinical syndrome is one with a combination of peripheral
neuropathy and CNS effects.

Signs and symptoms of peripheral neuropathy may include: muscle
weakness, sensory loss in the "glove and stocking" pattern, and
depressed deep tendon reflexes.

CNS signs and symptoms include memory loss, delirium, ataxia, and
encephalopathy. Examples of toxins responsible for this syndrome are
lead, thallium, organic mercury, acrylamide, hexane, carbon disulfide
and inorganic arsenic.

Although this syndrome can present after an acute exposure to these
agents, the signs and symptoms may develop days to weeks . . . and even
months . . . after the initial exposure.

We will really have to be hypervigilant about recognizing these
presentations. I believe Martin has an excellent example for this
syndrome.

BELSON

Yes. In 1988, three members of the same family became ill with an
unknown disease.

They acutely developed parasthesias,

extremity weakness, blurred vision, dry mouth, and cranial nerve
abnormalities followed by psychosis.

Initially, botulism was the suspected diagnosis. However, all three
developed alopecia or hair loss This finding prompted urinary screening
for heavy metals. Thallium poisoning was confirmed in all three
patients.

The mother died two months later of an acute respiratory arrest and her
two sons survived but suffered from persistent upper and lower muscle
weakness.

Following an exhaustive epidemiologic and environmental investigation,
it was determined that the source of the thallium was the contents of
soft drink bottles found in the home.

The evidence that thallium was introduced into the bottles after
purchase from a store included the fact that cases were only within one
family, evidence of bottle tampering existed, and an anonymous death
threat against the family six months before the illnesses had occurred.
Ultimately, a neighbor was arrested for the crime one year later.

PATEL

Good example! Lastly, the classic syndrome that we have all heard about
is cholinergic crisis.

The typical signs and symptoms leading to diagnosis of this syndrome
will be excess secretions such as salivation, lacrimation, diarrhea,
diaphoresis, bronchorrhea, and urination. Other signs and symptoms
include miosis, fasciculations, weakness, bradycardia or tachycardia,
hypotension or hypertension, delirium, and convulsions. Toxins resulting
in the cholinergic crisis might include nicotine, organophosphates,
nerve agents, and carbamates.

BELSON

Let me give you an example of an outbreak involving signs and symptoms
consistent with cholinergic crisis.

On June 29, 1985, in Oregon an astute physician reported to the State
Health Division illness in five people occurring 30 minutes after eating
striped watermelon. Two families were involved, and watermelon was the
only food eaten in common. Symptoms included vomiting, diarrhea,
salivation, blurred vision and fasciculations. This symptom complex
initially led the reporting physician to suspect organophosphate
poisoning.

Two nights later, on July 1^st^, a second incident occurred involving
two people who consumed striped watermelon. Symptoms were similar to
those of the first group. These incidents were reported to the Health
Division which determined all the watermelons were linked to the same
distributor. The distributor voluntarily recalled the watermelons.

Surveillance was initiated after the second group of cases in which five
area emergency departments were alerted and asked to report cases. Over
the July 4th holiday, additional cases were reported from Oregon,
Washington, and California.

Both striped and green watermelons were implicated from multiple
distributors, and residues of the pesticide Aldicarb, a potent
carbamate, was detected in some watermelons. Consequently, all
watermelons were recalled on July 5th by the Health Division and the
Oregon Department of Agriculture. Similar action took place in
California and Washington.

GOOD

Wow. Let me ask you guys another question. I have heard that patients or
their clothing may have a particular odor after a chemical exposure. Is
this true and do you have any specific examples?

PATEL

Yes, for example, the smell of tobacco suggesting nicotine or the smell
of garlic suggesting arsenic or organophosphates. A description of
rotten eggs odor suggests hydrogen sulfide, and the smell of freshly cut
hay suggests phosgene.

However, we must admit that chemical odors have not traditionally been a
sensitive method of detecting poisonings. If you smell it, great, you
may have a diagnosis. But, don\'t expect an odor on every patient
exposed to a chemical.

GOOD

The watermelon-Aldicarb outbreak just discussed exemplifies some
important points that we would like to turn our attention to. Up until
now, we have talked about how critical it is for health care providers
to recognize illness related to a possible CT event. Now

Manish, let's switch our focus to the reporting of events . . . a
critical step for improving and protecting public health.

PATEL

Thank you, Cynthia. There are surveillance programs that are undertaken
by state and federal public health agencies to recognize CT events.
However, the Achilles' heel for these surveillance programs is
reporting.

For example, when I'm working in the ED, I may not consider one or two
suspicious cases to be important to report; however,

one or two cases at each of the ten EDs in a city might add up to a
significant public health event. And for covert CT events, time is of
the essence! The earlier an event is recognized and reported, the sooner
we will be able to implement the measures to limit further disease.

BELSON

I can see myself in the ED hesitant to report a case unless I have
laboratory confirmation. How would you advise the emergency physician on
that point?

PATEL

Well, we want to hear about cases as soon as possible. I would recommend
not to delay reporting for laboratory confirmation but to report based
on clinical suspicion or presumptive diagnosis. Remember, surveillance
was initiated at the onset of the watermelon-aldicarb outbreak because
of the initial report filed by the physician who recognized the index
case. This probably led to an earlier identification of the outbreak
than would otherwise have occurred over a holiday weekend.

BELSON

One misconception that may discourage me from reporting is that my
notification may lead to unnecessary and unfruitful investigations.

PATEL

That is also a very important point. I think it's crucial to note that
reporting does not necessarily mean that some serious action must take
place. Beyond data gathering, other steps of surveillance include data
analysis and interpretation before any action takes place. Going back to
our analogy, one or two cases from a single ED may not cast any further
suspicion by the public health agency other than logging the cases in a
database. However, if more similar cases are detected, from other EDs in
the area for instance, then a detailed investigation may be warranted.

It is important to re-emphasize that reporting should be burden-free and
replete with redundancies . . . for example, clinicians should not have
to take a great deal of time out of their busy workload to decide who to
report to. Just getting the ball rolling by calling any of the following
agencies such as the PCC, local or state health department, or even the
hospital's infection control nurse, will be enough to mobilize the
necessary resources.

GOOD

Good point. Now, Martin can we take a look at how reporting potential
chemical exposures to your regional poison control center not only will
assist you with patient management but also have a potential impact on
poisoning surveillance on a local and national level?

BELSON

Of course Cynthia. It would be my pleasure.

Poison centers are contacted nationally using a single number, and that
is 800-222-1222. That number connects the caller to the poison center
covering their calling area. Calls are initiated by the general public,
people in the workplace, and health care professionals, including
pre-hospital workers, emergency department (ED) and hospital physicians,
and nurses.

Calls commonly fall into two general categories: either a suspected or
known exposure to a chemical or a simple request for information
regarding a chemical. Many callers are seeking diagnostic or treatment
recommendations for suspected or known poisonings. The majority of calls
come primarily from private residences that otherwise would not be
identified by health care systems.

Poison centers have a critical role in public health response and
response to potential chemical and biological terrorism incidents. PCCs
provide information about preparedness and response; some centers may
even provide strategies for responding to discovery of powders in
envelopes or packages; information regarding treatments and antidotes;
and information about water or food contamination, or tampering, as well
as state health notification.

For example, this figure depicts the increased number of calls to poison
centers following the loss of electrical power during the Northeast
power blackout.

As you can see, there are a steady number of calls per day until you see
this large peak in August 2003 during the Northeast power blackout.
These calls were questions about potential water contamination because
of the blackout.

Trained poison specialists at each poison center collect and
electronically record call data, while providing triage and case
management recommendations.

Call data, such as clinical effects and medical outcome, is uploaded
every four to ten minutes from 62 of 63 regional poison centers in the
US to the only national toxicology database, known as the Toxic Exposure
Surveillance System (TESS).

TESS is a compilation of all calls reported to U.S. poison centers,
represents over 99% of the US population, and is maintained by the
American Association of Poison Control Centers.

There are several goals for toxicosurveillance utilizing real-time
national poison control center data. One is to identify early markers of
chemical events such as temporal and regional increases in
hospitalizations; another is to recognize sudden increases in case
frequency or severity; toxicosurveillance is also used to detect cases
with characteristic symptom complexes, such as those with a cholinergic
syndrome. We believe toxicosurveillance will ultimately improve public
health surveillance for chemical exposures.

PATEL

An excellent example that this surveillance system can detect an early
marker of a chemical event involves the arsenic poisonings in Maine.

We saw earlier how this event was detected by an increase in case
volume, but it was also detected by the comparison of all poison control
center reports of clinical effects to historical background.

As shown in this figure, for April 27, 2003, the day of the arsenic
poisonings, the number of cases reported with hypotension and
tachycardia were greater than the historical background, suggesting a
possible outbreak.

GOOD

Martin and Manish . . . thank you both for your insight. Now, let's now
conclude with what public health agencies, both state and federal, can
do to help facilitate the recognition and response to a covert CT event.
Manish?

PATEL

Physicians, public health agencies, and poison control centers might be
the first to recognize illness, treat patients, and implement the
appropriate emergency response to a chemical release.

Therefore, strategies for recognizing and responding to intentional
chemical releases are useful and may include providing information or
reminders to physicians and clinical laboratories.

State and local health departments should also educate themselves and
physicians to recognize unusual illnesses that might indicate release of
a chemical agent.

BELSON

CDC may be able to assist state and local health departments and
health-care providers with this important information through various
resources.

The first CDC website listed here summarizes CDC's Emergency
Preparedness and Response activities and includes notification
procedures for state and local public health officials.

The second website is dedicated to chemicals and toxins and provides a
variety of educational information that may be useful for the public,
health-care workers, and public health officials; documents on this site
include public fact sheets, case definitions, toxic syndromes,
Toxicological profiles, and medical management guidelines.

Also, you will find links to web casts on ricin poisoning and radiation
emergencies.

Nowhere is good communication more important than WITHIN the public
health community. To allow our public health partners at the state and
local levels to exchange the most current, accurate information possible
regarding emerging threats, CDC maintains many lines of communication.

*Epi-X* allows CDC officials, state and local health departments, poison
control centers, and other public health professionals to access and
share preliminary health-surveillance information quickly and securely.
Users can be notified as breaking health events occur and can consult
with their peers.

They also can receive CDC's assistance in coordinating investigations.
The Health Alert Network or HAN and MMWR are other examples of
communication tools.

PATEL

A second strategy for public health agencies to help facilitate the
recognition and response to a covert CT event includes encouraging
health care professionals to report acute poisonings to poison control
centers.

Another public health strategy includes initiating surveillance for
incidents that potentially involve the covert release of a chemical
agent.

For example, on October 15th, 2003, an envelope with a threatening note
and a

sealed container containing ricin was processed at a mail processing and
distribution facility in Greenville, SC. The note threatened to poison
water supplies if demands were not met. The envelope was isolated from
workers and other mail was removed from the facility. There were three
major aspects to the investigation involving assessment of human health
effects and the search for cases suggestive of ricin-related illness in
the community.

First, the South Carolina Department of Health and Environmental Control
and CDC interviewed all workers at the postal facility. The two agencies
also initiated statewide surveillance in the EDs and the ICUs for cases
suggestive of ricin-related illness. Lastly, we also initiated regional
and national surveillance using poison control center data. Luckily, no
ricin-related cases were identified during this event.

Another important public health strategy is implementing the capacity to
receive and investigate reports of events around the clock.

As we mentioned earlier, the Maine Arsenic event is a perfect example of
how to recognize and respond to a potential CT event. However, there
were several things the state also learned that are important to point
out. After the local hospital's infection control nurse was notified of
the cases, she attempted to contact the state Bureau of Health which had
an automated telephone menu-system response. She dialed the number and
selected one of many choices to get to the appropriate branch in the
bureau of health.

Due to technical difficulties, the nurse was initially unable to reach
the appropriate branch at the bureau of health. She subsequently called
the poison control center to see if the PCC could help her get in touch
with the health department contact. The reporting and the response still
occurred in a timely manner and this event resulted in an enhanced
partnership between the health department and the PCC; the PCC now takes
after-hours calls for the health department.

The message that local providers echoed was that they would prefer to
have a live human receive and field their calls rather than an automated
system.

Lastly, cooperative relationships are essential in order for an outbreak
response to run smoothly.

BELSON

A great example of cooperation with a health department from other
agencies was during the watermelon-Aldicarb outbreak in Oregon.

The Sheriff's Office, the Regional Poison Control Center, FDA, the
Oregon Department of Agriculture, and the physicians all played a
valuable role in the investigation and worked closely together to
prevent further morbidity.

GOOD

Thank you Martin. This has been an informative discussion with lots of
valuable information. Do each of you have any key take-home messages for
our viewers?

BELSON

Yes. One thing to remember is that there is a likelihood of further
illnesses related to intentional chemical releases. Also, there are some
challenges in the recognition of a covert illness due to chemical
exposure.

We hope that despite these challenges this program will better enable
physicians and public health professionals to be prepared for a chemical
event.

We have learned several important points.

First, physicians have a vital role in recognizing epidemiologic clues
and clinical patterns of illness suggestive of a chemical release.

PATEL

Also, we have emphasized the importance of reporting and surveillance;
early detection of outbreaks of illness from chemical exposures would
allow medical and public health communities to render the most timely
and clinically relevant treatment possible and reduce morbidity and
mortality.

And finally, we have discussed what public health agencies, both state
and federal, can do to help facilitate the recognition and response to a
covert CT event.

GOOD

It\'s interesting to me that poison control centers play such a large
role in chemical events. It seems that they are really one of the first
line responders.

PATEL

Absolutely. Historically, poison control centers are information centers
that provide diagnostic and treatment recommendations in drug overdoses,
such as accidental ingestions of drugs by children in the home. But over
the years its role has expanded and today it does play a key role in
chemical terrorism preparedness and response activities in most states.
So, we highly encourage all physicians and public health officials to
utilize this important health resource. And the bottom line is that our
chances of detecting and responding to a CT event are much better if
poison control centers are involved in the process.

We really appreciate speaking to our viewers and allowing us an
opportunity to discuss this timely issue with the people who are most
likely to be impacted by a CT event.

GOOD

Thank you, Dr. Martin Belson and Dr. Manish Patel for joining us today
with all your important information.

I'd also like to thank you, our viewing audience, for joining us today
for this very informative program.

But before we go, we would like to show the web site once again. You may
also use this site, EHHEINQ@cdc.gov, to e-mail questions, comments, or
requests for further information.

Finally, an archive of this program will be available for viewing at
this website:

[www dot phppo dot cdc dot gov slash phtn slash webcast slash chemical
hyphen exp](http://www.phppo.cdc.gov/phtn/webcast/chemical-exp)

In addition, videotapes and CD-ROMs of this program will soon be
available from the Public Health Foundation for \$25 a copy. You may
order online at [http://bookstore.phf.org](http://bookstore.phf.org/) or
by calling 877-252-1200.

And so, that brings us to the close of today\'s program "Recognition of
Illness Associated With Chemical Exposure"

On behalf of everyone at CDC and the Public Health Training Network, I'm
Cynthia Good wishing you a Good Day from Atlanta.