**Weapons of Mass Destruction Events With Contaminated Casualties**

**Effective Planning for Health Care Facilities**

[aainfoaainfo]{.underline}*Anthony G. Macintyre, MD; George W.
Christopher, USAF, MC, Lt COL; Edward Eitzen, Jr, MC, USA, COL; Robert
Gum, MC, USA, LTC; Scott Weir, MD; Craig DeAtley, PA-C; Kevin Tonat,
DrPH, MPH, USPHS, CDR; Joseph A. Barbera, MD*

Biological and chemical terrorism is a growing concern for the emergency
preparedness community. While health care facilities (HCFs) are an
essential component of the emergency response system, at present they
are poorly prepared for such incidents. The greatest challenge for HCFs
may be the sudden presentation of large numbers of contaminated
individuals. Guidelines for managing contaminated patients have been
based on traditional hazardous material response or military experience,
neither of which is directly applicable to the civilian HCF. We discuss
HCF planning for terrorist events that expose large numbers of people to
contamination. Key elements of an effective HCF response plan include
prompt recognition of the incident, staff and facility protection,
patient decontamination and triage, medical therapy, and coordination
with external emergency response and public health agencies.
Controversial aspects include the optimal choice of personal protective
equipment, establishment of patient decontamination procedures, the role
of chemical and biological agent detectors, and potential environmental
impacts on water treatment systems. These and other areas require
further investigation to improve response strategies.

*JAMA. 2000;283:242-249*

The perceived threat of chemical or biological weapons directed against
the US civilian population has increased substantially.[1-3]{.underline}
The designation of these weapons, along with nuclear materials and high
explosives, as \"weapons of mass destruction\" emphasizes their
potential catastrophic effect on the health of a large population.
Comprehensive communitywide management programs for civilians exposed to
chemical or biological warfare agents are still under development and
many response issues have not been fully addressed. Health care
facilities (HCFs) are an integral yet often overlooked component of the
overall community response.

Although response requirements differ for chemical and biological agent
releases, in both cases there might be situations necessitating the
removal of the agent from exposed individuals (decontamination). We
discuss the planning of an effective HCF response to incidents that
require decontamination of exposed persons. Such a response must be
coordinated within the entire community response framework, as in the
incident command system, the most widely accepted command and control
model for emergency response in the United States.[4]{.underline} Events
that are likely to challenge the decontamination capability of a HCF
include 2 types of worst-case scenarios, chemical and biological.

With the release of a chemical weapon in a populated area, casualties
may present en masse with little or no advance notification. The
chemical agent deployed could be a traditional militarized agent (such
as the vesicant mustard) or a more readily obtainable industrial
hazardous material. As shown in the Tokyo sarin attack, a significant
number of exposed individuals may find their own means of transportation
to the HCF unassisted by emergency medical services
(EMS).[5]{.underline} These patients will not have undergone triage or
decontamination, and the least injured will often present first. The HCF
must have the ability to immediately decontaminate and treat those who
are ill from the agent.[6]{.underline} Some persons may have experienced
very little exposure to the agent, or none at all. They may still
require decontamination because exposure cannot be ruled out. Symptoms
may be accompanied by anxiety and may be diverse and
confusing.[5]{.underline}, [7]{.underline} Residual chemical agents on
those exposed may pose a risk of secondary spread to the HCF and its
workers by contact or vaporization.[8]{.underline}, [9]{.underline}

In a biological attack, an infectious agent may be released
surreptitiously and discovered after the incubation period, when
patients present with illness. However, if a biological attack is
announced or discovered publicly as it is occurring, it could result in
large numbers of patients suddenly presenting for services. In contrast
with chemical agents, most biological agents (except mycotoxins) are not
dermally active or volatile. Reaerosolization of infectious particles is
theorized to be a low but possible risk.[10]{.underline} Therefore,
decontamination to lessen the effects of primary exposure and to prevent
secondary exposure is less important than with chemical agents, but may
be necessary.[11]{.underline}, [12]{.underline} The procedure could be
as simple as taking a shower and changing clothes (exposure to
mycotoxins would call for procedures similar to those used for chemical
agents, including extensive patient decontamination).[13]{.underline} A
sudden biological event may require administration of prophylactic
medications and vaccines and could place extraordinary demands on
medical and public health staff and facilities.[14-16]{.underline} We do
not address the epidemiological investigation and large-scale measures
needed to control infection in the event a mass exposure to infectious
agents is recognized in a delayed fashion. Plans for HCF response to
these types of events are under development.[11]{.underline},
[17]{.underline}

**BACKGROUND**

Until recently, any threat to civilians from hazardous materials
(HAZMATs) primarily has come from industrial events.[18]{.underline}
While unintentional releases are relatively common, they generally cause
few serious toxic exposures per event.[19]{.underline} HAZMAT response
guidelines have been developed and implemented for managing these
incidents.[20]{.underline}

The unintentional release of militarized chemical agents from US
military depots has been another civilian concern. In response, a major
preparedness initiative, the Chemical Stockpile Emergency Preparedness
Program, has been implemented in communities surrounding the
depots.[21]{.underline} The response system has never been
activated.[22]{.underline} No similar community preparedness program for
biological release has been developed, since the US military ceased
maintaining biological weapons in 1972.[23]{.underline},
[24]{.underline}

The newly perceived threat entails the deliberate use of chemical and
biological weapons against civilians. In many instances, these weapons
are relatively easy to produce, inexpensive, and can be deployed
covertly. Most significantly, the widespread terror caused by the use of
these weapons could complicate response needs.[25]{.underline},
[26]{.underline}

The toxic and psychological threats posed by chemical terrorism were
demonstrated by the 1995 sarin attack in the Tokyo subway
system.[5]{.underline}, [27]{.underline} The assault resulted in 11
deaths and more than 5000 emergency medical evaluations, of which 73.9%
had no identifiable clinical injury.[28]{.underline} The majority of
those exposed apparently had either a subclinical exposure or
psychogenic symptoms. No chemical attacks of this nature have been
reported in the United States.

No successful biological attack has occurred in the United States with
an aerosolized agent, but other crimes and hoaxes involving biological
agents have occurred.[29-31]{.underline} The potential psychological
effects of bioterrorism were demonstrated by the 1997 B\'nai B\'rith
incident in Washington, DC.[32]{.underline} A Petri dish found in the
mail room of the B\'nai B\'rith headquarters was labeled to indicate the
presence of *Bacillus anthracis* and *Yersinia pestis*. Responders and
incident managers were unaware that nonaerosolized, agar-based organisms
pose no inhalation or cutaneous exposure hazard (it was later proven
that neither organism was present). As a result, an expensive
scene-control operation took place, causing fear and inconvenience among
those potentially exposed. Other recent biological hoaxes have also
disrupted communities across the country.[33]{.underline}

**CURRENT CAPABILITY**

As the potential threat of civilian exposure increases, the new
challenge for the medical emergency response community will be managing
contaminated mass casualties, some of whom may be ill. Many HCFs are
poorly prepared for the decontamination requirements of even small-scale
HAZMAT incidents,[34]{.underline}, [35]{.underline} as demonstrated by
the temporary closures of well-run, full-service emergency departments
after presentation of only 1 or 2 contaminated patients in
1997.[36]{.underline} The most comprehensive HCF response plans to date
were designed to cope with specific individual chemical or biological
agents and radioactive nucleotides.[37]{.underline}

Development of HCF response plans has been hampered by many factors.
Foremost is the lack of civilian experience with mass casualty events of
a chemical or biological nature. Many civilian plans are derived from
the experiences of prehospital HAZMAT response teams or military defense
procedures that may not be appropriate.

The HAZMAT approach assumes that responders will enter a highly toxic
environment near the source of release (away from an HCF). Maximum
protection is provided for a few workers rescuing a small number of
patients, usually without time pressure for decontamination. The primary
objectives are scene containment and environmental protection. In line
with these assumptions, the Occupational Health and Safety
Administration (OSHA) has mandated the use of a \"Personal Protection
Level based upon site hazards.\"[38]{.underline} However, site hazards
are more easily defined at the point of release than at the HCF, where
patient care is conducted. Thus, current OSHA guidelines may be
inappropriate for HCFs. Traditional HAZMAT products, such as
decontamination tents, trailers, and isolation rooms, are expensive,
require prolonged setup time, or are inadequate for large numbers of
patients.[39]{.underline}

Military countermeasures for chemical and biological weapons are also
inappropriate for civilian use without modification. Military personnel
are a more homogenous population, generally physically fit, mentally
disciplined, and equipped for chemical warfare. Because they are
designed for operations in very toxic environments, military contingency
plans can be complex.[40]{.underline} Incorrect civilian use of military
protective equipment and decontamination procedures may be hazardous, as
with the use of military-style gas masks by Israeli civilians during
Gulf War missile attacks. Fatalities resulted from improper mask
use.[41]{.underline}, [42]{.underline}

The US government has recently begun addressing civilian preparedness
deficits. A 1995 presidential initiative funded the prototype for
Metropolitan Medical Strike Teams,[43]{.underline} which were composed
of specially trained local personnel were organized to help communities
respond to events. This effort has been revised to include a systems
approach and has been renamed Metropolitan Medical Response Systems
(MMRS). The overall goal of the MMRS program is to link first-response,
public health, and health care systems. As a component of the MMRS, HCFs
will remain responsible for initial management of contaminated patients.
To date, 47 urban areas have received funding for development of an MMRS
and more communities are expected to receive similar support.

The Nunn-Lugar-Domenici congressional legislation allocated federal
funds to the Department of Defense to upgrade the capabilities of
civilian first responders, including HCF personnel.[44]{.underline} This
Domestic Preparedness Program is being conducted serially in 120
metropolitan areas by the US Army Soldier and Biological Chemical
Command.[45]{.underline} This program is intended to provide
operational-level preparedness, with educational tracts for community
response entities, including emergency management, law enforcement,
fire, and medical personnel. The current program for hospital personnel
has lacked detailed operational methods.[46]{.underline},
[47]{.underline} A large-scale chemical agent exercise in New York City,
conducted after hospital personnel had participated in the Domestic
Preparedness Program, demonstrated that hospitals would still have
difficulty managing patient decontamination.[48]{.underline}

The federal government has established a National Domestic Preparedness
Office (NDPO) under the auspices of the Department of Justice to act as
a clearing house during responses to domestic chemical and biological
terrorist incidents. The NDPO will handle information pertinent to law
enforcement, emergency medical response, medical, and public health
sectors.

Federal preparedness initiatives have been paralleled by private
industry\'s development of chemical and biological agent response
products and training programs. Self-described expert consultant groups
offer risk analysis and training for various components of local
emergency response, including HCFs. Some programs market equipment
packages supplied by vendors working in conjunction with the
consultants.[49]{.underline} Most offer operational guidelines based on
traditional HAZMAT procedures. As yet, no published large-scale exercise
or response experience has validated these programs.

**PROPOSED HCF CONCEPT OF OPERATIONS**

Owing to the complexity of a civilian event involving chemical or
biological weapons, HCFs should begin by delineating priorities that
guide their preparedness process. These objectives should be established
in coordination with the other members of the community involved in
emergency response. The priorities of the HCF could be ranked in this
order: (1) protection of the current patients, staff, and facility; (2)
provision of the best possible medical care for contaminated patients
presenting to the institution for care; and (3) environmental protection
external to the HCF. In a large-scale event, containment of wastewater
will probably be impossible, though no consensus has yet been reached on
this controversial point. This issue should be addressed through
comprehensive planning that includes local environmental and water
authorities.

Certain assumptions can be made to simplify planning. One is that the
exposure site is remote from the HCF (ie, the HCF is receiving patients
but is not within the primary release area). Otherwise, facility
evacuation or \"sheltering in place\" may be indicated. Key components
of the model preparedness plan are illustrated in [Figure
1]{.underline}.

**Event Recognition**

In an unannounced event, it is essential to recognize contaminated
patients before their entrance into the facility. Security personnel
must be trained in early recognition and should be stationed at the
hospital entrances. Security personnel should immediately notify
management personnel when they suspect a problem, and they should be
prepared to protect themselves by donning personnel protective equipment
(PPE). Even so, it is reasonable to expect some contaminated individuals
may gain entrance into the facility. These situations should be handled
on a case-by-case basis with a rational approach. It will not be
necessary to completely seal off the facility or a department in most
circumstances.[50]{.underline}

**Activation of Plan**

The alert mechanism should be expeditious: PPE must be immediately
accessible to decontamination and patient care personnel, and the
decontamination facility should be operational within 2 to 3 minutes.

**Management**

The principles of the incident command system should be incorporated
into the HCF\'s emergency preparedness plan.[51]{.underline} The use of
this system will enable HCF staff to fully integrate their activities
with community emergency response assets, since it is widely used by
fire, EMS, and police personnel as well as many state and federal
agencies. Although initial response efforts will be centered in the
decontamination and treatment areas, other HCF departments will play
vital roles. For instance, security officers must direct the flow of
casualties and vehicles to prevent facility compromise and must prevent
unauthorized access to the decontamination and treatment areas.
Personnel from departments including emergency, critical care services,
plant operations, pharmacy, supply services, infectious disease,
respiratory therapy, laboratory, and toxicology must be targeted for
education and training in the response plan.

A widespread chemical or biological incident will result in extended
operational periods. Staff should be coordinated to provide relief from
physically taxing activities such as patient decontamination. Providing
food and hydration in a hygienic manner will enhance staff performance.
Psychological support for staff should be available.

Personnel caring for contaminated patients should be properly outfitted
in PPE. Specific data to determine the appropriate level of hospital
worker protection remains limited, and a recent extensive review on
chemical and biological terrorism published by the Institute of Medicine
is inconclusive on this issue.[52]{.underline} Level C PPE consists of a
nonencapsulated, chemical-resistant suit, gloves, and boots, with a
full-face air purifier cartridge mask (powered or nonpowered). This gear
should afford adequate respiratory protection for outdoor exposure to
contaminated chemical casualties who have survived transport to the
HCF.[21]{.underline}, [53]{.underline} For HCF workers conducting
decontamination of patients acutely contaminated with infectious
biological agents, level D protection (standard work clothes) plus latex
gloves, eye splash protection, and N-95 respiratory masks (used in many
hospitals for protection against tuberculosis) should be
adequate.[54]{.underline}, [55]{.underline} If responders are concerned
about reaerosolizing an agent during clothing removal, a high-efficiency
particulate air (HEPA) filter mask could be added. If the agent class
for a sudden release cannot be identified, level C PPE with an organic
vapor/HEPA filter cartridge mask is recommended.

Training is essential for the correct use of PPE. Work times and
conditions must be monitored while personnel are using PPE to prevent
fatigue or heat stress. Personnel should be rotated if decontamination
operations are prolonged. Once patients have been decontaminated, they
may be handled by staff using universal precaution guidelines.

Crowd control will require firm, authoritative direction from hospital
security and, if available, police or the National Guard. Since PPE face
masks muffle the voice, loudspeakers should be provided to personnel
directing contaminated patients. Signs designating functional areas and
providing patient instructions should be in place.

**Primary Triage**

All exposed and potentially exposed individuals should receive an
initial brief triage, performed by medical personnel in PPE, before
decontamination. They should then be directed to 1 of 2 areas,
nonmedical decontamination or medical decontamination. The uninjured,
those with minor injuries requiring no medical intervention during
decontamination, and the majority of ambulatory patients will be
assigned to nonmedical decontamination. These individuals may require
nonmedical assistance with washing themselves (eg, unaccompanied
children, persons in wheelchairs, and those with other special needs).
Those with injuries or illness potentially requiring medical
intervention will be assigned to medical decontamination by staff.

Throughout the decontamination process, attention must be given to
symptoms of exposure to chemical or biological agents that may indicate
early life-threatening deterioration (eg, a sore throat or mild
shortness of breath after exposure to pulmonary or laryngeal irritants).

**Patient Sign-in/Identification and Securing Property**

A brief sign-in process should capture name and date of birth (full
registration can occur after decontamination and should be consistent
with the community patient tracking system). A number on a log can be
assigned to each patient, who would receive 2 identically numbered
plastic bags and a nonpermeable wristband. Clothing would be placed into
the larger clear, impervious bag. Separation of valuables into the
second, smaller bag would enhance the security of these items. A
meticulous, practical method of cataloging belongings will ensure their
return and possibly assist in forensic investigations.

**Patient Decontamination**

The HCF should possess partially fixed or preconstructed decontamination
facilities that can be activated immediately. This facility should be
designed to occupy little storage space and not disrupt routine
operations while in use. The Israeli model, developed during the Gulf
War, consists of showers permanently fixed to the ceiling structure of
an open-air parking garage or the side of a building.[56]{.underline}
The George Washington University Hospital model uses fire exit
alleyways. An outdoor decontamination facility can prevent entry of
contaminants into the HCF and obviates dedicating space with room
ventilation and vapor isolation. An outdoor facility is also more
suitable for the influx of mass casualties. Outdoor decontamination,
however, must offer protection from inclement weather and have adequate
lighting for night operations.

Because clothing will be removed before decontamination, privacy must be
protected to ensure compliance with full decontamination. The sexes
should be separated, with a visual barrier between shower lines. The
need for protection of privacy was demonstrated by a successful lawsuit
against a fire department whose personnel decontaminated 2 women without
ensuring adequate privacy.[57]{.underline}

Another important consideration is rapid patient progression through the
decontamination process. Traditional HAZMAT decontamination is passive
(using 2 responders to clean each patient), which is time consuming and
unnecessary for the majority of ambulatory patients in the nonmedical
decontamination area. Promoting patient self-decontamination will
significantly decrease the required number of health care workers. Of
course, decontamination assistance for some patients in the nonmedical
decontamination area and full passive decontamination in the medical
decontamination area must still be available.

Decontamination facilities should contain multiple shower stations that
are designed to allow patients to progress at various rates without
compromising overall flow. Patients whose clinical condition
deteriorates in the decontamination line can impede the progress of
others. Plans must include means for sidetracking these patients into an
area separate from the main decontamination sites, where treatment can
be initiated.

Decontamination can be accomplished by using a sequential copious warm
water rinse, a hypoallergenic liquid soap wash, another warm water
rinse, and then a final rinse after walking past other in-use showers.
Incapacitated patients will require soap and water cleansing by staff,
with attention to washing and rinsing the patient\'s back and the
nonabsorbent backboard. The water temperature must be adjustable.
Excessively warm water should be avoided, as this may promote peripheral
vasodilatation and toxin absorption. Stiff brushes or abrasives should
also be avoided as they may enhance dermal absorption of the toxin and
can produce skin lesions that may be mistaken for chemical
injuries.[58]{.underline}, [59]{.underline} Sponges and disposable
towels are affordable and effective alternatives.

**Secondary Triage**

Persons with major or moderate casualties would be referred to treatment
areas designated for such cases. Those with minor or no apparent
injuries should be sent to a holding area for further evaluation,
observation, and eventual treatment if needed.

**Holding Area**

Large spaces such as cafeterias or auditoriums can be used for
observation of large numbers of patients with minor or no apparent
injuries and illnesses by physicians and nurses. At this time, HCF staff
should also provide information on the agent involved, potential short-
and long-term effects, recommended treatment, stress reactions, and
possible avenues to further assistance. It is essential to provide
important information in writing because the memory of patients may be
impaired by the psychological stress of dealing with an exposure. All
potentially exposed individuals should also be enrolled in a long-term
surveillance program to monitor possible health effects.

**Logistics for Treatment**

Specific therapies for chemical and biological agent casualties vary
according to the etiologic agent and are described
elsewhere.[15]{.underline}, [16]{.underline}, [60]{.underline},
[61]{.underline} Mass casualties requiring specific chemical antidotes,
vaccinations, or antibiotics will quickly deplete available supplies. In
most cases, current hospital stocks of medications would be inadequate
to meet the needs of even a few of these patients.[62]{.underline}
Several efforts are under way to address this problem, including a
federal initiative to stockpile antibiotics and
vaccines.[63]{.underline} Other concerns have not yet been adequately
addressed. After a smallpox release, for example, postexposure
vaccination might be indicated, but smallpox vaccine is no longer
produced and current stocks are limited.[16]{.underline},
[64]{.underline}

Otherwise straightforward medical problems, including eye injuries,
bronchospasm, and burns, may also need mass intervention. Ventilators
and other critical care supplies may be needed in large quantities. This
problem could be resolved in part through mutual aid agreements between
HCFs. Such an agreement established in the Washington, DC, area provides
for pooling of resources (including personnel, supplies, and equipment),
and sharing of information.[65]{.underline} Contingency plans of this
type may be vital to saving lives, since time constraints prevent
reliance on resupply support from state and federal agencies during the
initial crucial period of an event.

**Epidemiological Considerations**

Health care facility involvement will extend beyond the treatment of
patients who are acutely ill or exposed. A comprehensive community
response will include epidemiological analysis undertaken by local and
national public health organizations to identify all potential exposed
individuals. This should be done during the brief interval when early
intervention can save lives and containment can reduce secondary
transmission of contagious agents. Such analysis will require
participation by HCFs.

**Information Resources**

Health care facility personnel must identify sources of expert
information on chemical and biological agents to ensure ready access to
such information. Ideally, a repository or data bank could be
established at the community or national level. This would allow for the
distribution of uniform information.

Other resources include medical management handbooks developed by the US
Army\'s chemical and biological defense medical
laboratories.[54]{.underline}, [60]{.underline}, [61]{.underline} Some
civilian-based protocols, such as pediatric recommendations, have also
been established; these are currently being revised by the US Public
Health Service.[66]{.underline} Consensus statements organized by the
Working Group on Civilian Biodefense also provide useful
guidance.[15]{.underline}, [16]{.underline} Consultation is also
available 24 hours a day by remote access through the National Response
Center at (800) 424-8802.

**Public Information**

Prompt attention must be given to information issued to the public
through the news media and bulletins. Media inquiries must be carefully
handled, and the content of these communications should be discussed
with appropriate emergency management authorities to prevent the release
of conflicting or erroneous reports.

**Postincident Actions**

Following the event, HCF management should conduct an incident review
with hospital personnel involved in the emergency response. The purpose
of such a review is to determine, in a nonpejorative manner, the
sequence of events and to disseminate the rationale behind controversial
decisions. Exposure risks and necessary countermeasures should be
discussed to alleviate some of the psychological impact of incident
stress. The incident critique, which will take place later, is a
technical review designed to evaluate and improve the response plan. The
staff should also have access to formalized stress debriefing at a later
date.

Because injuries and illnesses sustained during the response would be
covered under employee compensation insurance, all staff members
involved should be registered in a health surveillance program. This
will ensure that medical issues will receive proper attention, and
demonstrate the HCFs commitment to employee health. In view of the
possible delayed or chronic effects of some chemical agents,
surveillance could continue for years. Assistance for this type of
surveillance is available through the Agency for Toxic Substances and
Disease Registry, which the US Department of Health and Human Services
has identified as the lead agency for the registration of personnel
exposed to chemical or biological warfare agents.[67]{.underline}

It will be essential to clean the decontamination facilities and process
the possessions of contaminated patients, as well as dispose of solid
waste. Cleanup will be guided by the specific agent involved and the law
enforcement investigation. If no adequate, financially viable method is
available to inactivate a highly toxic, persistent agent such as the
nerve gas VX, assistance may be required from other local, state, or
federal entities.[68]{.underline}

**CONTROVERSIES AND RESEARCH REQUIRED**

**Personal Protective Equipment**

One major question concerns the optimal approach to PPE. To simplify
guidelines and reduce confusion about the variety of choices, PPE
recommendations could be standardized. This measure would ease financial
disincentives as well as training requirements. Although published
research on adequacy of PPE is limited, the consensus emerging among
researchers and medical planners is that level C protection (using a
full-face mask with powered or nonpowered canister filtration system) is
adequate for HCF workers.[21]{.underline}, [68]{.underline},
[69]{.underline} A few reports recommend a higher level of protection,
level B, which includes a mask supplied by an external air source
(hose-supplied air with an escape cylinder or a self-contained air
tank).[70]{.underline} However, these reports do not mention whether
higher levels of protection produce a quantified increase in safety, nor
do they discuss the possible disadvantages such as additional cost,
weight, and training requirements.

Choosing a specific material to provide chemical barrier protection for
HCF personnel is difficult. Many types of chemically resistant suits are
available. They vary in cost and each has unique
properties.[71]{.underline} Industrywide testing is based on permeation
rates of pure substances directly applied to the material, but such data
may not be relevant to the exposure in the HCF response
model.[72]{.underline} Health care workers remote from the impact site
or incident scene will be exposed only to the agent that remains on the
skin and clothing of those exposed, so concentrations of substances
encountered during decontamination at the HCF will be more dilute than
concentrations used for the testing PPE materials.[68]{.underline} Less
expensive barrier materials may therefore be adequate.

**Decontamination Solution**

Another controversial concept concerns patient decontamination. Should
decontamination be simplified by establishing a universal process for
all incidents, as suggested by Cox?[71]{.underline} Some authors have
already published universal decontamination protocols for chemical
exposures.[50]{.underline} There is little argument that soap and water
will be effective for most agents. In the past, an agent neutralizer
such as a 0.5% solution of hypochlorite was recommended. It inactivates
biological agents (except mycotoxins) and, at a slower rate, chemical
agents such as mustard and organophosphates.[13]{.underline},
[60]{.underline}, [61]{.underline} The studies indicate, however, that
15 to 20 minutes of contact time is necessary for hydrolysis or
oxidation and, thus, for the inactivation of chemical
agents.[60]{.underline} Furthermore, dilute bleach can cause tissue
damage in open wounds, exposed nerve tissue, and the
eyes.[13]{.underline}, [73]{.underline} The lack of clear safety and
efficacy data for bleach decontamination suggests that it should be
avoided, especially if soap and water are immediately available. There
may be rare exceptions to a universal decontamination process. For
instance, pure metals and strong corrosives require dry decontamination
(ie, gentle brushing or vacuuming of larger particles) before water is
applied.[68]{.underline}, [74]{.underline}

**Agent Detectors**

Yet another controversial issue is what role agent detectors should play
in an HCF response plan. Agent detectors and monitors are used in the
military and HAZMAT/EMS arenas. In the HCF environment, however, they
would only complicate and lengthen the decontamination process. Much of
the monitoring and detection equipment for chemical and biological
agents is expensive and training intensive. Even handheld assays require
attention to standard protocols. Moreover, some agent detectors can give
false-positive readings when perfume, diesel vapors, or nonthreatening
contaminants are present.[75]{.underline} In some cases, cool air, the
presence of a nonmilitarized agent, or other factors can produce
false-negative results. Detection can also be time consuming. If an HCF
is operating without any means of detection, HCF personnel must consider
that most biological agents and some selected chemical toxins (eg,
mustard) have delayed clinical manifestations. Contingency plans must
include the capability to treat potentially exposed persons, if
indicated, while confirmatory tests are under way.

**Decontamination Wastewater**

Questions have also been raised about the potential environmental impact
of releasing decontamination wastewater into the water treatment system.
To date, the Environmental Protection Agency has not published an
official statement on this issue in relation to HCF planning. The
decision not to contain wastewater can be justified for most agents in a
life-threatening mass casualty situation. Biological agents may pose
only a temporary risk to the environment or to the people in the area
because of rapid environmental degradation or difficult
reaerosolization.[10]{.underline}, [13]{.underline} On the other hand, a
large-scale chemical incident usually results in significant
environmental pollution; the amount of agent borne by patients
presenting to HCFs will constitute only a small fraction of the total
environmental burden. Some authors suggest that as much as 75% to 90% of
the hazardous agent may be removed by disrobing.[70]{.underline},
[71]{.underline}, [75]{.underline} The remaining skin contaminant may be
minuscule and can be diluted further during washing and passing into
public wastewater systems. The installation of a large-volume wastewater
containment system is a prohibitively expensive undertaking. Even if
installed, the final disposition of wastewater containing hazardous
materials can be a catastrophic financial burden. If the facility design
does not provide wastewater containment, appropriate water authorities
should be notified at the time of the event.

**Unanswered Questions**

These and other pressing questions must be investigated if research is
to help improve response strategies:

-   What are the actual risks to first responders, clinicians, and other
    health care workers from reaerosolizing biological agents on
    contaminated clothing, skin, or environmental surfaces?

-   What is the minimum adequate amount of washing/rinsing time required
    for adequate decontamination from most agents?

-   What are the specific limitations of level C and level B PPE for HCF
    personnel caring for exposed patients removed from a site where a
    chemical or a biological agent has been released?

-   What are the ideal avenues through which HCFs can disseminate
    information during an event of this type or magnitude?

-   What equipment and training requirements can HCFs realistically
    support for this preparedness? Should public policy provide funding
    for HCF preparedness?

-   Does every HCF in a defined area need this preparedness capability?

-   Are there specific chemical and biological agents (in the amounts
    carried by contaminated patients presenting to HCFs) that cannot be
    safely washed into public water runoff?

**CONCLUSION**

The threat of a large-scale incident involving intentional release of
chemical or biological agents in the United States is significant, but
currently, no practical models exist for HCF response to a suddenly
recognized event requiring the decontamination of mass casualties. The
time has come to establish a forum of experts to address the questions
presented in this article and elsewhere and to reach a consensus on how
to develop and disseminate comprehensive guidelines for HCFs. These
solutions should be fully integrated into the community response plan
for chemical or biological terrorism.

Precedence for this consensus approach may be found in the method used
by the Federal Emergency Management Agency for the creation of the
National Urban Search and Rescue System.[76]{.underline} Above all, the
process must be an operationally oriented cooperative effort and remain
uninfluenced by financial gain and unproved technologies.

The threat posed by chemical and biological terrorism must be kept in
proper perspective. Disaster preparedness plans must maintain readiness
for these events as well as the terrorist use of conventional
explosives.[77]{.underline}, [78]{.underline} Accidental HAZMAT
exposures remain even more likely. Robust, effective HCF preparedness
integrated with local community planning will help address the more
conventional threats.

**Author/Article Information**

**Author Affiliations:** Institute for Crisis, Disaster and Risk
Management (Dr Barbera) and Department of Emergency Medicine (Drs
Macintyre and Weir and Mr DeAtley), George Washington University Medical
Center, Washington, DC; US Army Medical Research Institute of Infectious
Diseases, Fort Detrick, Md (Lt Col Christopher and COL Eitzen); US Army
Center for Health Promotion and Preventive Medicine---Europe, Landstuhl
Army Regional Medical Center, Landstuhl, Germany (LTC Gum); and the
Office of Emergency Preparedness, US Public Health Service, Rockville,
Md (CDR Tonat).

**Corresponding Author and Reprints:** Anthony G. Macintyre, MD, 2140
Pennsylvania Ave NW, Washington, DC 20037 (e-mail:
[emdagm@gwumc.edu]{.underline}).

**Disclaimer:** The opinions and findings in this article are those of
the authors and should not be construed as official policies or
positions of the US Department of the Army, US Department of the Air
Force, US Public Health Service, or US government.

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