DRAFT/FOR PUBLIC COMMENT

1

2

i 

# P a ti e n t D e c o n t a m i n a ti o n in a

M a ss C h e m i c a l E x p o s u r e

I n c i d e n t:

N a ti o n a l P l a nn i n g G u i d a n c e

f o r C o mmun iti e s

D R A F T /

FOR PUBLIC

COMMENTDRAFT/FOR PUBLIC COMMENT

1 

### Fe d eral P o ints of Co n tact 1

2



### Susan M

. C i b ulsky, P h D 3

Med i c a l C ou n t er m eas u re S t ra t e g y & R equ i re m

en t s D i v i s i on 4

O ff

i ce o f P o l i cy & P l an n i ng 5

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry f o r P rep a red n ess & R

espon s e 6

U S D epar t m ent o f H e a l t h a

nd H u m an S er v i ces 7

susan

. c i b u l s ky @ hhs. g ov 8

9



### M a r k A

. K i r k, MD 10

Program D irector, Chemical Defense 11

Health Threats Resilience Division, Office of Health Affairs 12

US Department of Homeland Security 13

mark.kirk@hq.dhs.gov 14

15



### Pr i m ary Aut h ors 16

17



### Susan M

. C i b ulsky, P h D 18

Med i c a l C ou n t er m eas u re S t ra t e g y & R equ i re m

en t s D i v i s i on 19

O ff

i ce o f P o l i cy & P l an n i ng 20

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess & R espon s e 21

U S D epar t m ent o f H e a l t h a

nd H u m an S er v i ces 22

23



### M a r k A

. K i r k, MD 24

Program Director, Chemical Defense 25

Health Threats Resilience Division, Office of Health Affairs 26

US Department of Homeland Security 27

28



### Jos e li t o S. Igna c io, MA

, M P H, C IH, C S P

, R E H S 29

C ap t a i n, U S P u b l i c H e a lt h S er v i ce 30

Deputy P ro g ram D i re c t o r, C he m i cal De fen s e 31

H ea l t h T h r e a t s R e s i l i e n ce D i v i s i o n

, O f f i ce o f H e al t h A ff

a i rs 32

U S D epar t m ent o f H o m

e l a nd S ec u r i t y 33

34

A d am D

. L ear y , M A

, MS 35

Med i c a l C ou n t er m eas u re S t ra t e g y & R equ i re m

en t s D i v i s i on 36

O ff

i ce o f P o l i cy & P l an n i ng 37

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess & R espon s e 38

U S D epar t m ent o f H e a l t h a

nd H u m an S er v i ces 39

40

M i c h a el D

. S c h w art z , MD 41

C o m m ander, U S P ub l i c He a l t h S er v i c e 42

O ff

i ce o f E n v i ron m

en t a l H ea l th E m

er g enc i e s 43

N a ti o n al C en t er for E n v i r o n m en t al H e a lt h 44

C en t e rs for D i s e ase C o n t r ol and P r e v en ti o n 45

U S D epar t m ent o f H e a l t h a

nd H u m an S er v i ces 46v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

2 

## E x ecu t i v e S u mm a ry 1

2

This document is a draft and will be finalized once public comments have bee n received, adjudicated 3

and the guidance revised and finalized. 4

5

I n tro d u c t i on 6

E ach da y , su b s t a n t i a l qua n t i t i es o f ha za rdous che m

i c al s are pr o duce d

, t

ran s po r t ed, s t o red, and u s ed f or 7

i ndu s t r i a l or hou s eho l d p u r poses. S t o c k

p il e s of che m

i cal we apons ar o und t he w o r l d, w h i l e c u rr e n t l y 8

be i ng de s t ro y ed, st i l l e x i s t

. V a r i o us t e r ro r i s t or g a n i z a t i ons and non

- s t a t e a c t o r s h a v e sho w n i n t e r est i n 9

proc u r i ng or de v e l o p i ng a n d us i ng che m i c a l s i n t e r

ro ri st a t t ac k s. I

n each i n s t a

nce, t he s e c h e m

i ca l s pose 10

s i g n i f

i ca n t r i sk t o pub l i c h e a l t h due t o the p o t e n t i al f o r acc i de n t al or in t en t

i o n al r el ease t h a t c o u l d harm 11

l ar g e nu m

bers o f p e op l e. C i v il i an f i r st re s pond e rs (e. g ., f

i re, HA Z M A T

, a nd e m

er g ency m

ed i cal s er v i ce 12

resp o nd e rs) and h ea l t h ca r e f i rst r e ce i v e r s ( e. g ., hea l t h care f a c i l i t y

- based and o t h e r c l i n i c a l p e rso n ne l ), 13

a l ong w it h e m er g ency m ana g ers, pu b l i c h e al t h p r a c t i t i oner s

, l aw enf o r c e m ent of fi c i a l s, a nd r i sk 14

co m m

un i ca t i on ex p e r t s, m

ust be pr e pa r ed t o r e spond t o such i n c i de n t s. 15

16

T he po t en t i a l f or a l a r g e

- s c a l e che m

i cal r e l e a se res u l ti ng i n t he n eed t o d eco n t a m i nate an o v er w h e l m

i ng 17

nu m

ber of pe o p l e has g ar n e red wi de i n t e r e st a m ong po l i cy m a k

ers and e m

er g ency p l an n er s

. G u i d ance 18

and b e st

- prac t i ce docu m en t s ha v e been pub l i s hed a nd s pec i a l i z ed eq u i p m ent has b een p u rch a sed. 19

H o w e v er, deco n t a m i na t i on pra c t i ces ha v e e v o l v ed bas e d on sp a r s e e v i de n ce. Limited r es e ar c h has been 20

c ondu c t ed on d e con ta m i na ti ng c i v i l i a n s. P a

ti e nt deco n t a m

i na t i on, li k

e o t her asp e c t s of d i s a s t er resp o nse, 21

m

ed i c i ne

, and p u b li c he a lt h

, co u l d b ene fi t f r o m an a ssess m

ent o f t h e bo d y of e v i dence, enhance 22

i nc o rpo r a t i on o f t he e v i de n ce i nto p l a nn i ng a nd pr a c t i ce, and add i t i on a l s t udy t o g en e ra t e needed 23

e v i den c e. F u r t h er m ore, m any curre n t g u i d a nce and b e s t

- prac t i c e docu m e n t s do not add r ess t he fu l l 24

s p ec t

rum of i s su e s t h at a co m m un it y m a y face w h e n l a

r g e

- sca l e pa t i e n t d e co n t a m i na ti on i s ne c ess a

ry i n a 25

m ass c h e m i cal e xpos u r e i n c i d e n t

. 26

27

T he ne e d f o r e x a m i na ti o n o f cu r

re n t p a t i e n t de c on t a m

i na t i on p ra c t i ces wa s i d en t i f i ed by exp e r t s i n t h e 28

e m

er g ency response and m

ed i c al c o m m

un iti e s. T he Wh i t e H o u se Na ti o n al S ec u r i t y S t a f f f o l l o w ed wi t h a 29

requ e st for an e v i d ence

- ba s ed n a ti o n al p l a nn i ng g u i da n ce f o r m ass p a ti e nt d eco n t a

m i na ti on i n a l a

r g e

30

sca l e c h e m i cal re l ea s e. E f

f o r t s t o e nha n ce p rep a

re d ness for p a t i e n t d e co n t a m i na t i o n i n a m ass e xpos u re 31

i n c i de n t m ay a l so ben e f i t t h e ca r e t hat i s pro v i d e d t o i n d i v i du a l co n t a m i na t ed p a t ie n t s i n o t h e r 32

c i r cu m s t anc e s. 33

34

A ud i e n ce, S co p e, a n d I n t e nt 35

T he i n t en d ed a u d i e nce i n cl udes s en i or l ea d e r s, p l ann er s, i n c i d e nt co m m anders, e m er g ency m an a g e m

ent 36

pers o nn e l , and t r a i n e r s of l ocal r e spon s e or g a n i z a ti o ns and h e a l t h c are f a ci l i ti e s. T hou g h t he g u i da n ce 37

w as de v e l o p ed wi t h t h i s s p ec i f i c au d i en c e i n m

i n d

, i t m a y be of v a l ue t o o t her a u d i en c es, i n c l u d i ng f i rst 38

resp o nd e rs a n d f i r s t rec e i v ers, co mm

un it y l ead e rs, s c ie n t i sts

, and re s ea r ch e rs, a s w e l l as o t h e rs from t he 39

resp o nse and e m er g ency m ana g e m

ent f i e l ds. A ba s i c assu m

p ti on of t h i s do c u m

ent i s t h at m ass p a t i e n t 40

deco n t a m

i na t i on takes place a t t he l e v el of t h e l ocal a f fe c t ed co m m

un it y

. D ue t o t he n eed for c h e m ic a l ly

41

con t a m

i na t e d p a t i en t s t o be d eco n t a m i na te d as s o on as po s s i b l e, t he f e der a l g o v ern m

ent w ill li k

e l y not b e 42

a b l e t o p a

r t i ci pa t e d i re c tl y i n t he re s pon s e i m m ed i a t e l y fo l l o wi ng t h e r e l e a se. T h er e f o re, t h i s g u i dance i s 43

d i r ec t ed p r i m a r il y at l o c al o f f i c i a l s. 44

45

T he su b

j e c t m a tt e r c o ns i de r ed h e re i s l i m it ed t o e x t e rn a l co n t a m

i na t i on o f li v i ng p e op l e (henceforth 46

defined as patients; see Lexicon, p. 114) w it h t o x ic i ndu s t r i a l c h e m i ca l s, t o x i c i ndus t

r i al m a t e r i a l s

, or 47

c he m

i c a l w a r f a re a g en t s i n a m ass ca s ua l t y i n c i de n t res u l t i ng from an a c c i d en ta l or i n t e n ti o n al r e l e a se. 48

T h i s g u i d a nce a t t e m p t s t o a ddre s s t he f

u l l sp e c t rum of t he d eco n t a m

i na t i on res p o n se op e r a

ti o n, f rom 49

i n i t i al ass e ss m ent a n d de c i s i o n

- m a k

i ng t hrou g h e v a l u at

i on o f de c on t a m

i na t i on e ff

e c ti v en e s s

. F u r t h er, t he 50

en t i re a f

fe c t ed co m m

un it y i s con s i d e red, w it h e m phas i s on co o r d i n a ti on b e t w een on

- scene and h e a l t h c a r e 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

3 facility

- based res p onse a c t i v iti es and c o m m un i ca t i on o n m

u lti p l e l e v e l s. 1

2

P a t i ent dec o n t a m i n a ti o n p ri nc i p l es a r e s e t f o r t h h e re f

r om a s t r a t e g i c p e rs p ec t i v e, ra t h er t h a n a t a c t i cal 3

one. T he p r i n c i p l es a re m eant t o g u i de, but n ot spe c i fy

, ope r a t i on a l p r a c ti c es. T h e g u i dance i s e v i d enc e

4

based t o t he ex t ent p os s i b l e and t h e s u ppo r t i ng e v i den c e i s d ocu m en t ed and b r i e f

l y d i s c us s ed. 5

6

Th e appr

o ach i n t h i s g u i d a n ce i s f l e x i b l e a n d sc a l

a b l e acc o rd i n g t o t h e reso u r c e a n d ca p ab i l i t y 7

l

i m i t a ti o n s of t

h e o rga n i z a t i o n

. Th e rec o m m e n d

a t i o n s s h o u l

d be ad a p t e d as each un i q u e c o mm u n it y 8

sees f

i t

. 9

10

E xa m

p l es of how t h e g u i d ance m i g ht be u s ed i n c l ud e : 11

• P l ann e r s : i nc o rpo r a t e c u rr e nt e v i de n ce

- based r eco mm e nda t i ons du r i ng de v e l op m ent or re v i s i on o f 12

an or g an i za ti o n ’s re s ponse p l an s

. 13

• C o m m un it y l eader s

, pu b li c hea l t h o f f i c i a l s: enh a

nce s y s t e m

- w i de coor d i n at i on a n d de v e l op p l ans 14

for c o m m un i ca t i ng w it h p a t

i e n t s a n d t h e w ho l e co mm u n it y

. 15

• T r a i n e r s: d e v e l op, i m pro v e or au g m

ent t r a i n i ng of r es p onse p ers o nn e l f o r p a t i ent d econ t a m

i na t i on 16

oper a t i ons, u s i ng c u rr e nt e v i den c e

- based r e co m m enda t i ons. 17

• E m

er g ency m an a g ers: g e n er a t e p o l i cy and p l ans t o a d dre s s i ssu e s r e l a t ed t o s y s t e m

- w i de 18

coor d i n a ti o n, t he w h o l e c o m m un it y response, and c r is i s a n d r i sk co m m un i ca t i on s , as we l l a s o t her 19

o v erarc h i ng i s s ues. 20

• R ese a rch e r s : i de n t i fy k

n o w l ed g e g aps and c ondu c t re sea r ch t o i n v e s ti g a t e t h e m

. 21

22

G u i d a n ce S ta t e m e n t ( G S ) F o rm a t a n d Q u i ck Re fe r e n ce G u i d e 23

24

I n S ec ti on III , each of t he g u i da n ce s t a t e m en t s i s d es c r i bed i n f

u l l a l ong wi t h a s so c i a t ed i nf o r m a ti on i n t he 25

fo l l o w i ng f o r m a t : 26

F unc t i on a l A r e a I den ti f i e s o n e of t he s i x fu n c t i on a l a r eas re p re s en t e d

. 27

28

G u i dan c e S t a t e me nt F u l l t e x t o f t h e g u i da n ce s t a t e m en t. 29

30

C ons i d er a ti o n s A dd i t i on a l f

a c t o r s t h at sho u l d be con s i d e red w h en i m p l e m en ti ng 31

t he g u i dance s t a t e m en t

. 32

33

L O C L e v el of C o n f i d en c e r a t i ng (de s c r i bed i n A p p end i x E ) f or t h e 34

e v i de n ce on w h i ch t he G S i s bas e d. 35

36

D i scu s s i o n B r i e f l y de s c r i bes t he e v i d e nce a p p l i ca b l e t o t he g u i d a nce s t a t e m en t

, 37

from re v i e w s o f t h e s c i e n t if i c li t e r a t u re, cu r

re n t p r a c ti c es

, and 38

su b j e c t m a t ter e x pe r

t o p i n i on a n d e xpe r i en c e. 39

40v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

4 G S # G u i dan c e S t a t e m ent P a g e #

F un ct i o n a l Area 1 : Deter m i nin g t h e Need f

o r P a t i e n t D e c o n t a m

in a t i on

1.1 I nd i ca t o r s t o ass i s t i n t

he d e c i s i on t o d ec on t a m

i n a t e 18

1.2 D ec o n t a m

i n a ti on s hou l d be p erf

o r m e d i f t h er e i s a reas on a

b l e r i s k of e x p o s u r e t o f

i rs t res pond ers /

rece i v er s

or c on t a m i n a ti on of cr iti ca l i n fras t

r u c t u r e 21

1.3 Li k e li hood of a d v er s e c on s e qu e n ce s of g r o s s or t ec h n i ca l w a t er

- b ase d d ec on t a m i n a ti o n 23

F un ct i o n a l Area 2 : O p t i m i z e d T ec h n i c a l Pr a ct i ces

2.1 U s e r i s k

- b ase d a pp r o a c h t o d e t er mi ne t he a pp r op r i a t e res p on s e l e v e l a nd ass o c i a t e d s t r a t e g i e s a nd t ac ti cs 25

2.2 The ti ere d res p o n s e a p p r o a c h t o p a ti e nt d ec on t a m i n a ti on 26

2.3 S e l f

- car e a nd / or g r o s s p a ti e nt d ec on t a m i n a ti on ac ti ons s hou l d o cc ur a s qu i c k l y a s po ss ib l e

, wit hout d e l a y

,

w h il e a t ec hn i ca l p a ti e nt d e c on t a m i n a ti on c o rr i dor i s es t a b li s h e d 29

2.4 A tt e m

pt t o i m m e d i a t e l y d ecr eas e on g o i ng e x p o s u r e by re m o v i ng a l l p a ti e n t s out of t

he are a of re l eas e a nd

p r o v i de a n are a of ref

u g e 31

2.5 C l o t

h i ng re m o v a l f or p a ti e n t s w ho h a v e b ee n v i s i b l y c on t a m i n a t e d 33

2.6 P r i v ac y f

or p a ti e n ts 35

2.7 Wa t

e r i s t he p referre d d e c on t a m

i n a nt 37

2.8 T ec hn i ca l p ara m

e t er s f or w a t er

- b ase d d ec on t a m

i n a ti on 40

2.9 U s e of m

il d s o a p 43

2.10 The u s e of a n o n

- a b ras i v e s p onge or w as h c l o t h 45

2.11 A lt er n a ti v e p rac ti ce s or d ec o n t a m i n a n t s 47

F un ct i o n a l Area 3 : E va lu a t i n g t h e E ffect i v e n e s s o f Dec o n t a m i n a t i on

3.1 I nd i ca t o r s t o h e l p d e t er mi ne w h e t h e r c on t a m

i n a ti on h a s b ee n re du c e d t o a l e v e l w h er e a dd iti on a l

d ec on t a m i n a ti on i s not n ece s sa r y 50

3.2 R a p i d p ac e m

u s t be b a l a n ce d wit

h qu a li t y a nd c on s i s t e n c y of p a ti e nt car e 52

F un c t i o n al Ar ea 4 : Patient Prior itization for Medical Care and Decontamination

4.1 I m m

e d i a t e

, l i fesa v i ng m

e d i c a l car e a nd / or a n ti do t a l t h er a p y s hou l d not be d e l a y e d b y p a ti e nt

d ec on t a m i n a ti on, a s res ou rc e s a ll ow 53

4.2 P r i o r iti z e p a ti e n t s f or d ec o n t a m

i n a ti on b y es ti m a ti ng re l a t i v e r i s k a nd g r oup i ng p a ti e n t s i n t o im m e d i a t e a nd

d e l a y e d d ec on t a m

i n a t i on g r oups 55

F un ct i o n a l Area 5 : S y s t e m

- w id e C oo r din a t i o n o f P a t i e n t Dec o n t a m in a t i on

5.1 D ec o n t a m

i n a ti on s hou l d be p erf

o r m e d a s s oon a s po ss i b l e , p refera b l y a t t he sce ne i f safe t y c on s i d era ti ons

p er m i t 58

5.2 D e v e l op a c o o r d i n a t e d w ho l e c o mm un it y res pon s e p l a n t o m a n a ge t he e n ti r e s p ec t

r u m of p a ti e n t s t o a dd res s

p a ti e n t s se l f

- e v ac u a ti ng fr o m t

he sce ne 60

5.3 R es po n d i ng a n d rece i v i ng o r g a n i za ti ons s hou l d p l a n f or b o t h a m bu l a t o r y a nd non

- a m

bu l a t o r y p a ti e n ts

s i m u l t a n e ou s l y 62

5.4 A t

- r i s k popu l a ti ons re qu i r e a dd iti on a l ass i s t a n c e a nd s p ec i a l t ac ti c s 63

5.5 A f

o r m a l ra p i d c o m m

un i ca t i on p r o c e du r e s h o u l d be u tili ze d t o p r o v i de a d v a n c e no ti c e t o are a h ea lt h car e

fac iliti e s 66

5.6 N o ti f

i ca ti on , by v i s u a l

, w r i t t e n, or v er b a l m ea ns s hou l d b e u se d t o rec o r d sce ne d ec on t a mi n a ti on p rac ti ce s 68

5.7 Con s i d era ti ons f

or PPE se l e c ti on, t

ra i n i ng, a nd u s e 70

5.8 Waste management, facility safety and environmental impact issues 72

F un ct i o n a l Area 6 : Cr is i s a n d E m er g e n cy R i s k C o m m un i c a t i o n

6.1 I n c o r po ra ti ng cr i s i s a nd e m

e r g e n c y r i s k c o m m

un i ca ti on i n t o a l l s t a g e s of d i sas t e r m a n a g e m e nt 74

6.2 D e v e l op a s t

ra t e g i c c o mm

u n i ca ti ons p l a n f

or d e li v er i ng v ar i ous t y

p e s of m essa g e s du r i ng a n i n c i d e n t

. P r e p ar e a s m

u c h m a t er i a l i n a d v a n c e a s po ss i b l e 77

6.3 A s t

ra t e g i c p l a n f

or p re

- e v e nt c o m

m un i ca ti on t o e nh a n c e c o m m un i t y p re p are dn es s s hou l d be d e v e l op e d t o

i n c l ude i n f

o r m a ti on a bout p a

ti e nt d ec on t a m

i n a ti on 81

6.4 I n c o r po ra t e effec ti v e t w o

- w a y c o m m un i ca ti on du r i ng a nd af

t e r a n i n c i d e nt 83v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

5 

## A cr o n y m D e s c r i p t i on

ACGIH American Conference of Governmental Industrial Hygienists

ASL American Sign Language

A S PR O ff

i c e of t he A ss i s t a nt S ecr e t a r y f

or P re p are d n es s a nd R e s pon s e, D e p ar t m e nt of H ea l t

h a nd

H u m a n S er v i ces

ASTM American Standards of Testing and Materials

A T S D R A g e n c y f or Tox i c Sub s t a n c e s a nd D i seas e R e g i s t r y

, D e p a r t m e nt of H ea lt

h a nd H u m a n

S er v i ces

C A L

- O ES C a li f o r n i a

, O ff i c e of E m er g e n c y S e r v i ces

C BRN Ch e m i ca l , B i o l og i ca l , R a d i o l og i ca l

, a nd N u c l e a r

C DC C e n t er s f or D i seas e Con t

r ol a nd P re v e n ti on , Department of Health and Human Services

CERCLA Comprehensive Environmental Response, Compensation, and Liability Act

C H E MM

- I ST Ch e m i ca l H azar d E m

er g e n c y Me d i ca l Ma n a g e m e nt

– I n t e lli g e nt S y

nd r o m e s Too l

C H E M T RE C Ch e m i ca l T ra n s po r t a ti on E m

er g e n c y C e n t er

CMAS Commercial Mobile Alert System

C ONO PS Con c e pt of O p era ti ons

C PR C ar d i opu l m on ar y R es u sc it a t

i on

C W A s Ch e m i ca l Warfar e A g e n t s

D H S D e p ar t m e nt of H o m

e l a nd S e c u r i t y

D O D D e p ar t m e nt of D ef

e n s e

D O T D e p ar t m e nt of T ra n s p o r t a ti on

DSM

- IV Diagnostic and Statistical Manual of Mental Disorders 4 th Edition

E C BC Edg e w o o d Ch e m i ca l B i o l og i ca l C e n t er

, D e p ar t m e nt of t he A r m y

ED E m

er g e n c y D e p ar t

m e nt

E MS E m

er g e n c y Me d i ca l S er v i ces

E PA En v i r on m e n t a l P r o t ec ti on A g e n c y

F D A F

ood a nd D r ug A d m

i n i s t ra t i o n

, D e p ar t

m e nt of H ea lt

h a n d H u m a n S er v i ces

FEMA Federal Emergency Management Agency

FOSC Federal On

- Scene Coordinator

GS Guidance Statement

HAZMAT Hazardous Materials

H A Z W O P ER H azar d ous W as t e O p era ti ons a nd E m er g e n c y R es pon s e

HCF Hospital Care Facility

H H S D e p ar t m e nt of H ea lt

h a nd H u m a n S er v i ces

HIV Human Immunodeficiency Virus

I A W I

n A cc o r d a n c e W it

h

I CS I

n c i d e nt Co m m a nd S y s t e m

ICU Intensive Care Unit

ID Identification

IOM Instit ute of Medicine

IPAWS Integrated Public Alert Warning System (FEMA)

LD 50 Lethal Dose for 50% of the population

L E P C L

o ca l E m er g e n c y P l a nn i ng Co m

mitt e e

L O C L

e v e l of Con f

i d e n c e

LRN

- C Laboratory Response Network

- Chemical

LT 50 Lethal Time for 50% of the population

MIST Man

- In

- Simulant Test

M S DS Ma t er i a l S afe t y D a t a Sh eet

N F P A N a ti on a l F i r e P r o t ec ti on A s s o c i a ti on

N I M S N a ti on a l I n c i d e nt Ma n a g e m

e nt S y s t e mv. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

6 N I O S H N a ti on a l I n s tit u t e f or O cc up a

ti on a l S afe t y a nd H ea lt

h

, C e n t er s f

or D i seas e Con t

r ol a n d

P re v e n ti on, D e p ar t

m e nt of H ea lt

h a nd H u m a n S er v i ces

NRF National Response Framework

O H A O ff

i c e of H ea lt

h A ffa i rs

, D e p ar t

m e nt of H o m

e l a nd S ec u r

i t y

ORCHIDS Optimization through Research of Chemical Incident Decontamination Systems

O S H A O cc u p a ti on a l S afe t y a nd H e a lt h A d m i n i s t ra t i on, Department of Labor

PEG Polyethylene glycol

PHMSA Pipeline and Hazardous Materials Safety Administration

PIO Public Information Officer

PPE Personal Protective Equipment

RSDL® Reactive Skin Decontami nation Lotion ®

SARA Superfund Amendments and Reauthorization Act (EPA)

SARS Severe Acute Respiratory Syndrome

S D S S afe t y D a t a Sh eet

S ME Sub

j ec t Ma tt e r E x p er t

S OP S t a nd ar d O p era ti ng P r o ce d u r e

S T A R T S i m

p l e T r i a ge & R a p i d T re a t

m e nt/Transport

T I C Tox i c I ndu s t r i a l Ch e m i ca l

T IM Tox i c I ndu s t r i a l Ma t er i a l

T LV Th res ho l d L i m i t V a l ue

T RA N S C A E R T ra n s po r t a ti on Co mm un i t y A w are n es s a nd E m

er g e n c y R es pon s e

TS WG T ec hn i ca l Suppo r t W o r k i ng G r ou p

, D e p ar t m e nt of D efe n s e

W I SER W i re l es s I n f o r m a ti on S y s t e m f

or E m er g e n c y R es pond e r s

UK United Kingdom

US United States

VX VX nerve agent

WG W o r

k i ng G r oup

W HO W o r l d H ea lt h O r g a n i za ti on

WMD Weapon of Mass Destructionv. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

7 

## T a ble o f C o n t e n t s 1

2



## E x ec ut i v e S u m m a r y

................................ ................................ ................................ ............ 2 3



## A cr on y m s L ist

................................ ................................ ................................ .......... 5 4



## T a bl e o f C o n t e n t s

................................ ................................ ................................ ..... 6 5



## I. I nt r o d u c t i on

................................ ................................ ................................ .............. 7 6

P urpo s e

................................ ................................ ................................ ................................ ............ 7 7

H ow t h i s w o rk i s u n i q ue

................................ ................................ ................................ ....................... 8 8

A ud i en c e and i n t e nt

................................ ................................ ................................ ............................... 8 9

S cope

................................ ................................ ................................ ................................ ............... 8 10

Me t h od o l o gy

................................ ................................ ................................ ................................ .......... 9 11

R a ti ng t h e e v i de n ce

................................ ................................ ................................ ....................... 11 12

F u t u r e p l ans

................................ ................................ ................................ ................................ ... 12 13



## II. G u i d in g p r i n c i p l es

................................ ................................ ............................. 13 14

D ef i n i ng pa t i e n t and p a ti e n t de c on t a m i na ti o n

................................ ................................ ............... 13 15

P a t i ent dec o n t a m i n a ti o n i s a m

ed i cal cou n t er m

eas u re

................................ ................................ .. 13 16

D es i r ed e n d p o i n t s f o r p a t ie nt d e con t a m

i na t i on

................................ ................................ ............ 14 17

P a t i ent dec o n t a m i n a ti o n i s a w ho l e co m m

un i ty i ss u e

................................ ................................ ... 15 18

T i e r ed r i s k

- based res p onse appr o ach

................................ ................................ ............................. 16 19

P ra c ti c es i n m ass c a su a lt y i nc i d e n t s

................................ ................................ .............................. 17 20



## II I. G u i d a n ce S t a t e m e n t s

................................ ................................ ........................ 18 21

F unc t i on a l Ar ea 1 : D e t er m

i n i ng t he Ne ed f

o r P a t i ent D econ t a m

i na t i on

................................ ....... 18 22

F unc t i on a l Ar ea 2 : O p t i m

i zed T ec h n i c al P

ra c t i ces

................................ ................................ ....... 25 23

F unc t i on a l Ar e a 3 : E v a l u a t i ng t he E f f e c ti v ene s s of D e c on t a m

i na t i on

................................ .......... 50 24

F unc t i on a l Ar ea 4 : Patient Prioritization for Medical Care and Decontamination

......................... 53 25

F unc t i on a l Ar ea 5 : S y s t e m

- w i de C o o rd i n a t i on o f P a t ie nt D ec o n t a m i n a ti on

................................ . 58 26

F unc t i on a l Ar ea 6 : C r i s i s a

nd E m er g ency R i sk C o m m un i c at i on

................................ .................. 74 27



## B i bl i o g r a

p h y

................................ ................................ ................................ ........... 85 28



## A pp e n d i x A : W o r k i n g G r o u p C h a r t er a n d Me m

b er s h ip

................................ ..... 1 02 29



## A pp e n d i x B: L e x i c on

................................ ................................ .......................... 1 14 30



## A pp e n d i x C: G l o s s a r y

................................ ................................ ......................... 1 17 31



## A pp e n d i x D : To x i c C h e m i cal S y nd r o m

e L e x i c o n

................................ .............. 1 18 32



## A pp e n d i x E : L e v el o f C on f i d e n ce ( LO C) R a n k i n g s

................................ ........... 1 20 33v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

8 

## I. In t r o du c t i o n 1

2



### Purpose 3

Whe t her as a r e su l t o f an a c c i de n t a l r e l ease at a c h e m i cal p l a n t , a t r a nsp o r t a t i on ac c i de n t, o r an i n t e n ti o nal 4

m

ilit a ry or t e r r o r i st a c ti o n

, t

he t h re a t o f exp o su r e of t h e pub l i c t o ha z a r dous che m i cals i s r e a l

. An 5

acc i de n t a l g as l e ak at t h e U n i on C a rb i de c h e m

i cal p l a n t i n B h opo l

, I

nd i a, re s u l t ed i n t h e r e l e ase of 6

m

e t h y l i soc y an a t e i n t o t h e en v i r o n m ent expos i ng t hous a nds ( Z a i d i , 198 6 ). T h e I raqi m ilit a ry used 7

c he m

i cal w arf a re a g en t s ( C W As ) a g a i n s t I ran and I raqi K ur d s ( G

hanei et al., 201 0 ; D a r ch i n i

8

Mara g heh et a l

., 2012). A um S h i n r i ky o, a re li g i o u s c u lt

, pro d uced and re l ea s ed s a r i n, a n er v e 9

a g e n t p r e v i ous l y po s se s sed on l y by na ti o n s, on m u l t i p l e sub w ay ca r s i n T o ky o, J a pan ( O k u m ura et 10

a l ., 1 9 96). I n G ran it e v i l l e, S o u t h C aro l i na

, a r a i l c a r a cc i de n t res u l t ed i n t h e r e l e ase of c h l o r i ne g as 11

i n a p opu l a t ed ar ea ( D u n can e t a l

., 2011). I n each o f t he s e c as es, s i g n i f i ca n t nu m bers o f p eop l e 12

w ere k

il l ed or s i c k

ened. 13

14

E ach da y

, l ar g e qua n t i t i es o f ha z ard o us c h e m i ca l s a r e p rodu c e d

, t

ra n s p o r t e d, s t or e d , and u s ed f or 15

i ndu s t r i a l and hou s eho l d p u rpos e s. D u r i ng each of t h es e a c ti v i t i e s

, t h ere i s r i sk t h a t t h e che m

i c a l s cou l d 16

be r e l e a sed i n t o t he en v i ro n m ent due t o an a c c i d ent or i n t e n ti o n al a c t t o ca u se h ar m

. S t oc k p il es o f 17

che m

i cal we apons ar o und t

he w o r l d, w h i l e cu r

re n tl y b e i ng de s t ro y ed, s t i l l e x i s t

. A dd i t i on a ll y

, v ar i o us 18

t e r

ro r i s t o r g an i z a t i ons a nd i nd i v i du a l s h a v e i n d i c a t ed i n t e r e s t i n de v e l o p i ng and u s i ng che m i ca l s as 19

w eapons. M o reo v er, c he m i cal su i c i d e 1 , bo t h a b road a n d i n t he U n it e d S t a t e s ( U S ), i s a t r oub l i ng re c ent 20

t re n d a ff

e c t i ng not o n l y t he patients but a l so c r ea t i ng r is k for t he f i r s t r esp o nde r s a n d f

i r s t r e c e i v ers 21

rend e r i ng ass i s t a nce. C i v i li an f i r s t r esp o nd e rs a n d he al t h c a re f i r s t r e c e i v ers, a l ong w it h e m er g ency 22

m ana g ers, pub l i c h e a l t h p r a c t i t i on e rs, l aw e n fo r ce m ent of f i c i a l s, and r i sk co m m

un i ca t i ons exp e r t s m

ust 23

be p r epa r ed t o r espo n d t o i nc i d e n t s i n v o l v i ng t he r e l e a se of che m i c a l a g en t s

. 24

25

T he t h

re a t o f a c he m

i cal r el ease ca r

r i es wi t h i t t he pos s i b i l i t y t h a t w or k ers, b y s t a n ders, or o t h e rs m ay 26

beco m

e con t a m i na t ed. T h e se co n t a m

i na t ed i nd i v i d u a l s ( i

. e ., p a t i en t s ) req u i r e a s se s s m ent for 27

deco n t a m

i na t i on n eeds and t hen p o t e n t i a l l y , deco n t a m i na t i on a t t he s cene of t he i n c i de n t a nd / o r a t a 28

hea l t h c are f a c i l i t y

. I n recent y ears, t h e po t en t i a l f or a l ar g e

- sca l e c he m

i cal r e l e as e re q u i r i ng 29

deco n t a m

i na t i on o f an o v er w he l m

ing n u m ber of p eo p l e has a t t r a c t ed i nc r ea s ed i n t ere s t. I n respo n se, 30

m

e t hods and p ro c edu r es for c i v i l i an m ass p a t i e n t de c o n t a m i na t i on ha v e b een d e v e l oped l ar g e l y t h rou gh 31

ex t r ap o l a t i ng t e chn i ques u s ed on ha za rdous w as t e s it e pers o nn e l and ha z ardo u s m a t e r i a l s r e spond e rs i n 32

pers o nal pr o t e ct i v e equ i p m ent ( PPE ) ( N I O S H , 1985) a nd m ili t ary pe r sonn e l i n p r o t e c ti v e g ear ( DO D F M 33

3

- 11.5, 2006). I nfor m a ti on sha r i ng a m

ong f i re and e mer g ency ser v i c e s, ha z a r do u s m a t er i al res p onse, 34

m

ed i ca l

, a n d D ep a

r t m ent o f D efen s e ( DOD ) che m i ca l

, b i o l o g i ca l

, r a d i o l o g i c a l and nuc l ear ( CBR N ) 35

defe n se c o m m un iti e s i m pr ov ed t hese pr a c t i c e s. D e c o n t a m i na t i on p ra c t i ces e v o l v ed ra p i d l y and i nd u s t ry 36

resp o nded w it h cu s t o m i z ed equ i p m

ent b ut n o t n ece s s ar il y w it h t he ben e f i t o f e v i d e nce t o g u i de s uch 37

eff

o r t s ( L e v it i n et a l

. , 200 3 ; S t o p ford et a l

., 200 5 ). Limited r e se a rch h as b een condu c t ed on 38

deco n t a m

i na t i ng peop l e a n d m

uch of w hat h as b een d one i s ba s ed on t he m ili t ary per s pe c ti v e: 39

deco n t a m

i na t i ng t r a i n e d p r ofe s s i o n al ser v i c e m e m bers w it h t he end g oal b e i ng t o re t u rn t hem t o t h e 40

oper a t i on a l en v i r on m ent so t h a t t h ey can co n t i nue a m i ss i o n. 41

42

M ass p a t

i e n t d e co n t a m

i na ti on, l i k

e o t h e r aspe c t s of d i s a s t er res p ons e

, m ed i c i ne

, and pu b l i c h e a lt

h, c ou l d 43

be n e f

i t from an a ss ess m

ent of t he body of e v i dence, enh a nced i n c orp o ra t i on o f t he e v i d ence i n t o p l an n i ng 44

and p ra c t i ce, a nd add i ti o nal s t u dy t o g enera t e ne e ded e v i d ence ( IO M, 1999; L e v i ti n et a l

., 2 003 ; S t op f ord 45

et a l

., 2 005; A uf der H e i d e, 200 6 ). V a r i o u s or g a n i z a ti o ns h a v e pub l i sh e d g u i dan c e a n d b e st

- prac t i ce 46

docu m

en t s b ut t hese g en e ra l l y do not ca t e g o r i z e r e co m m enda ti o n s as e v i d ence

- based o r n o t, nor do t hey 47

de s c r i be t he p e r ti n ent e v i den c e. F ur t h er m ore, m any curre n t g u i dance and b e st

- pra c ti c e docu m en t s do n ot 48

1 C h e m

i cal s u i c i d e s (a ls o d u bb ed “ d e t er g e n t s u i c i d e s ” b y t h e m e d i a) are s p ec i f i c ac t s carr i e d o u t b y t h e patient t h r ou g h t h e

m i x i n g o f h o u s e ho l d c h e m i ca l s t o p r od u ce t o x i c c h e m i c a lv. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

9 add r ess t he f

u l l spe c t r um of i ss u es, s uch a s c o or d i n a ti o n and co mm un i ca ti o n, w h i c h a co m m un it y m a y 1

face w h en p a ti e nt deco n t a m

i na t i on i s n ece s s a

ry i n a m ass che m

i c a l ex po sure i n c i d e n t

. 2

3

T he ne e d f

o r e x a m i na ti o n o f p a ti e nt d eco n t a m i na t i on p ra c ti c es wa s i d en t i f i ed by expe r t s i n t he e m

er g ency 4

resp o nse and m ed i c a l co mm

un iti es. T he U S G o v er n m ent fo l l o w ed wi t h a re q u e st f or a n e v i de n c e

- based 5

na t i on a l p l an n i ng g u i dance for m ass p a t i ent dec o n t a m i na t i on i n a l ar g e

- s ca l e c h e m i c a l r e l e ase. E f f o r t s t o 6

enhan c e p r ep a red n ess for p a t i ent dec o n t a m i n a ti on i n a m ass exposu r e i nc i de n t m ay a l so h e l p t o i m pro v e 7

t he c are t h at i s p ro v i ded t o i nd i v i du a l co n t a m i n a t ed p a ti en t s i n o t h e r c i r cu m s t anc e s. 8

9



### How this work i s u ni q ue 10

“ P a t

i e n t D ec o n t a m

i n a ti on i n a M a ss C he m

i c a l E xp o s u re I

nc i de n t : Na t i on a l P l a n n i ng G u i dan c e f o r 11

C o m m

un iti es” d i ff

e rs from pre v i ous p l a

nn i n g

, g u i da n c e, and b e s t

- prac t i ce d o cu m en t s i n t w o s i g n i f

i c ant 12

w a y s: 13

1. T h e g u i dan c e i s e v i de n ce

- based t o t he ex t ent p os s i b l e and t h at e v i den c e, or l a ck t he re o f, i s 14

docu m en t ed a nd b r i e f

l y d is cuss e d. A s a

pp l i ed i n t h i s g u i dance d ocu m en t

, “ e v i de n c e

- based ” r e fe r s 15

t o t he c ons c i e n t i ous, d e f i n i ti v e

, and j ud i c i ous u se o f c u rr e nt s c i e n t i f i c e v i d e nce and / o r sou n d 16

t e ch n i c a l i np u t f rom su b j e c t m a tt e r e xpe r t s i n de v e l o p i ng p a ti e nt deco n t a m i na t i on 17

reco mm e nda t i ons f

o r t he care of p a t i e n t s, b o t h i n d i v i dua l l y and i n a m ass c a su al t y che m i cal 18

i n c i de n t, i n or d er t o sa v e l i v es ( S ac k e t t e t a l ., 199 6 ). 19

2. T h i s d ocu m ent a tt e m p t s t o addr e ss the fu l l s p e c t rum of an i n c i d en t

, f r om i n i t i a l a ss ess m

ent and 20

dec i s i o n

- m a k i ng t hrou g h e v a l ua t i on o f de c on t a m i na t i on e f fe c ti v en e ss. F u r t her, a co m prehen s i v e 21

appr o ach i s t a k en t o t he en t

i re a f fe c t ed co m m

un it y w i t h e m

phas i s on co o rd i na t i on be t we en on

22

scene and h e a lt h ca r e f ac i l ity

- based resp o nse ac t i v i t i es and co mm un i ca ti on on m

u lti p l e l e v e l s. 23

24



### A u dience a n d i n tent 25

T he m a i n i n t en d ed au d i e n c e i n c l u d es s en i o r l ea d er s

, i n c i de n t c o m m anders, p l ann e rs

, a n d t ra i ne r s f o r 26

e m

er g ency response o r g an iz a ti ons and h ea l t h ca r e f a c il i t i es, as we l l as e m

er g ency m ana g e rs and m

ili t ary 27

pers o nn e l sup p o r ti ng do m es t i c r espo n ses. T hou g h t h e g u i dan c e w as d e v e l oped w it h t h i s s p ec i f i c aud i e nce 28

i n m

i nd, i t m ay be of v a l ue to o t h e r au d i e n ce s

, i n c l u d i ng f i r st re s pond e rs, f

i rst r e ce i v e r s, and l ea d ers of 29

p ub l i c h ea l t h o r g an i z a t i on s

. 30

T he g u i dan c e s e t s fo r t h p a ti ent d eco n t a m i na t i on p r i nc i p l es f

r om a s t r a t e g i c s t a nd p o i n t

, r a t h e r t han a 31

t a c t i cal one. I t i s m eant t o g u i de, but not spe c i f y , op er a t i on a l p r ac t i c es. T h e ap p r oach i s f l e x i b l e a nd 32

sca l ab l e a c co r d i ng t o t he r e sour c es a nd c a pa b i l it y l i m it a t i ons o f p l an n i ng and r es p onse o r g an i z a t i ons i n a 33

co m m

un it y

. T he g u i d a nce s t a t e m en t s co m p l y w it h t he N a ti o n al R espo n se F ra m e w ork ( N RF ) and d o n o t 34

pro m

o t e any add it i ons o r c han g es t o t he Nat i on a l I nc i dent Ma n a g e m

ent S y s t em ( N I M S ) or t he I nc i de n t 35

C o m m and S y s t em ( I CS )

. 36

37



### Scope 38

T he su b

j e c t m a tt e r c o ns i de r ed h e re i s l i m it ed t o e x t e rn a l co n t a m

i na t i on o f patients i n a m ass c asu a lt y 39

i n c i de n t r es u l t i ng from an a cc i d en t al o r i nt e n t i on a l c h e m i cal r e l e a se. C o n t a m

i n a t i on of p a t i e n t s wi t h 40

che m

i ca l s

, i n c l u d i ng t o x i c i ndus t r i al che m i ca l s, t ox i c i ndus t

r i al m a t e r i a l s

, and c h e m

i cal w a r fa r e a g en t s

, i s 41

t he p re s ent fo c us. R a d i o l og i cal m a t e r i a l s a n d b i o l o g i c al a g en t s a l so p ose i m por t a nt r i s k s. M any of t h e 42

conce p t s pr e se n t ed h ere may app l y t o t ho s e a g en t s; i n f u t u re w o r k

, t h i s g u i d a nce c a n be b u i l t u pon t o 43

ad d r e ss r ad i o l o g i c al a nd b i o l o g i cal a g en t s. W h i l e t h i s g u i da n ce i s a i m ed at m ass ca s ua l t y che m i cal 44

incidents, the recommendations and principles may be applied to individual patients or m u lt i

- pa ti e n t 2 45

2 Multi

- Patient decontamination (defined in Appendix E

– Lexicon ) signifies a small scale incident of more than one patient

requiring decontamination. This incident is well within the resources of the initial responding agencies. Mass M ulti

- Patient

decontamination indicates a large scale incident that requires mutual aid from n eighboring jurisdictions ; this m ay also

indicate a need to utilize crisis standards of care and patient prioritization for decontamination. As an examp le, think of five

patients versus 500.v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

10 incidents as wel l. 1

2



### Methodo l

ogy 3

A fed e ral i n t e ra g ency expe r t w or k i ng g roup, t he M a ss H u m an C h e m i cal D e c on ta

m i na ti on Wor k

i ng G roup 4

( W G ), d e v e l oped t h i s na t i o n al p l a n n i ng g u i dan c e w it h t he ad v i ce of a l a r g er g roup of f

ed e r a l and non

5

feder a l su b

j e c t m a tt e r expe r

t s i n e m er g e ncy res po nse, e m

er g ency m

ed i c i ne, t ox i c o l o gy , r i sk 6

co m m

un i ca t i on, b e ha v i or a l hea l t h

, a nd o t h e r r e l e v ant f i e l ds. T he WG w as e s t a

b l i s hed a t t h e r eque s t o f t h e 7

Wh i t e H o u se Na ti o n al S ec u r i t y S t a f f and co

- cha i r e d by t he D e p a r t m ent of He a l t h a

nd H u m an S er v i ces 8

( HH S )

, O f

f i c e of t he A ss i s t ant S e c r e t a ry for P re p are dn ess a nd R es p onse ( A SPR ) a nd t he D ep a

r t m ent of 9

H o m

e l and S ecu ri t y ( DH S ), O ff i ce o f H e a lt h A ff

a i r s ( O HA ). 10

11

I n order t o d e f i ne t he p ro b l e m , core que st i ons con s i d er ed e s se n ti a l t o p e rf o r m i ng pa t i ent dec o n t a m

i n a ti on 12

and m

ost l i k e l y t o i n f l u en c e on

- scene and h ea l t h c a r e f a c i l it y ap p ro a ches w ere i d e n t i f i ed

. C ore qu e s t i ons 13

and t h e i r sub

- ques t i o n s n at ura l l y f e l l i n t o t h ree c a t e g o r

i es, w h i ch f

o ll ow a l o g i c al r espon s e p r o g res s i o n : 14

1. r i sk a s sess m ent and d e c i s i o n m a k

i ng 15

2. deco n t a m i na t i on p ro c ess a n d pro c edu r e 16

3. e v a l ua t i on o f r es u l t s and p a ti e nt fo l l o w

- up 17

18

C ore q u es t i o n s w e r e f u r t h er d i v i ded so t h at t he t h ree c a t e g or i e s w e r e e a ch a

pp l i ed t o t w o d i s t

i n c t 19

s i t ua t i o n s: i nd i v i du a l p a t i e n t d e co n t a m i n a t i o n

, i n w h i ch o n e t o a few p o t e n ti all y con t a m i na t ed p a ti e n t s 20

pre s ent for a s sess m ent and l oc a l r eso u rc e s a

re n o t o v e rw he l m

ed ; and m ass p a t

i e n t d eco n t a m i n a t i o n

, 21

w hen a m ass c a su a lt y i n c i d ent res u l t s i n numerous p o t e n t i a l l y con t a m i n a t ed p a t i e n t s and l oc a l resp o nse 22

capa

b i l i t i e s m ay be o v er w h e l m

ed. T h ese t w o c i r cu m s t ances a l l o w ed t he WG t o s e par a t e l y cons i de r : ( 1) 23

ques t i o n s p e r t i ne n t t o an i n c i de n t i n w h i ch s i g n i f i ca n t reso u r c es a n d a t t e n t i on c an be br o u g ht t o b ear on a 24

s i n g l e p a t i e n t or s m a l l nu m ber o f p a t i en t s and t h e r e fo r e, op t i m al m e t hods c an be a ssu m

ed ; and ( 2) 25

ques t i o n s u n i que t o a m ass casu a lt y s it u a t i on, w h e n p at

i e n t ne e ds a

re li k e l y t o exc e ed a v a i l ab l e r eso u rc e s 26

and t h us p r i o r i ti za ti on w i l l be ne c es s ary and c r i s i s s t a n dards of ca r e wi l l n eed t o b e con s i d e red. S ee T ab l e 27

2 for t he co r e qu e s t i o n s and t h e i r o r g an i z a t i on. 28

29

A n ex t e ns i v e s ea r ch o f t h e pu b l i sh e d l it e r a t u r e f o r a n sw ers t o t h e r es u l t i ng s i x co r e que s t i ons was 30

condu c t ed. T he f o l l o w i ng d a t a b as e s w e r e s e ar c he d

, alt hou g h t h i s i s not an e x hau st i v e li st : P ub M ed, 31

SC O P U S , Web of S c i ence, and G oo g l e S c h o l a r. A d d i t i on a l s e a r ches we re cond u c t ed t hr o u g h t he 32

N a ti o n al I

ns t i t u t es of He a lt

h ’s National Library of Medicine

. I n iti al se a rch t er m s w ere li m

it ed t o : hu m an; 33

che m

i ca l ; deco n t a m

i na t i on. A d d i t i o n al s ea r ch t er m s w ere t o p i c depen d en t

. E xa m p l es i n c l u de: 34

• t r i a g e; a ss e ss m en t ; d ec i s i o n t o d e con t a m i na t e 35

• r i sk co m m un i ca t i o n ; e m

er g ency co m m

un i ca t i on; cro w d beha v i o r; d i s a s t er c ro w d m ana g e m ent 36

• hosp i t a l p r ep a red n es s ; h e a lt h ca r e f

ac i l i t y res p onse 37

• de t e c t i on c apa b i l i t i e s; p o r t a l se n sor t e chn o l o g y 38

• ef

f ec t i v ene s s c r i t e r i a ; d e t e r m i na ti on o f c l e a n 39

40

O n l y ar t i c l es i n E n g l i sh we re e v a l u a t e d and no l i m it s w ere p l a ced o n t h e pu b l i ca t i on d a t e

. O nce an i n i t i al 41

se a

rch wa s co m

p l e te d, t he r e fe r en c es s ec t i o n s of re v i e w ed a r ti c l e s w e r e us e d as s o ur c es o f additional 42

material for evaluation. T h rou g hout t h i s p r ocess t h e WG h a s sou g ht t h e as s i s t a n ce o f su b j e c t m a tt er 43

e x pe r t s i n i de n t i f y i n g add it i on a l r ef

e re n ces, un p ub l i shed da t a, a n d on g o i ng s t u d i es. 44

45

T he l it e r a t u r e r e v i ew r e su lt s w ere su m m ar i z ed and p r e sen t ed, a l ong w it h t he c o re ques t i o n s and su b 46

ques t i o n s, t o a g roup o f e m er g ency resp o nd e rs, e m er g ency m

ed i c i ne c l i n i c i a n s

, t o x i c o l o g i s t s, r es e ar c h e r s, 47v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

11 and o t her r e l e v ant exp e r t s a t t h e S y m pos i um on C h e m

i cal De co n t a m

i na t i on o f H u m ans 201 0 3 hos t ed by 1

t h e D e p a

r t m ent of H o m

e l a nd S ec u r i t y (see l i st of p a r t i c i pa n t s i n A p p end i x A ). S y m pos i um par ti c i pa n t s 2

he l p e d t o i d en t i fy ad d i t i on a l so u rc e s of e v i den c e

, r e f i n e t he su m m ar i es of t he e v i d ence, and i n i t i a t e d l i s t s 3

of k

no w l ed g e g aps or re s e a

rch n eeds for e a ch c o re q u e s t i on. 4

5

W i t h s t

rong su mm ar i es of t

he a v a i l ab l e e v i de n ce, as w e l l as t he i m por t a n t k no w l e d g e g aps i den t i f

i e d , an 6

i n i t i al d

r a ft g u i d ance w as cr ea t e d. T he g u i d an c e f o ll o w s t he pa t h s e t by t he co r e q u es t i ons, w h i ch de f i n e 7

t he e ss e n t i al i n for m a t i on n e eded t o co n du c t p a t i ent d e c on t a m i na t i on. F or t he g u i d ance, each co r e 8

ques t i on has b een con v er te d t o a fu n c t i on a l a rea ( s e e T ab l e 2). E ach d i s ti n ct p r i n c i p l e i s de s c r i bed as a 9

g u i dance s t a t e m en t

, wi t h as soc i a t e d co n s i d er at i ons i f a pp l i ca b l e. G u i da n ce s t a t e men t s a r e ba s ed on 10

pub l i sh e d e v i de n ce i f a v a il ab l e, and h a v e been add i t i o na l l y shaped by o t her g u i d a nce a n d be s t p ra c t i ce 11

docu m

en t s, e x pe r t o p i n i o n

, and ex p e r i en c e. 12

13

3 T h e S ym

po s i u m o n C h e m i cal Dec o n t a m i n a ti o n o f H u m a n s w a s h e l d i n W a s h i n g t o n

, D C o n Dec e m b er 6

- 7

, 2010. T h e

s y m po s i u m w as c o

- s po n so red b y DH S/ O H A a n d HH S / A S P R

. T h e f i n al sum m a r y c a n b e f

ou n d a t :

h tt p :/ / ww w

. p h e. g o v

/ P re p are dn e s s / m

c m / D o c u m e n ts / s um m a r y

- c h e m d ec o n

- 20Ju n e 12

. pdfv. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

12 T a b l e 2 : K ey E l e m e n ts o f P a t i e n t De co n t a m i n a t i on 1

2

Core Question Stage of Response Function al Area Individual Patient

Decontamination What criteria can guide the decision on

whether the patient needs

decontamination or not? Risk assessment and

decision making Determine the need for

patient decontamination

What are the optimal methods for

deco ntamination of a patient with an

unknown level of exposure to an

unknown agent? Decontamination

process and procedure Optimized technical

methods for patient

decontamination

What metrics can be used to determine if

patient decontamination was effective? Evaluation of results

and patient follow

- up Evaluating the

effectiveness of patient

decontamination Mass Patient Decontamination What t e ch n i qu e s can be u s e d for

ass e ss m ent and t r i a g e of p a ti e n t s (b o t h at

t he s cene a n d at h ea l t h c a re fa c i l i t i e s ) t o

p r i o r i t i z e deco n t a m

i na t i on a nd m

ed i c al

t r e a t m en t? Risk assessment and

decision making Patient Prioritization for

Medical Care and

Decontamination

Where and when should decontamination

take place? Decontamination

process and procedure System

- wide

coordination of patient

decontamination and

emergency risk

communication

Communication: (1) What information

should be provided to patients to promote

safety and compliance during

decontamination and how should it be

communicated? (2) How can

communication about the incident with

the whole community support the

response and recovery? Evaluation of results

and patient follow

- up

3

A s e v i dence of cu r re n t p r a c ti c e, t he WG p e r for m ed a n ana l y s i s o f six c urr e nt g u i d ance or bes t pr a ct i ce 4

do c u m

en t s f o r reco mm

enda ti ons t h a

t a d d r ess o n e of t he s i x c o re q u e s ti o n s. T he f o ll o w i ng docu m

en t s 5

w e r e i nc l uded i n t he an a l y s i s: 6

7

• United States Department of Health and Human Services, Agency for Toxic Substance sand Disease 8

Registry (ATSDR). (2000) Mana g i ng h aza r dous m a t e r i a l s i n c i d

en t s

– V o l

. I ( E M S ) and V o l

. I I 9

( H osp it a l E m er g ency D epa r

t m en t s) 10

A g ency for T o x i c S ub s t an c es and D i s e ase R e g i s t ry ( A T S D R ) 11

• United States Department of Defense, Department of the Army, Edgewood Chemical Biological 12

Center (ECBC) and CBRN School. (2009) G u i de l i n e s f or m a s s ca s ua lt

y dec o n t a m i na t i on d ur i ng a 13

H

AZ M AT / W eapon of M

a ss D es t r uc t i on Inc i de n t ( V o l . I and I I ) 14

• United States Department of Labor, Occupational Safety and Health Administration (OSHA). 15

(2005) B est p ra c t i ces f or hos p it a l

- based f

i rst re c e i ve r

s of patients f

ro m m a s s c a sua l t

y i n ci den t s 16

i n vo l v i ng 17

t he r

e l ease of h aza r

dous s u bs t a n ces 18

• United States Department of Labor, Occupational Safety and Health Administration (OSHA). 19

(2005) B est p ra c t i ces f or pr o t e c ti n g E MS r esp o nde r s du r i ng t rea t

me nt a nd t rans

p ort of patients o

f 20

hazard o us s ub s t anc e s r

e l e a ses 21

• California Governor’s Office of Emergency Services (OES). (2006) Mu l t i

- c a su a lt y m a ss 22v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

13 d eco n t a m i na t i on g u i d

a nce d ocu m ent f or f i rst re s pond e rs 1

• United States Department of Defense Technical Support Working Group (DOD TSWG) . (2 00 4 ) 2

B est p ra c t i ces a nd g u i d e li n es f o r CB R m ass pe r

sonn e l deco n t

a m i n a t i on 2 nd edition. 3

4

T he i n i t i a l d r a f t g u i da n ce st a t e m

en t s, t h e i r con s i d e r a ti o ns, and t he supp o r t i ng e v i d ence we re p re s en t ed t o 5

a g roup of su b j e c t m a tt e r e xpe r t s a

t t he Mass H u m an C he m

i cal D ec o n t a m

i n a ti on 2012 S y m

pos i u m 4 6

hos t e d by t he D e p a r t m ent o f H o m

e l and S e c u r it y (s e e li st o f p a r t i c i pa n t s i n A ppe nd i x A )

. P a r ti c i p a n ts 7

re v i e w ed, d i s cus s ed, su gg es t ed re v i s i ons, and v o t e d t h e i r ap p ro v al or r e j e c t i on o f each g u i d ance 8

s t a t e m

en t

. T he e v i den c e t o sub s t a n ti a t e each g u i dan c e s t a t e m ent w as a l s o re v i e w e d. F o l l o w i ng t h e 9

sy m

pos i u m

, g u i dance s t a te m

en t s w ere s i g n i f

i c a n t l y r e v i sed, t h e su p po r ti ng e v i d e nce w as su m m ar i z ed, 10

and a l e v el o f co n f i den c e ( L OC ) (s e e Rating the evidence se c ti o n b e l ow and A ppend i x E )

– w h i ch 11

re f

l e c t s t he a m

ount and q u a l i t y of e v i de n ce s u ppo r t i ng a re c o m m enda ti on

- w as a s s i g ned t o ea c h g u i dance 12

s t a t e m

en t

. I n add i t i on, e x t e ns i v e s t a k eho l der re v i ew of t h i s g u i d a nce do cu m ent has b een condu c t ed, 13

i n c l u d i ng t h r o ug h profe s s i o n al so c i e ti e s a n d pub l i c a t i on i n t h e F e d er a l R e g i s t e r f o r pu b l i c co m m

en t

, 14

bef

o re f i n al i z a ti o n and d i s t

r i bu t i on t o t he t a r g et aud i ence. 15

16

T he WG a l so d e v e l op e d a l ex i c o n f o r c i v i l i an p a t

i e n t d econ t a m

i na t i on, a s a s t e p t o w ard s t an d ar d i z i ng t he 17

t er m s used a c ross v a r i ed o r g an i z a ti ons ( i n c l uded as A p pend i x B ). 18

19



### Rating t

he evide n ce 20

A L e v el of C o n f i d ence ( L O C ) sc o re i s a ss i g ned t o e ach g u i dance s t a t e m en t

. T h i s c onf

i d en c e r at i ng (ba s ed 21

on a f

i v e po i n t s c a le ) g i v es t he rea d er a s e nse o f t he s t r en g t h o f e v i de n ce s u bs t a n t i a t i ng a p a r t i c u l a r 22

g u i dance s t a t e m en t

. T h e f

o ll o w i ng li s t p ro v i des a s y n o ps i s of t he L O C s ca l e ( add i ti o n al i n f or m a ti on can 23

be fo u nd i n A ppen d i x E ) 24

 L O C I

– T he h i g hest re c o m m enda ti on i s s uppo r t ed by s t r o ng s c i e n t i f i c e v i d e nce, i nc l u d i ng c l i n i cal 25

or f i e l d r es e arc h

, i n ad d i t i o n t o c u r r ent pr a c t i ce and s tr ong S ME cons e nsus. 26

27

 L O C I I

– T he s e cond ti e r re co m m enda ti on i s supp o r t ed by so m e sc i en t i f i c e v i d en c e w h i ch i s not 28

def

i n i ti v e or w he r e m

e t ho d o l o g i c a l p r ob l e m s l i m i t t h e u t i l i t y of t h e s t a t ed c on c l u si on s ; cu r re n t 29

pra c t i ce a n d s t rong S ME c o nsens u s a l so sub s t a n t i a t e t h e re c o m m enda ti on. 30

31

 L O C II I

– T he t h i rd ti e r r e c o m menda ti on i s o n e f o r w h i ch v ery li m

it e d s c i e n t i f

i c li t e r a t u re i s 32

i nf

o r m a ti v e, but f

o r w h i c h t here i s p r e cede n t i n c u r

r ent pra c t i ce a n d f

o r w h i ch t he r e i s m a

j o ri t y 33

S ME co n sen s us. 34

35

 L O C I V

– T h e f ou r t h t i e r re co m m

enda ti on i s supp o r t ed by at l e ast m a j o r i t y conse n sus a n d c u rr e nt 36

pra c t i ce b u t li t t l e o r no s c ie n t i f i c l i t er a t u r e. 37

38

 L O C V

- T he f i f t h ti e r r e f l e c t s an a b sen c e of l it e r a t u r e and p r ece d en t ; S ME co n s e nsus for m s t he 39

so l e ba s i s for t he r e co m m e nda t i on. 40

41

S i nce t h i s i s d e s i g ned t o be a li v i ng docu m en t

, L O C sc ores m ay chan g e i n f u t u re v er s i ons w h en new 42

e v i dence beco m es a v a i l a b l e t o i nf

o rm t he g u i dan c e s t a t e m

en t s. A dd i ti o na l l y

, t he L O C sco r i ng s y s t em 43

he l ps t o i d e n t i fy t h o s e t op ic s re q u i r i ng ad d i t i on a l r es ea rch. 44

45

4 T h e Ma s s H u m an Dec o n t a m i n a ti o n 201 2 S y m po s i u m w as h e l d i n W a s h i ng t o n

, DC o n 2 4

- 2 6 J a nu a r y 2012

. T h e s ym po s i u m

w a s c o

- s pon s o red b y D H S/ O H A a n d HHS / A S P R

.v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

14 

### F u ture p l ans 1

A s t he e v i den c e

- based p r i n c i p l es for cond u c t i ng pa t i e n t de c on t a m

i na ti o n s e t f

o r t h here are i m

p l e m en t ed, 2

resp o nse p l a n s a n d op e r a ti o nal p ra c t i ces sho u l d t he m se l v es beco m e m ore e v i denc e

- based. D ur i ng 3

d e v e l op m

en t , a v a r i e t y of g aps i n t h e e v i de n ce we re i d en t i f i ed, m any of w h i ch are ou t l i n e d i n t he g u i dance 4

s t a t e m

ent d i sc u s si ons. T h ese k no w l e d g e g aps w i l l b e f

o r m u l a t ed i n t o a res e a r ch r o ad m ap des c r i b i ng 5

and p r i o r i ti z i ng ques t i o n s f o r w h i ch e v i d e n ce

- based ans we rs cou l d h el p t o i m pro v e t he ef

f ec t i v ene s s of 6

p a t i e n t d ec on t a m i na t i on (s e e D e s i r ed end p o i n t s s e c t i on b e l o w )

. T he r e se a rch road m ap w il l be d i r e c t ed a t 7

g rant a n d con t r a ct a w ar d i ng en t i t i es and m e m bers of t h e r e se ar ch co m m un it y

. S ubseq u ent re v i s i ons t o 8

t h i s g u i dan c e w i l l re f l e c t u p d a t ed reco mm

enda ti ons ba s ed on co m

p l e t i on o f res e a r ch s t ud i es a s we l l a s 9

w i de l y a c ce p t ed c han g es t o cur r e n t f i e l d p r ac t i c es. 10

11

I

t i s cru c i a l t o i n t e g r a t e t h i s g u i dance i n t o t r a i n i ng c u r ri cu l a and t he WG i n t en d s t o w ork c l os e l y w ith 12

fed e r a l p a

r t n ers t o d o so. I dea l l y

, t h i s g u i da n ce wi l l b e pa r t o f an i t er a ti v e p roc es s of u p da t i ng t r a i n i ng 13

pro g ra m s, oper a t i on a l r e s p onse p l a n s, and r e spon s e st anda r ds d u r i ng t h e i r n o r m al re v i s i on c y c l e s. 14

A dd i t i on a ll y

, i t i s i m por t a n t t o ens u re t h a t t he i n t e nded aud i ence i s a w a r e of t he gu i dan ce

. P ro m o ti on wi ll 15

be ne c es s ary upon t h i s do c u m en t ’s r e l e ase and s ubs e q uent u pd a t es. T o su p po r t t h i s s oc i a l i z a t i on a n d 16

per i od i c up d a t in g , a w eb

- based v er s i on o f t h e g u i da n ce docu m ent m ay be des i g ned and pu b l i s hed. 17

18

Recommendations for meeting the unique needs of infants, children, pregnant women, th e elderly, and 19

animals (e.g., household pets and service animals) are described in principle in Guidance Statement 5.4, 20

but the specific implementation processes are beyond the scope of this document. These topics require 21

add itional work. 22v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

15 

## II. G u i ding prin ci ples 1

2



### Defi n ing patient a n d p atient dec o nta m ination 3

F or t h e p u rpo s e of t h i s g u i d ance, any i nd i v i d u al w ho m ay requ i re d eco n t a m i na t i on i s c o n s i de r ed a pa t i e n t

. 4

5

“ P a t i e n t” i s d e f i n ed h e re as: 6

A ny i nd i v i dual w ho w as at or n e ar t he l oc at i on o f a h a z ardo u s m a t e r i a l s r e l e ase a n d w ho w as p o t e n t i a l l y 7

expos e d and t h e r e fo r e p o t e n t i a l l y con t a m i n a t ed a nd m ay requ i re s o m e form of ca r e (e. g

. deco n t a m i na t i on, 8

supp o r t i v e m ed i cal ca r e, l i f

esa v i ng i n t er v e n ti o n s, a n t i do t al t h er ap y , co mm un i ca ti o n

, and rea s su r anc e ). 9

• N ot a l l p at i e n t s wi l l re q u i re fo l l o w

- on t re a t m ent or e v a l u a ti on at a h e a l t h c a re fa cil it y ; 10

• S o m e pa ti e n t s w i l l l ea v e t h e i n c i d e nt s ce n e p r i or t o re s ponde r s a r r i v i n g ; 11

• S o m e i nd i v i du a l s, w ho wer e not at o r n e ar t he sc e ne, a re n o t l i k e l y t o ha v e b e en c on t a m

i na t ed, o r 12

m a y not req u i r e any m ed i c a l a s s i s t a n ce, m ay s ti l l p re se nt f o r e v a l u a t i on and t

r e a t m ent

, 13

i n c l ud i ng requ e s t i ng deco n t a m i na ti on ( s ee G u i dan c e S t a t e m ent 1. 1 )

. 14

15

U se of t he t e rm “pa t i en t ” t o re f er t o a po t en t i a ll y co n t a

m i na t ed i n d i v i du a l wa s de c i d e d u pon f o l l o w i ng 16

ex t e n s i v e d i sc u s s i on a m ong WG m

e m bers, s y m pos i a par t i c i pa n t s, and a sp e c i al s u b

- g roup of su b j e ct 17

m a tt er e x pe r t f i r st re s pond e rs, f

i r st re c e i v e r s, e m

er g ency m ana g ers, po l i cy ana l y s ts , and m il i t ary 18

pers o nn e l. T he t e rm w as car e fu l l y chosen t o r e f l e ct t h e p r i n c i p l e t h at d eco n t a m i n a t i on of a p e rson i s a 19

f

i r st a i d m eas u re t h a t c a n s a v e li v es and red u ce o t h e r a d v erse h e a l t h e ff e c t s. Candidacy for a preventive 20

medic al intervention based on significant risk of exposure to a toxic chemical should qualify a pers on as a 21

patient. This definition does not imply that all decontamination will be conducted by hospital or medical 22

personnel, and does not imply that by conducti ng decontamination the patient must be transported to or 23

evaluated in a healthcare facility. 24

25

In this case, the patient designation does not encumber the same financial or contrac tual responsibility as 26

a formal provider

- patient relationship. The WG has fo und no formal definition of patient which would 27

exclude use of the term for an individual evaluated as to the need for decontamination. Finally, use of the 28

term patient a v o i ds ne g a t i v e conno t a t i o n s po t en t i a ll y a ss oc i a t ed w it h o t h er t e r m s su c h as v i c ti m or 29

c a su a lt y

. 30

31

“ P a t i e n t d eco n t a m i n a t i o n ” i s d e f i n ed h e re a s : 32

A ny process, m e t ho d , or a c ti on t h a

t l ea d s t o a r edu c t i o n, re m o v a l , neu t r a li z a t i on

– by partitioning or 33

binding (as opposed to chemical neutralization, which is not recommended; see Guidance Statemen t 2.11) 34

- o r i n ac t i v a t i on o f con t a m i n a ti o n on o r i n t h e pa t i e n t i n or d er t o: pre v ent or m iti g a t e ad v erse he a l t

h e ff e c t s 35

t o t he pa t i e n t; pro t ect e m er g ency f i r s t r e s ponde r s, h e a l t h c are f a c i l i t y f i rst r e ce i v e r s

, and o t h er p a ti e n t s 36

f

r om second a

ry con t a m i n a ti o n; a nd r edu c e t he po t en t i a l f or s econ d ary c on t a m

i na t i on o f resp o nse a nd 37

he a lt h c a

re i n f ra s t r u c t u re. 38

39

T h i s d e f

i n i ti o n i s s i m

il ar t o o t h e r pu b l i shed d e f i n it i ons of d e con t a m

i na t i on ( e. g

., DO D F M 3

- 11.5, 2006; 40

N FP A 472, 2013) but un i q ue l y foc u ses on hu m an he al t h o u t co m e s

. T he i m

por t a n ce of dec o n t a m

i n a ti ng a 41

po t e n t i a l l y con t a m i n a t ed p a ti e nt for p r o t e c t i ng t hat pa t i en t ’ s h e a l t h, t he h ea l t h o f t h e re s pond e rs and 42

rec e i v ers t r ea t i ng t h a t p at i e n t

, t he h e a l t h o f o t her co mm un it y m e m bers, and t he i n t e g r i t y of t h e e m er g e ncy 43

resp o nse and h ea l t h c a r e s y s t e m s are ex p li ci t i n t he de f i n i ti o n

. S i nce n u m

erous a c ti o n s s u ch as d i st a nc i ng 44

ones e l f from t he s i t e o f a c h e m i cal r e l e ase, w i p i ng v i s i b l e c o n t a m i n a ti on f rom s k i n and c l o t h i n g , and 45

re m

o v i ng c l o t h i ng can red u ce or re m o v e con t a m

i na t i o n from a p a ti e n t

, t hey a r e c ons i d er e d p a t i ent 46

deco n t a m

i na t i on. O u r d e f

i n i t i on i s t h e re f

ore bro a d a n d i n c l ud e s s t eps t h at a p a ti e nt c a n t a k e on h i s / h e r 47

o w n, e v en bef o re f i r s t r e s p onde r s a r

r i v e, t o p ro t ect t he hea l t h o f h i m / hers e l f and o t he r s ( see a l so T i er e d 48

r i s k

- based app r oach se c t i on be l ow a nd G u i d an c e S t a t e m ent 2.2). 49

50

51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

16 

### Patient de c onta m ination is a m edical co u nt e r m easure 1

When condu c t ed w i t h i n t he appr o p r i a t e t i m e w i ndow (w h i ch i s r e l a t i v e l y sho r t f o r m ost che m i cal 2

expos u re s ) a n d u s i ng appr o pr i a t e s t r a t e g i es (s e e F un c t i onal A rea # 2 : O p ti m

i z ed T echn i c a l P r ac t i c es), 3

pa t i e n t de c on t a m i na ti o n c a n li m i t t he p a t i e n t ’ s exp o s u re a n d t h e t o x i c i t i e s t h at fo l l ow f rom che m i cal 4

con t a m

i n a ti o n. T h e r e for e

, p a t i e n t de c on t a m i na ti o n i s an e s se n ti a l e a r l y s t ep i n t h e re s pon s e t o a c h e m i cal 5

i n c i de n t and can be c o ns i d e red a t y pe of f i r s t a i d

– a

n i n i t i a l a c t i on t h at po t en t i a ll y red u ces m orb i d it y and 6

m

or t a l i t y

. L i fe s a f

e t y i s alw a y s t he h i g he s t p r i o r i t y

. P a t i ent dec o n t a m i n a ti o n s h ou l d a l so i d ea l l y not 7

de l ay o t h er l i fe sa v i ng m e a sur e s or t h e ra p i e s. 8

9

P a t i ent dec o n t a m i n a ti o n c a n sa v e li v es d i re c tl y by pr e v en ti ng or r edu c i ng che m i cal a g ent abs o r p ti o n

. 10

S econd a

r i l y

, i t f a c i l i t a t es t h e exp e d i ti o u s m o v e m ent of pa t i e n t s i n t o t he he a l t h c a re s y s t em w here t h ey can 11

be t

re a t ed by r e c e i v ers i n a redu c ed l e v el o f p e rso n al p r o t e c ti v e e q u i p m ent ( PP E ) ; t

he h i g her l e v e l s of PP E 12

w orn by res p ond e rs o r rec e i v ers t r e a ti ng po t en t i al l y con t a m i na t ed p a t i e n t s ca n i n h i b i t p a t i ent c a re by 13

redu c i ng v i sua l

, au d it o ry, a n d t a c t i l e se n ses. 14

15

S econd a

ry con t a m i na t i on le ad i ng t o a d v erse h e a lt h e f f e c t s i n r esp o nd e rs a n d r e c e i v ers w ho han d l e 16

pa t i e n t s i n a c he m i cal i n c i d ent i s a w e l l

- docu m en t ed pheno m

enon ( M e r

r i t and A n d erso n , 198 9 ; H u f f, 17

19 9 1; N o z a k i et a l

., 199 5 ; O k

ude r a et a l

., 199 7 ; O k

u m ura et a l ., 199 8 a

/ b ; Z e it z e t a l ., 20 0 0; G e l l e r e t a l

., 18

200 1 ; Ki m

, 2001; H o r t on e t a l

., 2 003, 200 8 ; O k u m ura et a l

., 2005; S ca n l on, 2 0 10). P r o per u se o f PP E c a n 19

m

i n i m i z e t he r i sk of seco nd ary con t a m i na ti o n and t he a sso c i a t ed h ea l t h c ons e que n ces. H o w e v er, 20

espe c i a ll y f o r h e a l t h c a

re f a c i l it y

- based r e ce i v e r s, d e c o n t a m i na t i on o f t he p at i e n t p r i o r t o en t ry i n t o pa t

ie n t 21

c a

re a r e as m ay be t he m

ost appr o p r i a t e w ay t o r educe t he po t en t i a l f o r s ec o ndary co n t a m

i na t i on. 22

S i m

il a r l y , secon d ary co n t a

m i na ti on o f f

a c i l i t i es and e qu i p m

en t

, w h i ch c an c a

use s i g n i f i ca n t d i s rup t i o n s t o 23

e m

er g ency hea lt h c are f

o r a n en t i r e co mm

un it y ( H uff, 1991; B u r g ess e t a l ., 19 9 7, 1999; K i m , 2001; 24

H or t on et a l

., 200 8 ), i s p r e v en t a b l e by decon t a m i na t i ng pa t i e n t s b e f

o re t hey co m

e i n t o c o n t a ct w it h such 25

fa c i l i t i es and e q u i p m en t

. 26

27

T he he a l t h be n e f it s of p a t i e nt d e con t a m

i na t i on

– m

iti g a t i ng ad v erse h e a l t h e f f ec t s i n t h e p a t i en t ; 28

per m

it t i ng fa s t e r a c ce s s t o m

ed i cal c ar e ; p ro t ec t

i ng t he hea l t h o f r espo n de r s and r e ce i v er s ; a nd p r o t e c t i ng 29

hea l t h c are i n f r as t ru c t u r e i n t e g r i t y

– w arr a nt i t s i d en t i fi ca t i on a s a m

ed i c al c oun t e r

m easure. I t shou l d be 30

addr e ss e d w i t h t h e ur g ency appro p r i a t e f o r a m ed i c al c oun t e r m

easure and i n t e g ra t ed i n t o p l an n i ng for 31

o t h e r m

ed i c a l cou n t e r m

easure u t i li z a t i on. 32

33



### Desired e n d poin t s for patient de c o n ta m i n at ion 34

A l ong

- ti m e w ea k ness i n t h e pr a c t i ce of p a t i e n t d e con t a m i na ti on i s t he l a ck of w e l l

- def i ned, o u t c o m

e

35

based g o a ls. C o m p l e t e r e m o v al of c h e m

i cal con t a m

i na ti on co u l d be con s i d e red o n e end p o i n t, one t h at 36

req u i r e s co n s i d e r ab l e e f f o r t

, ti m e, and res o ur c es. H o w e v er, i f pe r f o r m i ng such c o m

p l e t e p a ti e nt 37

deco n t a m

i na t i on l ed t o no d i f

f e r ence i n t he sho r

t

- t erm or l o ng

- t erm hea lt h ou t co m e for t h e p a t i en t s, d i d 38

not p re v ent a ny secon d ary con t a m i n a ti o n of re s pond er s and t h e i r equ i p m ent or r e ce i v ers and t h e i r 39

fa c i l i t i e s, or con t r i bu t e t o t h e sa f

e t y and re s i l i e n cy of t h e co m m un it y

, w ou l d complete d e co n t a m i na ti on be 40

w o r t h t he e f f o r t ? Mi l i t ary de c on t a m

i na ti on do c t r i ne h as a w e l l

- def i n ed a nd w e l l

- reco g n i z ed g oa l : 41

re s t o r a t i on o f pers o nn e l and m a t e r i el t o o per a ti o nal s t a t u s i n or d er t o acco m p li s h t h e m

i ss i o n

. T h i s g oal 42

d r i v es p l an n i n g , re s ou r ce a n d t i m e a l l oc a ti o n, i n f

o r m s perf o r m ance of a l ess t h an a b so l u t e l e v el of 43

deco n t a m

i na t i on n ec e ss a

r y , and p r o v i des for a m

easure of e ff

e c t i v eness ( i

. e

. , t he a

b i l it y t o re s u m

e and 44

co m

p l e t e t he m

i s s i on). 45

46

W i t ho u t a h ea l t h o u t co m e

- based g o a l f

o r m ass p a ti e nt deco n t a m i na t i on, t hen abs o l u t e de c on t a m i na ti o n 47

it s e l f b e co m es t he end p o i n t

– c l ean f

o r c l ea n ’s sa k

e. T h i s b e l i ef i n t u r n d r i v es re sea r ch, e duc a t i on, and 48

proc e ss d e v e l op m ent and r e f

i ne m ent t o wa rds t he e nd p o i nt of “ c l ean” w i t hout qu e s t i on i ng w he t her des i red 49

g o a l s

– s uch as r e d uc t i ons i n m

orb i d it y or m

o r t a l it y , or pre v e n ti on of sec o ndary co n t a m i na t i on

– are 50

a c t u a l l y be i ng ac h i e v ed. 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

17 T he r i s k s of a dh e r i ng t o t h i s m odel ar e: 1

1. T he sa m e su i t e o f p roc e ss es

, t o o l s, a nd t ech n i qu e s wi l l be us e d i n e v ery con t a m i n a ti on i n c i d e nt, 2

re g ard l ess of t he spe c i f i c s o f t h e s i t u at i o n ; 3

2. C er t a i n p ro c es s es (e. g

., w a t er

- based de c on t a m i na ti o n) w il l be a

p p l i ed w it h o ut q u e s t i on i ng w he t her 4

t he p ro c ess i t se l f i s c a u s i ng harm (e. g ., en v i ron m en t a l i ll n ess, deco n t a m

i n a ti on

- re l a t ed i n

j u r i e s

, 5

and ps y ch o l o g i c a l s t r e ss i n here n t i n t h e p roc e ss ) ; 6

3. F u t u r e e ff o r t s i n t he pa t i e n t deco n t a m i na t i on f i e l d w i l l be d r i v en t o wa

rds g e t t i ng m

ore peop l e 7

c l e a ner, m ore qu i c k l y , and w it h i m

pro v ed t oo l s and e q

u i p m en t

, e v en as t he e v i d e n ce t h at i t 8

i m

pro v e s hea l t h r e m a i n s u nce r t a i n

. 9

10

T h i s n a t i on a l g u i da n ce h as depa r t ed f r om pre v i ous e f

f or t s by focu s i ng on e v i de n c e

- based de t e r m i nan t s of 11

succ e s s ful p a t i e n t d e co n t a m i na ti on w h i ch d e l i v er m

easu r ab l e, po s i t i v e i m

pact o n he a lt h, i n fr a s t

ru c t u r e, 12

and co mm

un it y ou t co m

es. I n do i ng so t he WG h a s i d e n t i f i e d , n o t e x c l u s i v e l y

, t he fo l l o w i ng : 13

14

G oa l s o f P a t i e n t D e c on t a m i na ti o n: 15

I. A ch i e v i ng an i m pro v e m ent i n p a t i en t s’ ac u t e h e a l t h o u t co m es by redu c i ng sho r

t

- t erm m orb i d it y and 16

m

or t a l it y ; 17

18

II. A ch i e v i ng an i m pro v e m ent i n p a t i en t s ’ l on g

- t erm hea l t h ou t c o m e by pre v en ti ng d e l a y ed m orb i d it y ; 19

20

III. P ro t e c t i ng t he he a lt h and f u nc t i on i ng of r e spon d ers and rec e i v ers by pre v en t i ng t h e i r s eco n dary 21

con t a m i n a ti o n ; 22

23

IV. A ssu r i ng t he b est h e a l t h o u t co m e for t he m

ost p a t i e n t s. T h i s m

i g ht r e su l t i n a d e p ar t u re from 24

t he cur r ent pa r ad i g m by a ll o wi ng for de c on t a m i na ti o n t o a l e s s t h an co m p l e t e l e v el b u t w h i c h 25

en s ur es e v er y one w i l l g et t i m e l y decon t a m

i n a ti o n so t h a t: 26

a. t hose p a ti e n t s re q u i r i ng su p p or t i v e or d e f i n i ti v e m ed i c a l c a re re c e i v e i t i n a t i m

e l y 27

fas h i o n ; 28

b. t he m a j o r it y of m

i n i m a ll y e xposed pa t

i e n t s m ay be ab l e t o b y pa s s m ed i c a l e v a l u at

i o n

, 29

pre s er v i ng m ed i cal res o ur c es f

o r t hose w it h t h e m

ost u r g ent n e ed s 30

31



### Patient de c onta m ination is a w h ole co m m u n ity issue 32

“

A W ho l e C o mm un i t

y app r oach a tt e m

p t s t o e ngage t h e f

u l l capa c i t

y of t h e p r i v a t

e and no n pr o f i t s e c t o rs, 33

i n c l ud i ng bu s i n e ss e s, f a i t h

- based a nd d i sa b i l i t

y org a n i za t i ons, and t

he g e ner a l p u b l i c, i n co n

j un c ti o n w i t h 34

t he p a r t i c i

pa t i on of l oc a l

, t r i ba l

, s t ate, t e r r it o r i a l , and F

eder a l g o vern me n t a l p a r t

ners ” ( FE M A , 2 0 11). 35

36

P a t i ent de c on t a m i na ti o n as des c r i b ed i n t h i s d ocu m ent a i m s t o w ar d s s u ch an ap p r oach. T h e r espo n se t o a 37

che m

i cal r e l ea s e, r e g ard l e s s of c i r cu m s t an c es, req u i r e s a con c e r t ed e f fo r t f ro m m u l t i p l e or g an i za ti o n s, 38

w h i ch m ay i nc l ude 9

- 1

- 1 f i r s t r e s ponde r s, f

i r st re c e i v e r s, e m

er g ency m ana g e m

en t , pub l i c he a lt h, po i son 39

c en t e r s, ana l y t i c a l l abo r a t o r i es, and m e m bers of t h e pu b l i c. R e sponse t o and r eco v ery f r o m t hese i n c i d en t s 40

can a l so re q u i re a c t i on f rom t he pr i v a t e s e c t o r ( e. g ., e m er g e ncy m ed i c a l s e r v i ce s p ro v i d ers, h e a lt h ca r e 41

fa c i l i t i es, che m i c a l co m pa n i es, t r ansp o r t a t i on co m pan i e s ) a s we l l a s f

rom m u lti p l e l e v e l s o f g o v ern m

ent 42

and m ay necess i t a t e r equ e s t i ng reso u rc e s f rom surr o u n d i ng j u r i s d i c ti o ns t hrou g h m u t ual a i d. 43

C o m m

un i ca ti on and c oor d i na t i on a m ong t hese g rou p s i s e sse n t i a l

, y et e v i den c e fr om past i n c i d e n t s 44

su gg es t s t h a t i m pro v e m en t s are n ee d ed. F o r exa m p l e, bas i c i n f

o r m a ti on a b out an i n c i de n t i s n o t a l w a y s 45

sha r ed i n a ti m e l y and e f f ic i e n t m anner b e t w een r e sp o nders at t he sc e ne a n d r ec ei v ers at h e a lt h ca r e 46

fa c i l i t i es ( A uf der H e i d e, 2 006; K i rk and D ea t on, 2007 )

. O ne of s i x fun c t i on a l a re a s of t h i s g u i da n ce i s 47

ded i ca t ed t o s y s t em

- w i de coor d i n a t i on of p at i e n t de c on t a m i na ti o n i n or d er t o en s u re t h a t t he co m m

un it y 48

ac t s a s a w h o l e t o p r o v i de c a re, i n for m a ti o n

, and o t h e r sup p o r t t o a l l m e m bers i n n eed. 49

50

T he c r i t i c al i m por t an c e o f r

i sk co m m un i ca t i on wi t h t he pub l i c i s a l so re c o g n i z ed, w it h i t b e i ng t h e su b j e ct 51

of an o t h e r o f t h e s i x f u nc t i o nal a

re a s. R i sk co m m

un i ca ti on be f

ore, du r i ng and a f

te r an i n c i de n t s u ppo r t s 52v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

18 resp o nse and reco v ery by enhan c i ng prep a re d ne s s, i n c rea s i ng t he l i k e li h o od t h at a

ppro p r i a t e pr o t e c ti v e 1

ac t i ons w i l l be t a k en a n d i n appro p r i a t e or po t en t i a ll y h ar m ful a c t i ons wil l not be t a k en by co mm

un it y 2

m

e m bers, and m

iti g a t i ng t h e s t

re s s, an x i e t y and d y sfu n c t i on t h at can re s u l t f rom a d i s a s t e r. 3

R eco m m

enda ti o n s t o p l an f

or t h e n e eds o f a

t

- r i sk popu l a t i o n s 5 5 are i n cor p or a t ed at e v ery approp r i a t e 4

p o i nt i n t h i s g u i d an c e. S uch p l a n n i ng req u i r es i de n t i f i c a t i on and un d er s t an d i ng of t he s p ec i f i c nee d s a n d 5

v u l nera b i l i t i e s of a l l i nd i v i d ua l s w it h i n a co m m

un it y

. S i m

il a r l y

, t he c o nce p t t h a

t r espon s e p l ans w i l l w ork 6

on l y i f t hey are b as e d on t he a c t u a l r eso u rc e s and ca pa b i l i t i e s a v a i l ab l e i n a c o m m un it y at t he ti m

e t hey 7

are nee d ed i s r epe a t ed t hrou g ho u t t h e g u i da n ce. T h i s g u i d a nc e ’s e m pha s i s on co m

m un i ca t i on, 8

coor d i n a ti o n, and und e r s t a n d i ng a co m m un it y ’s n e eds and c a

pa b i l i t i es r e f

l e c t s t h e v i ew t hat p l ann i ng for 9

m ass pa t i ent deco n t a m i n a t i on m ust i n v o l v e a w ho l e c o m m un it y , a v i ew w h i ch i s b e i ng fo s t e red by t he 10

F ede r al E m er g ency Mana g e m

ent A g enc y ’s ( FE M A ) c urr e nt i n i t i a t i v e on a w h o l e co m m un it y approa c h t o 11

e m

er g ency m ana g e m

ent ( FE M A

, 201 1 ). 12

13

O ne of t he m a j or a i m s of t h i s g u i da n ce i s t o a i d l oc a l p l ann i ng f

o r m ass p a ti e nt d e c on t a m i na t i on i n a 14

m anner t h a t su p po r t s co mm un it y r e s i l i ence and se l f

- suff i c i e n c y

. R es i li e nt co m m

u n i t i es ha v e been 15

i de n t i f

i ed as one o f t he k

e y s t o n a t i on a l h e a l t h s ec u r i t y by t he D ep a r t m ent o f H e al t h an d H u m an 16

S er v i ces ( HH S , 2009, 2 0 12 )

. T hro ug h i nfor m ed and e m

po w er e d i n d i v i dua l s, a re si li e nt c o m m un it y i s 17

ab l e t o w it h s t a n d, m iti g a t e t he co n seque n ces of, and r eco v er f rom a d i sa s t e r t o at l e a s t i t s pre v i ous 18

l e v el o f fun c ti o n i ng ( C ha n dra et a l

., 2011; F E M A , 201 1 ; HH S

, 2012). I t i s as s u med here t hat p a t i e n t 19

deco n t a m

i na t i on i n a m ass casu a lt y c h e m i cal i nc i de n t w il l be e x ec u t ed en t i r e l y by a l o c al co m m un it y

, 20

perh a

ps wi t h a s s i s t an c e f

r o m ne i g hbor i ng j u r i s d i c t i o n s

. D ue t o t he f

a st

- ac ti ng n at ure o f ha z ar d ous 21

che m

i ca l s

, t h e f

ede r al g o v ern m

ent w i l l m

ost l i k e l y not be a b l e t o p a

r t i c i p a t e d i r e c tl y i n t he p a t i e n t 22

deco n t a m

i na t i on res p ons e ; ra t h er, t he k no w l ed g e pro v i ded h e re rep r es e n t s a t ool t o be ad d ed t o a 23

l oc a l p l an n e r ’s t oo l box. 24

25

S e v eral p i e ces o f t h i s t o o l d i r e c t l y addr e ss a c t i ons t h a t con t r i b u t e t o re s i l i e n ce. R

i sk co m m un i ca ti on w it h 26

t he p u b l i c i s a m echa n i sm for i n f

o r m i ng and e m

po w er i ng i nd i v i du a l s a nd w as i d e n t i f i ed as a c o re 27

co m

ponent of co m m

un it y res i l i ence i n a s t udy by t he R AN D C orpora t i on ( C ha nd ra e t a l

., 20 1 1). 28

P ro v i d i ng f o r t h e ph y s i c al a nd beha v i o r a l he a l t h ne e ds, fun c ti o nal nee d s

, and so c i a l w e l l

- be i ng of a l l 29

co m m

un it y m e m bers, as i s reco mm

ended at a l l r e l e v ant po i n t s of t h i s g u i da n ce, i s nece s s a ry for 30

co m m

un it y res i li e nce. F i n a ll y

, t he dec o n t a m i n a ti o n r es ponse s t

ra t e g y rec om m

ended he r e i s a t i e red 31

appr o ach t h a t i n c l u des a s el f

- care t i er de v o t ed t o a c t

i o n s t h a t a pa t i e n t c an t a k e t o p ro t e ct h i m

/ he r se l f f rom 32

t he t ox i c e ff e c t s of che m

i c a l co n t a m

i na t i on b ef

o re f i r s t resp o nd e rs a

r r i v e at t he sc e ne ( s ee s e c ti on on 33

T i e r ed r i s k

- based res p onse appr o ach s e c ti on b e l ow and G u i da n ce S t a t e m ent 2.2). I n t e g ra ti on o f t h e w ho l e 34

c o m m

un it y

, i nc l u d i n g t he g ener a l pu b l i c, i n t o d i sas t er p l a nn i n g , r e spo n se

, a nd r e co v ery i s suppo r t ed by a 35

w ea l t h o f e m p i r i c a l e v i de n ce t hat t h e p u b l i c ha v e t he c apa b i lit i e s

, t he wi l l i n g nes s , and ac t u a l l y ha v e m ade 36

s i g n i f

ic ant c on t r i b u t i ons t o d i s a s t er m ana g e m ent ( S choc h

- S pana, 201 2 ). 37

38



### Tiered ris k

- based res p o n se app r oach 39

T he g ener a l a p pro a ch t o p at i e n t de c on t a m i na ti o n p r es e n t ed h e r e i s a t i e red re s po n s e s t r a t e g y des i g ned t o 40

m a t ch t he n a t u re and e x t e n t of d e con t a m i na t i on t o t h e cha r ac t e r i s ti c s of t h e i n c i d e n t

, i nc l ud i ng t h e t y pe 41

and e x t e n t of p a ti e nt c on ta m i na ti on, and t

he c apa b i l i ti es of t he r e spon d i ng and / or rec e i v i ng or g an i z a t i on s

. 42

R a t h e r t h an p re s c r i be a sp e c i f i c p r o t oc o l f

o r a l l i n c i d e n t s, t h i s ap p ro a ch a ll o w s fl exi b i l it y and a s c a l a b le 43

resp o nse. T he t h r ee t i e rs ( s e l f

- care, g ro s s p a t i ent dec o n t a m i na t i on, and t ech n i c al pa t i e n t deco n t a m i na t i o n ) 44

r e pr e se n t a pro g re s s i o n f rom re l a ti v e l y li m

it ed a c ti o ns t h a t can b e t a k en wi t ho u t f

i r st resp o nd e r or f

i r s t 45

r ec e i v er a ss i s t a nce and wi t ho u t s p e ci a li z ed equ i p m ent and s upp l i es, t o a m

ore i n v o l v ed, s y s t e m a ti c 46

5 N o t e t h at t h i s t e r m i s u s ed t h r o u g h o u t t h e do c u m

e n t a n d i s re p re s e n t a t i v e o f a l l s i m i l ar t er m s t o i n c l u d e: s p ec i al

n ee d s

, v u l n era b l e pop u l a ti o n s

, a n d acce s s o r f u n c ti o n al n ee d s

. T h e u s e o f t h i s t e r m i s c ons ist e n t w i t h t h e P a n d e m i c

a n d A ll

- Hazar d s P re p ar e d n e s s A ct o f 200 6 ( P A H P A ), P u b

. L

. N o

. 109

- 41 7 (Dec 19

, 2 0 0 6 ). T h i s d e f i n iti o n c a n b e

f ou n d i n t h e g l o ss a r y a n d o n t h e HH S / A S P R w e b sit e a t : ww w

. p h e. g o v / P re p are d n e ss/

p l a n n i n g / a b c / a t r i s k

. a s p xv. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

19 p ro c ess t h a

t wi l l req u i r e eq u i p m

ent and su p p l i es. 1

2

I n so m

e s it u a ti o ns, t

he ap p roa c h m ay be exec u t ed i n a s t ep w i s e m anner, s uch t h a t a p a t i e n t un d er g oes a l l 3

t h r ee d eco n t a m i na t i on t i e rs. I

n o t h e r s i t ua t i o n s, s t ep wi se c o m

p l e ti on of al l t h

ree t i e r s m ay n ot be req u i r ed. 4

S e l f

- care a n d g ross p a t i ent deco n t a m i na t i on ti e rs a i m t o red u ce c on t a m i na ti o n as e ar l y as p os s i b l e, w h i l e 5

t e c h n i c a l p a t i ent deco n t a m i na t i on a i m s at re duc i ng co n t a m i na t i on t o a l e v el as l ow as nec e ss a ry t o 6

i m

pro v e hea l t

h ou t co m es w h i l e p re v en t

i ng secon d ary co n t a m

i na t i o n

. P a t i en t s w ho a

re m i n i m a ll y 7

con t a m

i na t ed m ay req u i re on l y s e l f

- care, for e xa m

p l e

, w h i l e o t

h er pa t i e n t s m ay proceed f rom se l f

- care 8

d i r e c t l y t o t ech n i c a l pa t i e n t de c on t a m i na ti o n. T h i s a

ppr o ach i s d es c r i b ed m

ore f u l l y i n G u i d ance 9

S t a t e m

ent 2.2. 10

11

T h i s f

l e x i b l e t i er e d ap p roa c h t o p at i e n t de c on t a m i na t i o n co m

p l e m en t s t h e r i s k

- ba s ed r e spon s e s t r a t e g y for 12

ha z ardous m a t e r i a l s i n c i d e n t s p ro m o t ed, f o r e x a m p l e, b y t he N a t i on a l F i re P ro t ec ti on A sso c i a ti o n 13

( N FP A ): 14

“R i s k

- ba s ed re s pon s e pr o cess i s d e

fi n ed as a sy st e m a t i c pro c ess by w h i ch respo n de r s 15

ana l

y ze a p r ob l em i n vo l v i ng H

AZ M A T / w eap o ns o

f m ass d e s t ru c ti o n ( W

M D)

, as s ess t

h e 16

hazar d s, ev a l u a t e t

he p o t e n ti a l co n sequ e nc e s, and d e t er mi ne app r

op r i a t e res

po nse ac t i o n s 17

based o n t h e f a c t s, s c i e n ce, and c i rcu ms t an c es o f t he i n c i de n t .” N FP A 472, 3.3.55 (2013 e d .) 18

19

B o t h s t

r a t e g i e s r e co m m

end e v a l ua t i on of t he si t u a ti on fo l l o w ed by t ai l o r i ng of t he res p onse t o t he n ee d s 20

and a v a i l a b l e r eso u rc e s f or t h a t sp e c i f

i c s it u a t i on. T h i s shou l d r e su l t i n t he m ost ef fe c ti v e and e f

f i c i e nt 21

resp o nse p os s i b l e un d er t he c i r cu m s t an c es. 22

23



### Practices i n m ass cas u alty incid e n t s 24

A s w it h any o t h e r m ass ca s ua l t y i nc i d en t , an i n c i de n t i n v o l v i ng m ass pa t i ent dec o n t a m i na t i on wil l l i k

e ly 25

pre s ent ch a l l en g es w i t h r es ource con s t r a i n t s. T h e re wi l l p re s u m ab l y be m ore pa t ie n t s t han can b e 26

adequ a t e l y pro v i ded t he s a m e s t anda r d of ca r e as und e r nor m al c i r cu m s t anc e s. R espon d ers and re c e i v ers 27

w il l need t o p r i o r i t i z e pa t i e n t s for d eco n t a m i na t i on as w e l l as triage for m ed i c a l c are. O ne of t h e 28

f

u nda m en t a l pr i n c i p l es of re s pon d i ng t o m ass casu a lt y i n c i d e nts ap p li e s h e re a s w e ll : D o t h e b e st y o u can 29

f

or t he m ost peop l e wi t

h t he r eso u rc e s y ou have. 30v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

20 

## III. G uid a n c e S t a t e m en ts 1

2



### F u nctio n al Ar e a 1: D e ter m i n ing the Need for Patient D e co n ta m i n ation 3

F or t h e c a se o f a s i n g l e po t en t i a l l y con t a m i na t ed pa t i e n t

, G u i da n ce S t a t e m en t s 1

. 1

- 1.3 pro v i de i nf

o r m a ti on 4

t o h e l p a r e spon d i ng or g an iz a ti on, w h e t h e r i n t h e f i e l d or a t a h ea l t h c a

r e f a c i l i t y

, m a k

e dec i s i ons on t he 5

need for and t he e x t e n t o f d econ t a m

i na t i on. T h ey i nc l ude k

ey i nd i c a t o rs t h a

t t h e pa t i e n t m ay be 6

con t a m

i n a t ed, as we l l as r i s k s t o t he pa t i e n t

, res p on der s and re c e i v ers t h a t s hou l d be co n s i d ere d

. 7



### G u ida n ce S tat e me n t 1 .1

T he de c i s i on t o d e co n t a m i na t e sho u l d t a k

e i n t o a c cou n t a co m

b i na t i on o f k

ey i nd i c a t o rs

, i nc l ud i ng (but

not l i m it ed t o ) :

• S i g ns and s y m

p t o m s of exposure d i sp l a y ed by pa t i en t s;

• V i s i b l e e v i den c e of con t a m i n a ti on on t he p a t i e n t ’s s k i n or c l o t h i n g ;

• P rox i m

it y of t he p a t i e n t t o t he l o ca t i on of t he re l ea s e;

• C on t a m

i na t i on d e t ec t ed on t he p a t i e n t u s i ng appr o p r i a t e de t e c ti on t e chn o l o g y ;

• T he che m

i c a l i d en ti t y ( i f kn o w n) or ph y s i c a l s t a t e, c ha r ac t e r i s t i c s

, and beha v i o r ( i f un k no w n);

• R eque s t by t he pa t i e n t f o r d e con t a m

i na t i o n

, e v en i f con t a m

i na t i on i s u n li k

e l y

.

Considerations:

• S i g ns and s y m

p t o m s of ch e m

i cal exp o su r e m ay prese n t as a r eco g n i z ed t o x i d ro m e (see A ppen d i x D )

or as i n d i v i du a l s y m

p t o m s.

• S o m e s i g ns and s y m

p t o m s m a y not re f

l e ct ac t ual che m

i c a l ex p os u re, b u t m an i f

e st as a res u l t of fe a

r,

an ac u t e s t

re s s r e a c ti o n 6 , or so m a ti z a ti o n due t o t he p a ti en t ’ s p res e nce at t he i n c i d e nt i t s e l f

.

• E n v i ron m

en t al d e t ec t ors a r e a v a i l ab l e f o r m any Tox i c I

ndus t r i a l C he m

i ca l s ( T I C s), T ox i c I

ndus t r i a l

Ma t e r i a l s ( T I

Ms), and Chemical Warfare Agents ( C WA s) but a re n ot re a d i l y adap t ab l e t o o r a v a i l a b l e

for t he de t e c t i on o f con t a m i n a ti o n on p a t i e n t s l i k

e l y t o be en c oun t er e d i n a ha z ardous m at e r i a l s

i n c i d e n t.

Level of Confidence: III

8

D i sc u s s i o n : 9

O v era ll

, t h e re i s l i t t l e e m p i r i c a l or exp e r i m

en t a l e v i d e n ce i n t he l it e r a t u r e t h at w ou l d i n d i c a t e t h e re i s one 10

best m

eans t o a ss e ss t he d e con t a m i n a ti o n ne e ds o f a l l pa t i e n t s. H o w e v er, each of t he i n d i c a t o r s d e sc r i bed 11

i n t h e g u i da n ce s t a t e m ent i s rep r es e n t e d i n t he l it e r a t u r e, o t h er g u i d ance, and b e s t

- pra c t i ce d o cu m en t s. I n 12

add i ti o n, S M E s i n d i c a t e d, t o v ar y i ng de g rees, t h e i m por t a n ce o f e ach o f t h ese f a c t ors i n d e t e r m

i n i ng t he 13

need t o co n du c t de c on t a m i na t i on. T h e a s se r t i ons i n t h i s g u i da n ce s t a t e m ent m ay be d i f

f i c u l t t o e v a l ua t e 14

w it h a co n t r o l l ed, p ros p ec ti v e t r i a l

. As se s s m ent of t he ro l e of t he k

ey i nd i c a t o r s i n i n f

l ue n c i ng t h e 15

acc u racy of d ec i s i o n m a k i ng shou l d be ob t a i n ab l e, h o w e v er, t h r ou g h re t ro s pe c ti v e s t u d i e s, o t h e r an a l y ses 16

of a c t u a l i nc i de n t s, a nd e x e rc i ses. 17

18

S i gns and Sy m p t o m s 19

T he f

a c t o r r ec e i v i ng t he m

ost a t t en t i on i n t he l i t e r a t u re i s symptomatology

– t he use of a p a t i e n t ’s app a re n t 20

6 A cc o r d i n g t o t h e International Classification of Diseases

- 10 (Effective Date: Oct 1, 2014), Acute Stress Reaction is defined as:

A n anxiety disorder precipitated by an experience of intens e fear or horror while exposed to a traumatic (especially life

threatening) event. The disorder is characterized by dissociative symptoms; vivid recollections of the traumatic event;

avoidance of stimuli associated with the traumatic event; and a constant state of hyper

- arousal which lasts at least two days

and no longer than four weeks

. If symptoms of Acute Stress Dis order persist for greater than one month, a diagnosis of post

traumatic stress disorder (stress disorders, post

- traumatic) is more appropriat e. (For more information see Bryant 2011, and

Diagnostics and Statistics Manual V)v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

21 signs and symptoms of chemical exposure to determine the n eed for decontamination. Toxidromes are 1

clusters of symptoms that can help to identify a broad chemical agent category, and sometimes a more 2

specific chemical agent type, to which a patient may have been exposed. They represent a tool for rapid 3

triage and determination of appropriate emergency treatment of a patient (Kirk et al., 1994; Markel et al., 4

2008). Symptomatology is a frequently cited criterion for determining whether a patient is contaminated 5

and requires decontamination ; e q u i p m ent i s n o t r eq u i r e d, a l t hou g h r esp o nde r s a n d re c e i v ers m ust be 6

t r a i ned i n t he r e co g n i t i on o f t ox i dro m es ( K i rk and D ea t o n, 2007 )

. H o w e v er, so m e r ese a rch su gg es t s t h at 7

i nd i v i d u a l s w ho ha v e a l ow prob a b i l i t y of b e i ng con t a

m i na t ed c a n s t i l l e xh i b i t s y m p t o m s t hat d o n o t ha v e 8

an or g an i c o r i g i n (K i rk and D ea t on, 200 7 ), i n di c a t i ng t hat a dd i ti o nal i n for m a t i on s hou l d b e u s ed i n 9

de t e r m

i n i ng t he n eed t o d ec on t a m i na t e. M u l ti p l e ex i s ti ng g u i dance docu m en t s i d e n t i fy symptomatology 10

as a fa c t o r t h at sho u l d be con s i de r ed i n d e c i d i ng on t h e n e ed f o r d e con t a m

i na t i on ( D O D T S W G , 2 0 04; 11

O S H A

- FR , 2005; C A L

- O E S , 2006; ECBC , 2 0 09; O S H A

- E M S , 2009). A m a j o ri t y of S M E s, es p ec i a l l y 12

f

i r st r e ce i v e r s, w ho co mm

e n t ed o n t h i s g u i d ance s t a t e m en t

, i nd i ca t ed t hat s i g ns a nd s y m p t o m s are a m a

j or 13

cons i de r a t i on i n d e t e r m i n i n g t he need for p a ti e nt d eco n t a m i na t i on. 14

15

V

i s i b le 16

V i s i b l e e v i den c e of che m i c al c o n t a m

i n a ti on on t he p a ti ent o r t h e p a t i en t ’s c l o t h i ng i nd i c a t es an on g o i ng 17

expos u re wi t h accu m u l a ti n g conta c t t i m

e and sho u l d a l so b e us e d w hen d e c i d i ng i f a p a t i ent ne e ds 18

deco n t a m

i na t i on ( O k

u m ura et a l ., 2 0 05; K i rk and D ea t o n, 200 7 ; R a m esh and K u m ar, 2010). V a r i ous 19

ex i s t i ng g u i dance d o cu m en t s l i s t v i s i b l e co n t a m

i na t i on as a m a i n f

a c t or i n d e t e r m

i n i ng t he n eed for 20

deco n t a m

i na t i on ( DO D T S W G , 200 4 ; O S HA

- F R , 2005; C A L

- O ES , 2 006; ECBC , 2009; O S HA

- E M S, 21

2009). 22

23

P rox i m ity 24

I

t has been su gg es t ed t h at i nd i v i du a l s i n c l o s e pr o x i m it y t o t h e r e l e ase s i t e m ay need t o be 25

deco n t a m

i nat e d; at t he v ery l e a s t

, t h i s f a c t or sho u l d be i n c l uded i n t he e v a l u a t i on o f t h e ne e d f or 26

deco n t a m

i na t i on ( V o g t and S oren s en, 2 0 02). P a t i e n t s w ho a r e c l os e r i n pr o x i m it y t o a r e l e ase s i t e a

re 27

susp e c t e d of ha v i ng rec e i v ed a h i g her dose of con t a m i nant a nd t h e r ef

o re h a v i ng a g rea t e r ne e d f o r 28

deco n t a m

i na t i on t han a p a t i ent fu r t h e r f rom t he r e l e ase s i t e (K i rk and D ea t on, 200 7 ). P ro x i m it y t o t he 29

re l ea s e s it e i s re c o m m ended as o n e of t he f

a c t o rs t o c o ns i d e r w hen d e t er m i n i ng d e con t a m

i n a ti o n ne e ds 30

( R a m

esh and K u m ar, 201 0 ). 31

32

D e t e c ti o n 33

A lt hou g h en v i r on m en t al d e t e c ti o n t e chn o l o g i es are a v a il a b l e and a re used by f

i r st r espon d ers (e. g

., f

i r e 34

f

i g h t e rs, HA Z M A T res p o n der s ) t o ch a ra c t e r i z e ha za

r d ous en v i r on m

en t s, t he r e i s l i t

tl e d i scu s s i o n i n t he 35

l i t e r a t u re re g ar d i ng t he u se of t h ese de v i c e s i n de t er m i n i ng deco n t a m

i na t i on req u i re m

en t s. R a b er et a l

. 36

(2001, 2 004) and V o l k l and (200 0 ) us e d ex p osu r e g u i d e li n es t o a s se s s t h e p o t e n t i al of u s i ng de t e c t i on 37

capa

b i l i t i e s t o de t er m

i ne t h e e f f i c acy of d eco n t a m

i na ti on, but r e ached t h e co n c l u s i on t hat cu r re n t de t e c t i on 38

a ss e t s we re n e i t h e r se n s i ti v e en o u g h nor b ro a d enou g h t o u se wi t h pa t i e n t de c o n t a m i na ti o n. 39

40

K

no w n C he m i c a l I de n t i ty 41

S o m

e che m i cal i n c i d en t s m ay not ne c es s i t a t e p a ti e nt d econ t a m i na t i on (K enar and K a

ra y il a no g l u , 200 4 ). 42

I

f t he i de n t i t y of a che m

i cal c on t a m

i na n t i s k no w n, as i n t he c ase of a pro p e r l y p l a ca rded t r u ck or r a

i l

- car 43

acc i de n t

, t h en t h i s i n for m a t i on s h ou l d be u t i li z ed i n d e c i d i ng w he t h e r t o dec o n t a m i n a t e a p a t i e n t

. T he 44

che m

i cal i de n t i t y w ou l d all ow resp o nd e rs a n d he al t h c are re c e i v ers t o u se i nf o r m a ti on abo u t t

he ph y s i cal 45

and c h e m

i cal c h a r ac t e r i s ti c s f

r om a nu m

ber of so u rc e s (e

. g

., DO T E m er g ency R esponse G u i deb o o k

, 46

2012), w h i ch w o u l d as s i s t i n de t er m i n i ng app r op r i a t e e m

er g ency ac ti ons ( K i rk and D ea t on, 200 7 ). I t i s 47

un li k

e l y , ho w e v er, t h a

t t he i de n t i t y of t h e c h e m

i cal wil l be c on f

ir m ed w i t h i n t he i n i t i al pe r i od of a t e r ro r i s t 48

a t t ack or an ac c i d e n t a l r e l e ase, and e v en t hen, t he i nf o r m a ti on m ay be i n c orr e ct ( O k u m ura et a l

. , 1998a

/ b ; 49

Z e i t z et a l

. , 20 0 0). C o m m un i ca ti on ch a l l en g es be t we en r espo n de r s and r e ce i v ers can a l so pre v ent t he 50

h e a lt h ca

r e f ac il it y s t a ff f

r om l ear n i ng t he c he m

i c al i de n t i t y bef

o re p a t i en t s a r r i v e (K i rk and D ea t on, 51

200 7 ). T he ph y s i c al s t a t e o f a c he m i ca l

, e v en i f t he i de n t i t y i s n o t k no w n, can h e l p d e t er m

i ne t h e need for 52v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

22 d eco n t a m i na t i on ( e. g

., li q u i d v ers u s g as co n t a m i nan t ) ( H o us t on and H end ri c k son, 2005). S u b j e c t m a tt er 1

e x pe r t s ( S M E s), es p ec i al l y f i r st res p ond e rs, i n d i ca t e d t h at t he i d e n t it y an d / o r ph y s i c al s t a t e o f t

he 2

con t a m

i na n t a re i m por t a n t cons i de r a t i ons w hen d e t er m i n i ng t he need t o condu c t deco n t a m i na t i on. 3

4

P a t i ent R equ e st 5

P ar t i c i pa n t s i n t he Ma s s H u m an C h e m i cal D e c on t a m

i na t i on S y m

pos i um 2012 re c o m m

ended, based o n 6

t h e i r e xp e r i e nce w it h che m i cal i n c i de n t s, us i ng pa t i ent per c ep t i on o f t he i r o w n n e e d for dec o n t a m i n a ti on 7

as an i n d i c a t or f o r t h e n e ed for d eco n t a m

i na t i on. P a t i e n t s w ho p e r ce i v e t he i r r i sk for c on t a m i n a t i on as 8

h i g h, or w ho req u est or decon t a m i n a ti o n , sh o u l d be pro v i d e d wi t h t h i s o ppor t un i t y

. S o m a ti z a ti o n i s 9

f

re q ue n t i n ac u t e s t r ess r e ac t i ons and m ay m an i fe s t a s non

- ph y s i o l o g i ca l l y

- based sy m p t o m s t he pa t i e n t 10

none t h e l ess exp e c t s f rom t he p e rc e i v ed e x po su r e ( F et t er, 200 5 ). A d d i ti o n a l l y an ac u t e s t re s s rea c t i on 11

m ay occur w hen a pers o n has be e n exp o sed t o a t r au m a ti c e v ent i n w h i ch bo t h o f t he f o l l o w i ng w ere 12

p re s en t : ( 1 ) t he p er s on exp e r i e nced, w it n es s ed, o r w as co n fro n t ed w i t h an e v e nt o r e v en t s t h a t i n v o l v ed 13

ac t ual or t h r e a t en e d de a t h or s e r i o u s i n

j u r y , or a t h

re a t t o t h e ph y s i c al i n t e g r it y of s e l f or o t h e rs and ( 2 ) 14

t he p e rs o n ' s respon s e i n v o l v ed i n t e n se fe a r, h el p l e s sne s s, o r ho r

r o r ( Bryant, 2011 )

. D es p i t e t he 15

occ u r r ence of ac u t e st ress r e ac t i o n s an d

/ o r so m a t iz a ti on

– each of w h i ch cou l d r e su l t i n une x pos e d 16

p a t i en t s no n e t h e l e ss req u es ti ng or under g o i ng de c on t a m i n a ti on f o r s y m p t o m s per c e i v ed t o r e pr e se n t 17

t o x i c ef

f ec t s

- m ost a u t h o rs ha v e de m

ons t r a t ed t h a t pa n i c, or anx i e t y re s pons e s a n d beha v i o r s w h i c h a re 18

m a l a d ap t i v e, do not occ u r f re q u e n tl y i n d i s as t e r s, con v en t i o nal t e r r o r i s t a t t ac k s, and b i o t e r

ror i n c i d e n t s 19

( A uf der H e i de, 198 9 ; M u ra k a m i , 2000; D i G i o v ann i

, 200 3 ; F et t er, 2005 ; S hep p ard et a l ., 2 0 06; S u l li v an 20

and B on g ar, 20 0 7). 21

22v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

23 

### G u ida n ce S tat e me n t 1 .2

D econ t a m

i na t i on sh o u l d be per f

or m ed i f t he po t en t i a l con t a m i n a ti o n on a pa t i e n t req u i r i ng t r a nsp o rt t o,

o r care i n, a h e a l t h c a

re fa c i lit y poses a r ea s ona b l e r i sk of expos u re t o f i r st r e spond er s, f

i r s t r ec e i v ers,

o t h e r pa t i e n t s o r co n t a m

i na t i on o f c r i t i c a l i n f

ra s t r uc t ur e

. Considerations:

A s a s o l e c r i t e r i o n , p r e v en t i on of s eco n dary co n t a m i na t i on a l one m ay not j u s t i fy p a t i ent dec o n t a m i n a ti o n ;

pa t i e n t s m

ee ti ng a l l o f t he f

o ll o w i ng cr i t e r i a a r e u n li k e l y t o pose a s i g n i f

i c ant r i sk t o re s pond e rs and

rec e i v er s :

• D i sp l a y i ng ne it h er s i g ns n o r s y m p t o m s of che m

i c a l e x posu r e;

• N o v i s i b l e c o n t a m

i na t i on o n s k

i n or c l o t h i n g ;

• H i s t o ry t h a t m a k

es exposu r e un l i k

e l y ( i

. e

., n o t ne a

r t he l oc a t i on of r e l e as e )

. Level of Confidence: III

1

D i sc u s s i o n : 2

T he po t en t i a l f or s e con d ary con t a m

i na ti o n of r e spon d e r s

, r ec e i v ers, and c r i t i c a l i n f ra s t r u c t u re i s we ll 3

d i sc u ss e d i n t he l it e r a t u r e a nd be s t

- prac t i ces g u i des. T he e v i de n ce s u ppo r t i ng t h i s reco m m enda ti on 4

a m

oun t s t o d ocu m

en t ed ca s es of r e spon d ers or re c e i v e r s beco m i ng expos e d t o ch e m

i cal co n t a m

i nan t s 5

from pa t i en t s t hey w ere t r e a t i n g

. T he r e co m m enda ti o n i s a l s o ba s ed on su b j e c t m a tt er e x pe r

t o p i n i on a n d 6

o t h e r pu b l i shed g u i d anc e

. 7

8

F i r s t r esp o nde r s a n d r e c e i v ers m ust be co g n i z ant o f t h e po t en t i a l r i sk of s econ d a r y con t a m i na t i on t o b o t h 9

t he m se l v es and o t h er p eo p l e. S ec o ndary co n t a m i na t i o n of r esp o nd e rs a n d r e c e i v ers w as wel l docu m en t e d 10

fo l l o w i ng t h e s a r i n a t t a c k s i n J ap a n ( N o z a k i et a l

. , 19 9 5; O k

udera et a l

. , 1 997; O ku m

ura et a l

. , 19 9 8a

/ b; 11

O k

u m ura et a l

. , 20 0 5; S c a n l on, 2 0 10) and f r om ha z ar d ous m ate r i a l s i nc i de n t s i n t he U S ( M e r r i t and 12

A nders o n, 198 9 ; H u f f, 1 99 1; Z e it z e t al., 200 0 ; G e l l e r et a l

. , 20 0 1; K i m , 2001; H o r t on et a l

. , 2003, 2 008). 13

T y pic al l y , the g re a t e s t r i sk of s e cond a ry con t a m i na t i on i s d u r i ng t

ra n spo r t a ti o n of con t a m

i n a t ed p a t i e n t s 14

by e m

er g ency m

ed i cal ser v i ce s ( E M S ) p r o v i de r s, w ho a re c o n f i ned w it h i n t he e nc l osed e n v i ron m ent of an 15

a m

bu l ance. H o w e v er, t he po t e n t i al o f e xpo s i ng rec e i v ers a t h ea l t h ca r e f

a c i l i t i es r e m a i ns a h i g h 16

li k

e l i hood, pa r t i cu l a r l y w i t h se l f

- e v acua ti ng pa t i e n t s ( C one and K o en i g , 200 5 ). S e v eral e x i s t i ng g u i dan c e 17

docu m

en t s ( HH S A T S D R

- E D , 2000; O S HA

- FR , 2005; ECBC , 200 9 ; O S H A

- E M S , 2009) e m phas i z e t h e 18

nece s s i t y of p a t i ent deco n t a m i na ti on d u e t o t h e r i sk of secon d ary co n t a m i na t i on. 19

20

P ub l i shed l it e r a t u r e c i t e s t h e need f o r p a ti e nt d eco n t a m

i n a ti on i n o rd e r t o p r e v ent c on t a m i na t i on o f c r i t i c a l 21

i n f

ra s t r u c t u re, i n c l u d i ng h e a l t h c a re fa c i l i t i es ( H u f

f, 1 9 91; B ur g e s s et a l

. , 199 9 ; K i m , 2001). T h ere i s a 22

h i s t ory of e m er g ency dep ar

t m en t s ( E D ) c l o s i ng and e v acu a ti ng d ue t o s econ d ary c on t a m i na t i on, r e su l ti ng 23

i n l o ss o f a co m m un it y m ed i c a l c a re re s our c e and o t h er ess e n t i al m ed i cal s e r v i ces. S u b

j e ct m a t t er e xp e r t s 24

i nd i c a t ed t h a t t h e p o t e n ti a l for c on t a m i nated pa t i e n t s t o ef

f e c ti v e l y sh u t do w n a n E D or he a l t h c a re fa c i l ity 25

shou l d be c on s i d e red w h e n de t e r m i n i ng t he n eed for d e con t a m i n a ti o n. 26

27

Wh i l e the s e fa c t o rs m ust be t a k en i n t o ac c ount w h en d e t er m i n i ng t h e n e ed t o deco n t a m i na t e a pa t i e n t, t h e 28

r i sk of s eco n da r y con t a m i na t i on m ust a l so be w e i g hed a g a i nst t he ne e ds of an i nd i v i d u al pa t i e n t

. S uch a 29

r i s k

- based r espon s e ap p ro a ch w o u l d i nv o l v e: 30

• A de t e r m i na t i on of t h e ne e d for dec o n t a m i n a ti on by app l y i ng t he c r i t e r i a de s c r i b ed i n G u i da n ce 31

S t a t e m ent 1.1. 32

• A sses s i ng t he r i sk of ad v e r se o u t co m es r e su l ti ng f

rom decontamination pro cess itself (see 33

Guidance Statement 1.3)

. 34

• C ons i d e r i ng a l t er n a t i v e de c on t a m i na t i on p r a c t i c e s de sc rib e d i n G u i d a nce S t a t e m ent 2.11. 35

• C ons i d e r i ng re l e v ant c h e m i cal and e x pos u re i nf

o r m a t i on f

r om t he i n c i d e nt s ce n e and u n i que t o t he 36

i n c i de n t

, i nc l ud i ng w he t her t he p rop e r t i e s of t he co n t a m i nant pose a r i sk of seco n dary 37

con t a m i n a ti o n. 38

39v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

24 S u b j e c t m a tt e r e xpe r

ts g en e ra l l y a g reed t hat a p a t i ent w ho i s n o t ex h i b i t i ng sy m p t o m s, has no v i s i b le s i g ns 1

of con t a m

i na t i on, a nd i s neither li k

e l y t o be c o n t a m

i n a t ed d u e t o h i s /

h er l oc at i on r e l a ti v e t o t h e r e l e ase s i t e 2

i s u n li k

e l y t o req u i r e d e con t a m

i n a ti o n nor to pose a si g n i f i c a nt r i sk for s econ d ary con t a m i na ti o n. 3

4v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

25 

### G u ida n ce S tat e me n t 1 .3

I f t he li k e l i hood of a d v erse conse q uen c es from g ross p a t i ent or t ec h n i c al pa t i e n t d econ t a m

i na t i on

m e t hods ou t we i g hs t h e l i k

e l y hea l t h o u tco m

e g a i ns of deco n t a m

i na t i ng a p a ti e nt w it h wa t e r

- based

deco n t a m i n an t s, t hen d eco n t a m

i na t i on s h ou l d be p e r fo r

m ed us i ng a lt e rn a ti v e p ra c t i c es.

Considerations:

• P a t i ent dec o n t a m

i n a ti o n i s not wi t ho u t r i s k ; a p pro p r i a t e m

easures sho u l d be t a k

en t o m iti g a t e t h ese

r i s k s a n d to r e duce t he ne g a t i v e i m pact on pa t i e n t s.

• R efer t o G u i da n ce S t a t e m ent 2.11 f o r a l t e rn a ti v e p r a ct i ce s

.

• A d v erse co n seq u enc e s m i ght be cau s ed by se v ere we a t her ( e. g

., h y po t her m i a d u e t o co l d

t e m pera t u r e s), che m

i cal r ea c ti v i t y (e. g

., w a t e r

- react i v e che m i ca l s or m e t a ls, s uch a s l it h i um or

sod i u m ), d e l ay i n l i fesa v i ng car e , or ps y cho l o g i c al t r a u m a.

Level of Confidence: III

1

D i sc u s s i o n : 2

T he de c i s i on t o p e rf o rm decon t a m

i n a ti o n sho u l d t a k

e i n t o c o ns i de r a t i on a ny and a l l p o t e n t i al 3

conse q uen c es. A r i s k

- based re s ponse ( a s o u t l i ned i n G u i dan c e S t a t e m

ent 2.1) i s nece s s a ry t o en s ure t h a t 4

t he h ea l t h o u t c o m e bene f i t of d e con t a m

i na t i on e ff

o r t s ou t w e i g h t he p o t e n t i al con s equen c es o f ad v e r se 5

hea l t h e f

f ec t s f or p a t i e n t s. R espond e rs and rec e i v ers m ust cons i d er en v i ron m

en t al c o nd i ti o ns, c he m

i cal 6

rea c ti v i t y w it h wa t e r

, t h e p o t e n t i al for m echa n i c a l i n

j u r i e s ( e. g ., s l i ps, t

r i ps, f a ll s ), and t h e ps y ch o l o g i c a l 7

i m

pact on p a t i e n t s o f con du c t i ng decon t a m i na t i on ( L e v i t i n e t a l

. , 200 3 ; F re y berg et a l

. , 2 0 08). E l e m en t s 8

of t h i s g u i d ance s t a t e m ent ha v e suppo r

t i n t he a v a i l a b l e l i t e r a

t u r e or co u l d be con s i de r ed c ur r ent pr a c t i c e

. 9

T he a s se r t i ons i n t h i s g u i d a nce s t a t e m

ent w ou l d be d i ff

i c u l t t o e v a l u a t e i n a co m

para t i v e hu m an t r i a l

, but 10

m a y be e v a l u a t e d i n a r e t r o spe c ti v e s t udy and s u bseq u ent a na l y s i s. I n add i t i on t o i nf

o r m a ti on p r e se n t ed i n 11

t h e l i t e r a t u re, t he p o t e n ti al f or a d v erse con s eque n c e s i s d i s cus s ed i n v ar i o us e x i s t i ng g u i dance docu m en t s 12

( A T S D R

- E M S

, 2000; DO D T S W G

, 2 004; O S H A

- FR , 2005; ECBC , 2009; O S HA

- E M S, 2009). 13

14

E

nv i r o n m en t al con d i t i ons 15

T r ad it i on a ll y , p a ti e nt d eco n t a m i na t i on h a s i m

p l i ed wat e r

- based sho we r i n g

. H o w e v er, o t h e r 16

deco n t a m

i na t i on s t r a t e g i es are b e t t er s u it e d f o r c e r t a i n cond i t i ons a nd m ay ach i e v e s i m il ar ou t co m

es as 17

t ra d i ti o n a l l y i m p l e m en t ed d econ t a m

i na t i on m e t hods. T hese a l t e r

na t i v e s t r a t e g i es i nc l u d e t h e r e m

o v al of 18

patients from t he c on t a m i na t ed a re a , re m o v al of c l o t h i ng , and / or u se o f an i m p l e m ent ( i .e., c l ean ra g ) f

o r 19

spo t 7 deco n t a m i na t i on ( F e l d m an, 2010). T he s e m e t ho d s m ay pro v e espec i a ll y r e l e v ant w hen 20

en v i ron m

en t a l con d i t i o n s p res e nt r i sk of co l d w e a t h e r i n j u r i es or o t h e r e x t r e m

e w ea t h e r ( e. g ., fr e e z i ng 21

ra i n

, i cy co n d i ti o n s) ( L e p l e r and L uc c i , 200 4 ). De con ta m i na ti on s ho u l d be sc a l a

b l e and f l e x i b l e

. I f t he 22

r i s k s o f w a t er

- based d e con t a m i na ti on i n an e x t r e m

e l y co l d en v i ron m

ent a r e t oo g r e a t

, t hen d i s ro b i ng a 23

pa t i e n t and pro v i d i ng unc o n t a m i na t ed co v e r i ng i n t

he sho r t t erm m a y be suf

f i c i e n t t o sub s t a n t i a l l y redu c e 24

t he r i sk of che m i c a l

- spec i fi c he a lt h ou t co m es w it h o ut i nduc i ng c o l d w e a t h e r i n j u r i es. 25

26

I n co l der en v i r on m en t s, d ec on t a m

i na t i on m ay requ i re a lt e rn a ti v e l oc a ti o ns i n l i eu o f a l t e rn a t i v e 27

t ech n i q u es. Us i ng i ndo o r sw i m m i ng poo l s, gy m

nas i u m s, or o t h e r l a

r g e sho we r f

ac i l i t i es ( e. g ., ar e n a s, 28

sch o o l s, h o t e l s ) ha v e b e en cons i de r ed i n e x i s ti ng g u i d ance d ocu m en t s ( ECBC , 2 0 09); r e spon s e 29

or g an i z a t i on s ’ p l ans sho u l d con s i d e r t h ese as p o t e n t i al a l t er n a t i v es t o ou t d oor d ec o n t a m i na t i on. 30

31

C

he m i c a l r e ac t i v i t

y 32

A lt e rn a ti v e d e con t a m i na t i o n m e t hods sho u l d b e co n s i d ered for che m i c a l s t h a t a r e dee m ed w a t er

- rea c ti v e. 33

7 S po t d ec o n t a m i n a t i o n

- A s oppo s ed t o d e c o n t a m i n a ti o n o f t h e e n ti re bo d y

, t h i s t ec h n i q u e i nv o l v es t h e r e m o v al of v isi b l e

c on t a m i n a ti o n f r o m sm a l l areas o f e x po s ed s k i n (e. g

., h a n d o r po r ti o n o f t h e a r m o r l e g ). T h i s t ec h n i q u e m a y b e w a t er

- b a s ed

o r u tili ze s o m

e o f t h e a lt er n a ti v e d ec o n t a m i n a n t s d is c u s s ed i n t h i s g u i d a n ce do c u m e n t (e

. g

., RS D L ® ).v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

26 Wa t er

- rea c ti v e su b s t a nc e s under g o a d an g erous che m i cal re a c t i on w h e n t h ey co me i n t o co n t a ct w it h 1

w a t e r

. T h i s r ea c ti o n m ay r e l e a se a g as t h a t i s e i t her f

l a m m ab l e or p r es e n t s a t ox i c i n h a l a t i on ha z a r d. I n 2

add i ti o n, t h e h e at g en e ra t ed w hen w a t er a c t i v a t es such m a t er i a l s i s o f t en en o u g h f

o r t h e m a t er i al t o 3

sp o n t a neo u s l y co m bust o r ex p l ode, ca u s i ng se v ere b urns. T he U S DO T ’s E m e r g ency R esponse 4

G u i debook ( DOT, 2 0 12) pro v i d e s a l i st of wa t e r

- reac t i v e ch e m i ca l s t h at pro d uce t o x i c

- by

- i nha l a t i on 5

g as ( se s) w hen s p i l l ed i n wa t er. I n add i t i on t o t h i s l i s t , se v e r al a l k a l i m e t a l s a re v i o l en t l y r e ac t

i v e w it h 6

wa t e r

, as also referenced in the Emergency Response Guidebook ( DOT, 2012) 7

8v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

27 

### F u nctio n al Ar e a 2: O

p t i m ized Technical Pr

a ctices 1

G u i dan c e s t a t e m en t s i n F u n c t i on a l A r e a 2 d e sc r i be t e c h n i qu e s, m e t hods, and p ra c t i ces t o o p ti m i z e t he 2

per f

or m ance o f p a ti e nt d e c on t a m i na t i on. F un c ti o nal A rea 2 i n c l ud e s m e t hods f o r re d u c i n g , re m

o v i n g

, 3

neu t

ra l i z i ng or i na c ti v a t i ng con t a m i n a ti o n on a n i n d i v i dual p a t i e n t

, a ssu m i n g , for t he m ost pa r t

, t h a

t 4

reso u r c es a n d ca p ab i l it i es a re n o t c h a l l en g ed by a m ass expos u re sce n a r i o. 5



### G u ida n ce S tat e me n t 2.1

A r i s k

- based appr o ach sho u l d be e m p l o y ed by a respo n d i ng or r ec e i v i ng or g an i z a t i on t o d e t e r m i ne t h e

appro p r i a t e r e spo n se l e v el and a s so c i a t ed s t r a t e g i es a n d t a c t i cs ( i n c l u d i ng PPE

, med i c al i n t er v en t i o n s and

decontamination

Considerations:

• A pprop r i a t e l y t r a i ned sup er v i sory perso n nel (e. g

., s e e H a z ardous Wa s t e O p e r a ti o ns and E m er g ency

R espon s e ( HA Z

W O P ER ) s t and a

rd s , 29 CF R 191 0 .12 0 (q) o r N FP A 47 2 / 473, 2 01 3 ) sho u l d p e r form a

s i t ua t i o n al a ss e ss m

en t

.

• PP E de t e r m

i na t i on s hou l d be ba s ed up o n t h e u n i que c i rcu m s t an c es o f t h e e v en t

, i n cons u l t a t i on w it h

app l i ca b l e g u i d an c e and r e g u l a ti o ns ( O S HA

, N I O S H

, and N F P A

– s e e G u i d ance S t a t e m ent 5

. 7).

Level of Confidence: IV

6

D i sc u s s i o n : 7

T he r i s k

- based appro a ch a l l o w s HA Z M A T re s pond e rs and f i r st re c e i v er s ’ f

l e x i b i li t y i n ada p t

i ng resp o nse 8

capa

b i l i t i e s t o d y na m

i c s it u a t i ons. T h i s app r oach de v i a t es f rom s t and a

rd p ra c t i c e

- based re s pon s e 9

oper a t i ons by a l l o wi ng res p onde r s and re c e i v e r s t o m a k e cr i t i c al d ec i s i o ns b ased on an a ss e ss m ent of t he 10

ha z ards a nd r i s k s a s so c i a t e d w it h a p a

r t i c u l a r i n c i d en t

. T h e r i s k

- based resp o nse i s a s y s t e m a t i c ap p roa c h 11

t o r espo n d i ng t o an i n c i d e n t t h a t i n cor p or a t e s t h e k no wl ed g e and ex p e r i en c e o f t h e resp o nd e r, t h e u n i que 12

c i r cu m s t anc e s of an e v e n t

, and t h e r i sk an a l y s i s i n o r d er t o m a k e i nfor m ed re s po n se d e c i s i o n s. R espond e rs 13

and rec e i v ers s hou l d i nc o rp o r a t e t he s e p ri nc i p l es i n t o t he i r p l an n i ng a nd t r a i n i ng for deco n t a m i na t i on 14

o p e r a t i on s , us i ng k no w l ed g e of t he c h e m

i cal ( i f a v a il a

b l e ), si t e

- spec i f

i c i n for m a t i on, en v i ron m

en t a l 15

m

on it o r i n g , pa t i e n t s i g ns and s y m p t o m s , and o t h e r c l ues for de c i s i o n m a k i n g

. 16

17

R i sk

- based r e spo n se h a s b e co m e a co m m on prac t i c e o f HA Z M A T resp o nse f o ll o w i ng it s e v o l u t i on from 18

s t r eet

- s m art t a c t i cs, and i s i ncorp o r a t ed as a co r e co m pe t e n cy i n N FP A 472: S t a nd ard f o r C o m p e t en c e o f 19

R espon d

ers t o H a z ardo u s Ma t er i a l s

/ W eapons o f M a s s D es t ru c ti o n I

n c i d en t s (2 0 13), a s w e l l a s t e x t b oo k s 20

an d t

r a i n i ng g u i des

. S u b

j e c t m a tt er exp e r t s s t

r o n g l y encoura g ed g u i d a

nce w h i ch r ef

l ec t s t he r i s k

- based 21

resp o nse app r oach as a k ey e l e m ent o f p l an n i ng for m ass p a t i ent deco n t a m i n a ti o n

. T h o u g h a r i sk

- based 22

resp o nse i s a c u rr e nt s t a n d a rd of pr a c t i ce and S M E s s u pport i t s u se a n d i n c l u s i o n, t he r e i s a p au c it y of 23

e v i dence i n t he p ub l i s h ed li t e r a t u re e v a l ua t i ng i t s e ff ec ti v ene s s. 24

25v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

28 

### G u ida n ce S tat e me n t 2.2

A ti e red app r oach t o p a t i e n t deco n t a m i na t i on a l l o w s re spond e rs a nd r ec e i v ers t o b ase t he n a t u re a nd l e v el

of d e con t a m

i na t i on on t he t

y pe and ex t ent of con t a m i na t i on, as e s ti m a t ed t h

rou g h a r i sk

- based

a s se s s m ent of t h e i n c i d e n t , as wel l as a v a il a b l e r eso u rc e s. T h e t i e r ed de c on t a m i na ti o n r e spo n s e i s

f l ex i b l e and adap t ab l e t o v ar i o u s t y pes o f i n c i d en t s; each t i er can b e exec u t ed e i t h e r a t t h e s c e n e or a t a

he a lt h c a re fa c i l it y

. Recommended patient decontamination tiers

S e l f

- car e : a c t i ons t h a

t a p a ti ent c an p e r f

orm

for h i m / her s e l f, i nc l ud i ng d i s t an c i ng

h i m / hers e l f f rom t he s i t e o f re l ea s e,

re m o v i ng c l o t h i n g , and w i p i n g v i s i b l e

con t a m i n a ti o n f rom s k i n and c l o t h i ng i n

ord e r t o re d uce h i s / h e r o w n

con t a m i na ti o n l e v el i mm

ed i a t e l y

,

w it ho u t w a i t

i ng for a

for m al d e con t a m

i na t i on p r o cess t o b e s e t

up. A perc e p t i v e pa t i e n t or one

expe r i e n c i ng acu t e d i s t

re s s f rom t he

c h e m i cal con t a m

i n a ti o n m ay execu t e

se l f

- care e v en bef

o re r esp o nd e rs a

r r i v e;

h o w e v er, m

ost pa t i e n t s wi l l need

i n s t r uc t i o ns

. 8 S e l f

- care can b e co n du c t ed w it ho u t equ i p m ent o r

su p p l i e s ; i t m a i n l y depends on pa t i e n t s k no w i ng

w hat t o d o e i t h e r on t h e i r o w n or t hrou g h

i ns t ru c t i ons from resp o nd e rs.

G ross p a t i e n t d e con t a m i na t i on: a c ti o n s l i k e l y

t o be p e r for m

ed by or wi t h t he a s s i s t an c e

of f i r st r e spond e rs or f

i rst r e c e i v ers i n

or d er t o ach i e v e a g ross o r h a s t y

re d uc t i on i n con t a m

i n a ti o n, s i g n i f

i ca n t l y

reduc i ng con t a m

i n a ti o n on s k

i n o r

cl o t h i n g , as soon as pos s i b l e a f t e r

co n t a m i na t i o n has o cc u rre d

. 9 G ross p a t i e n t d e con t a m i na t i on i s

p e rf o r m ed w it h m i n i m al eq u i p m

en t

,

p rodu c t s o r i m

p l e m en t s, and c an be s e t up

qu i c k l y

. E xa m p l es i n c l u d e t

he L a dd er P i pe

D econ t a m

i na t i on S y s t em t o p ro v i de a h i g h

v o l u m e, l ow pres s ure wa t e r sho w er from

f i re appa r a t u s ( ECBC , 2 0 09) a n d spot

deco n t a m i na t i on u s i ng a p r oduct such as

R eac t i v e S k

i n D eco n t a m

i n a ti on L o t i o n ®

(RSDL) (Schwartz et al., 2012)

T e chn i c a l p a t i ent d eco n t a m i n a ti o n : p l an n ed

and s y s t e m a t i c a ct i ons, li k e l y t o be

per f or m ed und e r t h e g u i da n ce of or wi t h

t he ass i s t ance of f

i r s t r e spon d e r s or f

i rst

rec e i v ers, t o a c h i e v e con ta m i na ti on

red u c t i on t o a l e v el t h a t i s as l ow a s

p oss i b l e

. 10 T e chn i c a l p a t i ent d eco n t a m i n a ti on is

ach i e v ed t h rou g h a w e l l

- def i n e d, m u lt i

- s t ep

proc e ss t h a

t i n c l u des e v a l u a t i on of t he

r e su l t s and, i f n e ce s sar y

, r ep e t i ti on of t h e

p roc e ss. I

t usua l l y i n v o l v es a h i g h v o l u m e,

l ow pres s ure w a t er sho we r, wi t h t he

a dd i ti on of soap, espe c i a ll y f o r an o i l y

con t a m i nan t , and g en t l e ru bb i ng w it h a so f t

c l o t h or spon g e. T he sho w er m ay be

pro v i ded by a nu m

ber of d i f fe r ent t y pes o f

eq u i p m ent or fa c i li ti e s.

8 S e l f

- care i s s i m i l ar t o t h e c on ce p t s o f s e l f o r e m er g e n c y d e c o n t a m

i n a ti o n (DOD T S W G, 2 004 ; O S HA

- Fi r s t R ece i v e r s

, 2005 ; O S HA

- EM S

, 20 0 9 ), e m er g e n c y d ec o n t a m i n a ti o n (N F P A 472

, 2 0 13 ) a n d i mm e d i a t e decontamination (DOD FM 3

- 11.5,

2006)

9 Gr o s s p a ti e n t d ec o n t a m i n a ti o n i s s i m

i l ar t o t h e c o n ce p t o f f

i e l d

- e x p e d i e n t d ec o n t a m i n a ti o n (DOD T S W G, 2 0 04;

O S H A

- Fi r s t R ece i v er s

, 2005 ; O S H A

- E M S

, 2009 )) a n d t o DOD’s c o n ce p t o f op era ti o n al d ec o n t a m i n a ti o n (DOD F M 3

-

11

. 5

, 2 0 06 ) a n d c o n sist e n t w i t h N F P A ’s c o n ce p t o f g r o s s d ec o n t a m i n a ti o n (N F P A 4 72

, 2 01 3 ).

10 Technical patient decontamination is similar to the concepts of thorough decontamination (DOD TSWG, 2004; OSHA

First Receivers, 2005; OSHA

- EMS, 2009) and definitive decontamination (HHS ATSDR Vol. I, 2000)v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

29 Mass dec o n t a m

i n a ti o n can occur at any of t he p a t i ent d econ t a m i na t i on t i e r s ; i t i s d ef

i n ed a s r edu c i ng or

re m o v i ng surface c on t a m

i na t i on f rom l ar g e nu m

bers o f p a ti e n t s i n p o t e n t i a ll y l i fe

- t hr e a t en i ng s it u a t i ons

i n t h e f as t e s t t i m e poss i b l e.

Considerations:

• T he p a ti e nt d eco n t a m

i na t i o n t i ers a r e n o t nece s s a r i l y a s t e p

- w i se s y s t em t hat r e qu i res

condu c t o f e a ch i n or d er. T hey shou l d b e app l i ed i n a m ann e r t h at m ee t s t he n ee d s of each spe c i f i c

s i t u a ti o n

.

• S o m e hea lt h ca r e f

ac il i t i es m a y requ i r e t h at a pa t i e n t has been t e ch n i c a ll y deco n ta m i na t ed bef o re

h e / s h e e n t e rs t he fa c i l it y

. I n t h i s c a se, l oc a l p l ans sho u l d i nc o rp o r a t e a t e ch n i c a l pa t i e n t

de c on t a m i na ti o n c a pab i l i t y e i t her at t he h ea l t h c a r e f a c i l i t y or o n

- scene w it h f

i r s t resp o nd e rs t hat w i l l

b e a c c e p t ed as s u f

f i c i e n t by hea lt h c a

re f a c i l it y pe r s o nne l

.

Level of Confidence: IIIv. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

30 D i sc u s s i o n : 1

I n t he ti e red appr o ach t o p a ti e nt 2

deco n t a m

i na t i on, t he m

e t h o ds and g oa l s de p end 3

on t he de t a i l s o f t he e xpos u re a n d t h e r e so u rc e s 4

a v a il a b l e. S e l f

- care and g r oss p a t i ent 5

deco n t a m

i na t i on a re p r i m a r il y f

i r s t a i d 6

m

easur e s. T h e se s t e ps a

re a i m ed at sa v i ng a 7

pa ti e n t ’s l i fe and m iti g a t i ng ad v erse h ea l t h 8

e ff

e c t s by redu c i ng t he l e v el o f co n t a m i na n t i n 9

t he p a t i e n t ’s i m m ed i a t e e n v i ron m

ent, t h ereby 10

re d uc i ng t he a m ount abs o rbed and t he d ose 11

r ec e i v ed ( H a m ilt on et a l

., 2 004; P r es t on e t a l

. , 12

20 0 8; A m

l ôt e t a l ., 201 0 ; B r aue et a l ., 2 0 11 a / b; 13

F e l d m an, 2010 )

. S e l f

- care and g ross p a t i e nt 14

deco n t a m

i na t i on a re t he m ost t i m e

- sens i ti v e of 15

t he t h r ee t i e rs. G i v en t h i s, f or m ax i m u m 16

benef

i t

, t hey sho u l d be pe r for m ed a s soon as 17

p o s s i b l e af

t er c on t a m

i na t i on h a s oc c urr e d 18

( H a m

i l t on e t a l ., 2 0 04; B raue et a l

., 201 1 a / b )

. 19

T he p r i m ary o b j e ct i v e of t ech n i c a l p a t i e nt 20

d e con t a m

i na t i on i s t o r edu c e a p at

i e n t ’s 21

co n t a m

i na ti on t o a l e v el t h a

t i s a s l ow as 22

p o ss i b l e i n o r d er t o m i n i m i z e t he po t e n t i al for 23

se c ond a

ry co n t a m i na t i on o f resp o nd e rs, 24

rec e i v ers, o t h er peop l e, e q u i p m en t

, and 25

f

ac i l i t i e s. O nce a p a t ie nt h a s und e r g one 26

t ech n i c al d eco n t a m i na t i on

, co n t a m

i na t i on i s 27

redu c ed t o a l e v el w h i ch a l l o w s re s pond e rs and 28

rec e i v ers t o han d l e t he pa t i e n t , e v a l u a t e, a n d 29

ad m

i n i s t e r m ed i cal c are w h i l e op e r a t i n g i n a 30

re d uced l e v el o f PPE

. T e ch n i c a l p a t i ent 31

d ec o n t a m

i na ti on m ay a l so sa v e li v es a n d r e duce 32

ad v er s e h e a l t h e f fe c t s a m ong pa ti e n t s by 33

li m

iti ng add i t i on a l ab s o r

p ti o n of su r fa c e 34

con t a m

i na n t s, depe n d i ng o n how soon i t i s 35

ex e cu t ed. 36

37 38

39

40

E xa m

p l e ( a t t h e s c en e ): 41

A m ass che m

i cal ex p os u re occu r

r i ng i n a 42

j u r i s d i c ti on w i t h l i m it ed r e s ourc e s, w h e re 43

f i r st r e spond e rs m

ust wa i t o n m

u t ual a i d 44

suppo r t

, m ay requ i re s equ e n t i al c o m p l e t i on 45

of a l l t h r ee ti e r s : 46

47

 F i r s t r esp o nde r s a r r i v e at t h e sc e ne a n d 48

i n s t ru c t p a t i e n t s t o m o v e t o a sp e c i f

i c 49

area up w i nd of t he ar e a of r e l e a s e, 50

re m

o v e at l e a st o u t e r l a y ers of c l o t h i n g

, 51

and w a i t ( S e l f

- care). 52

53

 S hor t l y t h e re a f

t er, p a t i e n t s are g u i d ed 54

t hrou g h a d eco n t a m i na t i on cor r i d o r 55

es t a

b l i sh e d a t t h e s c ene u s i ng a L adder 56

P i pe De con t a m

i na t i on S y s t em ( G ross). 57

58

 S ubseq u en t l y , pa t i e n t s u nd er g o t e c h n i cal 59

deco n t a m

i na t i on i n a m

ob i l e t e n t s y s t em 60

a l so s e t up a

t t he s cene ( T e chn i c a l ). 61

62

I n a w e l l

- equ i pped j u r i s d i c t i on, t he ti e rs 63

m a y be co m

p l e t ed n ea

r l y s i m u lt aneou s l y : 64

65

 F i r s t r esp o nde r s a r r i v e on

- s cene a nd 66

d i r e ct pa t

i e n t s t o m o v e t o a spe c i f

i c a rea 67

up w i nd o f t h e s i t e of r e l e as e, i n s t r uct 68

pa t i e n t s t o r e m

o v e c l o t h i ng and p r oce e d 69

t hrou g h a m

ob i l e t ent s y s t e m for 70

t ech n i c al p a t

ie n t d e co n t a m

i n a ti on 71

72

Many o t h e r s eque n ces of e v en t s a r e 73

pos s i b l e; t he s e e x a m p l es i l l us t r a t e how t he 74

ti e red ap p roach can be f l e x i b l y app l i ed t o 75

spe c i f

i c s i t ua t i o n s as pa

r t o f a r i s k

- based 76

resp o nse. 77v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

31 1

E xa m

p l e ( a t he a l t h c a

re fa c i l it y ): 2

A s i g n i f

i ca n t p rop o r t i on o f 3

pa t i e n ts m a y l ea v e t he s cene 4

w i t ho u t b e i ng deco n t a m i na t e d or 5

e v a l u a t e d by resp o nd e rs a n d 6

e it h er p roc e ed d i re c tl y t o a h ea l t h 7

ca r e f

ac i l i t y or n ot s e ek care r i g ht 8

a w a y

. 9

10

T h e se p a t i e n t s wil l ha v e p e rf o r m ed 11

so m

e, but p e rhaps not a l l p oss i b l e, 12

se l f

- care a c ti o ns a n d t h en u nder g o 13

g ross p a ti e nt a nd / o r t ec h n i c al 14

p a t i ent deco n t a m i na t i on a t t he 15

h ea l t h c a re fa c i l it y

. 16

17

N o t e: I

n so m e m ass e xp o s u re 18

scen a

r i os, s uch a s one i n v o l v i ng 19

on l y a g as or v apor co n t a m i nan t

, 20

se l f

- care m a y be suf

f i c i e n t

. 21

22

23

24 T he t i e r ed a p pr o ach i s u sed t o t a i l or t he 25

deco n t a m

i na t i on res p onse t o t he spe c i f i c i n c i d e n t

. I

t i s 26

not m

eant t o su gg est t

hat d econ t a m

i na t i on m ust be a 27

seque n t i al pr o cess w he r e s e l f

- care i s c o ndu c t ed f

i r s t

, 28

fo l l o w ed by g ross p a t i e n t a nd t h e n t e ch n i c a l p a t i ent 29

deco n t a m

i na t i on, t hou g h s o m

e i nc i de n t s m ay proceed 30

i n s u ch a m anner. 31

32

T e chn i c a l p a t i ent d eco n t a m i n a ti on re q

u i res m ore 33

reso u r c es a n d t i m e t han g r o s s p a t i ent deco n t a m i n a ti on, 34

w h i ch req u i r e s m ore r e sou r ces a nd t i m

e t han s e l f

- care. 35

T he ca

p ab i l i t y t o p e r f

orm each t i e r of dec o n t a m i n a ti o n 36

depen d s on t he a v a i l a b i l i t y of t h ose re s ou r ces. T he 37

m

ore reso u rce i n t en s i v e pr a c t i ces can p ro v i de g r e a t e r 38

pr i v acy and c o m

fo r t, a s w e l l as p o t e n t i a ll y a l l o w i ng f or 39

fu r t h e r re m

o v al of c on t a m

i nan t s f rom pa ti e n t s. 40

41

S e v eral ex i s t i ng g u i dance d ocu m en t s ( HH S A T S D R

, 42

2000; DO D T S W G

, 2 004; O S H A

- FR , 2005; DO D FM 43

3

- 11.5, 2006; O S HA

- E M S

, 2009; N FP A 4 7 2, 201 3 ) 44

pro m

o t e a t i e red or p h as e d appr o ach t o p a t i ent 45

deco n t a m

i na t i on t h a

t i s co n s i s t e n t wi t h t

he 46

reco mm

enda ti ons of t h i s g u i dan c e d o cu m ent. 47

T he spe c i f

i c t er m s used d i ff

e r a n d

, i n so m

e 48

cases, t w o ra t

h er than three tiers are identified 49

N e v er t h e l e ss, t he conc e p t s a nd t he r a t i on a l e s a r e b a s i c al l y t he s a m e be t w e e n t h e e x i s ti ng g u i d a nce

d o cu m en t s and t h i s g u i dance docu m ent. Mo s t i m

por t a n t l y , pr i o r g u i da n ce e m phas i z es t h e ur g ency of

redu c i ng expo s ure and re m o v i ng l ar g e a m oun t s of ch e m

i cal co n t a m

i na t i on from pa t i en t s as soon as

p o ss i b l e w it h re a d i l y a v a il a b l e re s ou r ces ( i

. e., s e l f

- care a nd g ross p a t i ent deco n t a m i na t i o n ). P r i or

gu i dan c e d o cu m

en t s a l so d es c r i be a m

ore t ech n i c a l a n d o r g an i z ed t y pe of deco n t a m i na t i on d es i g ned t o

red u ce c on t a m

i na ti o n t o a l e v el t h a t i s as l ow as po s s i b l e o r as c l ean as pos s i b l e i n ord e r t o l i m i t t h e sp r ead

o f c o n t a m i n a ti on a nd pr o t e c t r esp o nd e rs, re c ei v ers, eq u i p m ent and fa c i l i t i es ( i .e., t ec h n i c al pa ti ent

d eco n t a m i na t i o n ).

T he ap p roa c h i s a l so e s t ab li shed i n t he Na ti o n al F i r e P r o t e c t i on A ss o c i a t i on ’ s ( N F P A ) S t a n dar d f or

C o m pe t ence o f R esp o nd e rs t o H a z ard o us M a t e r i a l s /W eapons of Ma s s D e s t r u c t i on I nc i den t s ( N FP A 472,

2013), w h i ch w i d e l y i m

pac t s f i r st re s pond e r p ra c t i ces. A s i m il ar t i e r ed ap p ro a ch i s i m

p l e m en t ed by t he

DO D ( DO D F M 3

- 11.5, 2006). A c o n t ro l l ed pro s pe c t i v e s t udy of t h e e ff e c t i v ene s s of a f

l e x i b l e, t h ree

ti e red ap p roach as d e f

i ned here m ay be d i f

f i cu l t t o ex e cu t e. H o w e v er, s u ch a s t u d y or e v i dence o f

succ e s s ful app l i c a t i on o f t h e ap p roach i n re a l i n c i de n t s or e v en i n ex e r c i s e s w ou l d be a we l co m e d add i ti o n

t o t he f i e l d.v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

32 

### G u ida n ce S tat e me n t 2.3

S e l f

- care and / or g ro s s p a t ie nt d e con t a m i na t i on a c t i ons shou l d oc c ur a s q u i c k l y as pos s i b l e, w h i l e a

t ech n i c al p a t i e n t d e co n t a m i na t i on c o r r i d o r i s e s t a

b l i sh e d.

Considerations:

• A de t e r m

i na t i on of t h e ne e d for t e chn i c a l p a t i ent d ec o n t a m i na t i on, o r any co n t r a i nd i c at i ons

nece s s i t a ti ng an al t er n a t i v e pra c t i ce, s hou l d be d e c i ded acc o rd i ng t o t he g u i dan c e i n F unc t i o n al Ar eas

1 and 2.

• N on

- a m

bu l a t ory or m

ob i l i t y i m pa i red p a ti e n t s m ay not be a b l e t o p e rf

o rm se l f

- ca r e.

Le vel of Confidence: II

1

D i sc u s s i o n : 2

T he i m

por t a nce o f e a r l y decon t a m i n a ti o n t o re d uce c o n t a c t t i m e and t h e r ef

o re re d uce t he op p o r t un i t y for 3

abso r

p t i on o f t h e c o n t a m

i n ant a nd t h e s u bse q ue n t do s e rec e i v ed by t he p a t i e n t

, ca nnot b e o v er s t a t ed. T h e 4

dur a ti on of t he ti m e w i nd o w for e f

f ec t i v e p a t i e nt d ec o n t a m

i na t i on i s n o t p re c i s e l y k

no w n. E v i dence 5

su gg es t s t h a t i t v a r i es w it h t he i d en t it y of t he co n t a m

i nan t

, t he d ose o f t he c on t a m i nan t

, and p roba

b l y o t h e r 6

f

ac t ors. C o m

pared t o b i o l o g i cal and ra d i o l o g i cal con t a m i n an t s, t he t i m

e w i ndow i s s ho r t : m

i n u t es t o 7

ho u rs i n m

ost c a ses. D e s p i t e t h e l ack of p r e c i se, or i n m any cases e v en rou g h, d e li m it a t i on o f t h e ef

f ec t i v e 8

t i m

e w i ndow for d econ t a m

i na t i on o f che m

i c al s, se v er a l s t u d i es pro v i de e v i dence t h a t t h e ef f i c a cy of 9

p a t i ent d eco n t a m i na ti on i n s a v i ng li v es a n d / or m i t i g a ti ng ad v er s e h ea lt h e f fe c t s d i m i n i s h es o v er ti m

e. 10

T h i s t

i m e fra m e ran g es f rom a few m

i nu t e s t o m any hours, de p end i ng on t he spe c i f i c con t a m i na n t

. 11

12

D a t a on t he t i m e w i ndow f

or e f f e c t i v e deco n t a m

i na t i o n of so m

e t o x i c i nd u s t

r i a l c he m i ca l s are a v a i l ab l e 13

from a se r i e s of s t u d i e s by We s t er and co l l ea g ues (19 9 0, 1991, 1 9 92, 19 9 9) u s i ng i n v i v o expos u re o f 14

rhes u s m

on k e y s. T h e e f

f ic acy (d i re c tl y m

easured as a prop o r t i on o f s u r f ace con ta m

i na ti on re m

o v ed) of 15

w ash i ng t h e s k i n wi t h s o a p y w a t er d e c l i ned as t i m e i ncre a sed p o s t

- exposu re

. M e t h y l ene b i s p hen y l 16

i soc y an a t e, g l y phosp h a t e

, a l ac h l or and A ro c l or 1 242 e xh i b it e d d i f

f er e nt d eco n t a m

i n a ti on t i m

e sen s i t i v i t i es 17

i n s ep a

ra t e s t u d i es. B ra u e and co l l e a g ues (2011 a / b ), s t ud i ed t he a

b i l it y of se v eral deco n t a m i nan t s t o 18

pre v e n t dea t h i n g u i n ea p i g s t h a t h a d been expo s ed t o 5x L D 50 of e it h er V X or so m an; s t u d i es i n v es t i g a t ed 19

t h e e f

f e ct o f i mm

ed i a t e and d e l a y ed deco n t a m i na t i on on l e t h a l it y

. T he L T 50

– t he l a t e s t de c on t a m i na ti o n 20

t i m

e a t w h i ch h a l f of t he co n t a m i na t ed a n i m a l s su b seq u e n tl y d i ed ( a t xx hou r s)

– w as 26, 48 and 31 21

m

i nu t es for soapy w a t e r, d il u t e b l ea ch and RS D L d e co n t a m i na t i on o f V X

- exposed an i m a l s, r es p ec t i v e l y

, 22

su g ges t i ng a sh o rt ti m e w i ndow for d eco n t a m

i na t i on (26 m

i nu t es f o r s o apy w a t e r ). T he w i ndow for 23

e f

fe c ti v e d econ t a m

i na t i on o f so m an

- e xposed an i m a l s wa s m uch s hor t e r : t h e L T 50 for deco n t a m i na t i on 24

wi t h RS D L w as fo u r m i nu t e s; t h i s r e f

l e c t s t he ra

p i d a g i n g ( i r r e v ers i b l e en z y m e i na c ti v a t i o n ) of so m an 25

spe c i f

i c a ll y

. I n ano t her i n v i v o s t udy of V X ex p os u re, d e c on t a m i na t i on o f do m

es ti c p i g s w it h soapy w a t e r 26

or d i lu t e b l ea c h w as l e s s e f fe c ti v e a t p r e v en t i ng dea t h a nd m iti g a t i ng s i g ns of se v ere i n t ox i c a ti on w hen 27

p e rf

o r m ed at 45 m

i n u t es t h a n at 30 m

i nu t e s po s t

- exposure ( B

j ar n aso n et a l ., 2 0 08). R e t ros p ec t i v e a na l y s i s 28

of c he m

i cal burn p a ti e n t s at t he B a l ti m ore R e g i onal B u rn C e n t e r f rom 1976

- 1985 de m

ons t r a t ed t h at 29

i n i t i a t i ng a w a t e r

- on l y w ash i ng of t he s i t e o f c he m i cal e x pos u re wi t h i n t hr e e m i nu t es s i g n i f

i ca n tl y r e du c ed 30

t h e e x t e n t of s k i n i n j u r y

, mean l en g t h of h os p it a l s t a y and de l a y ed co m p li c a ti o n s co m

pared t o t he 31

c ons e quen c es i n p a t i en t s w hose d eco n t a m i na t i on w as i n i t i a t ed l a t e r (M o ran e t a l ., 1 9 87; L eon ar d et a l., 32

1 982). 33

34

T he t i e r s of dec o n t a m i n a ti o n (s e l f

- care, g r o ss p a t i ent d econ t a m i na t i on a n d t ech n i c al p a t i ent 35

deco n t a m

i na t i o n ) a l l d i f

fer i n t h e a m

ount o f p r ep a

ra t i o n, ti m e, and re s our c es n ee d ed. E a r l y and 36

expe d i t i ous f o r m s of deco n t a m

i na t i on s ac r i f

i c e t h oro u g hness f

o r t h e s p eed wi t h w h i ch each can b e 37

i n s t i t u t ed. S e l f

- care, i n c l u d i ng re m

o v i ng onese l f from t he s ou r ce o f exp o su r e, w i p i ng che m i cal o ff t he 38

s k

i n and r e m

o v i ng con t a m

i na t ed c l o t h i n g

, m a y occur i ns t a n t l y , be ex e cu t ed by pa t i e n t s u s i ng w hat t hey 39

ha v e w i t h t he m , such a s a h and k erc h i ef or s c a

rf, and be per f

or m ed bef o re f i r s t r es p onde r s a r

r i v e. Gr oss 40

pa t i e n t de c on t a m i na ti o n m ay be exec u t ed by pro v i d i ng pa t i e n t s wi t h ra p i d a c ce s s t o a h i g h v o l u m e of 41

w a t e r , su c h as from a f i re h ose, i n an e f

fo r t t o qu i c k

l y ter m i na t e co n t a c t wi t h t

he c he m i cal c o n t a m

i na n t

. 42v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

33 L as t l y

, t ec h n i c al p a t i e n t d e con t a m i n a ti o n us u a l l y i n v o l v es sho we r i ng w i t h, i d e a l l y , soapy w a t er a nd a 1

w ash i t e m

, i n an ef f o r t t o r e m o v e an unabs o rbed che m

i cal t o a s l ow a l e v el as p os s i b l e, t h er e by 2

t er m

i n a ti ng f u r t h er d o s i n g. 3

4

T he i m

por t a nce o f r ap i d l y i m

p l e m en ti ng se l f

- care a n d g ross p a ti e nt d eco n t a m i na ti on i s des c r i bed by K i rk 5

and D e a t on (200 7 ) w ho l i k ened d eco n t a m

i na t i on t o a f

i r s t a i d p roc e du r e. M o ran e t a l . (1 9 87) a l s o eq u a t e 6

t he wa sh i ng of che m i cal b u rns wi t h c op i o us wa t er s t a rt i ng w it h i n t h r e e m

i nu t es of expos u re wi t h f

i r s t a i d. 7

S e v eral p r i or g u i d a nce d o c u m en t s des c r i be r ap i d l y i n i t

i a t i ng deco n t a m

i na t i on a c t i ons, s u ch as d i sro b i ng 8

( DO D T S W G

, 200 4 ; ECBC , 2009), as t he b est m eans of r ap i d l y red u c i ng co n ta m i n a ti on. 9

10v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

34 

### G u ida n ce S tat e me n t 2.4

A tt e m pt t o i m m ed i a t e l y d e cre a se o n g o i ng ex p osu r e by re m o v i ng a l l pa t i e n t s o ut o f t h e a r ea o f c h e m i cal

re l ea s e and pro v i de an a

rea of r e fu g e.

Considerations:

• F i r s t r esp o nde r s s h ou l d not en t e r c o n t a m i n a t ed a r e a s o f re l ea s e ( i .e., hot and wa rm z on e s) wi t ho u t

appro p r i a t e PP E and t

ra i n i ng

.

• A de t e r m

i na t i on of t h e su b s eque n t n e ed and l e v el of d e con t a m i n a ti o n m ay be dec i ded a c cor d i ng t o

cr i t e r i a i n G u i da n ce S t a t e m ent 1. 1

.

Level of Confidence: II

1

D i sc u s s i o n : 2

O ne of t he f i rst s t eps i n c o n t a m

i na t i on r edu c t i on i s t o t er m i na t e on g o i ng expos u r e by re m o v i ng pa ti e n t s 3

from t he h o t z one. S c i e n t if i c r e v i ew su b s t a n t i a t i ng t h i s f i r s t s t ep a m

ong pa ti en t s i s p r i m ar il y foc u sed on 4

t he e f

f ec t s a m ong f i r s t r es p onde r s and hos p i t al f i r s t r ec e i v ers. T he s t udy of t he 1 9 82 H ano v er C ou n t y

, 5

V i r g i n i a i n c i d ent ( i n v o l v i ng pen t ab o rane r e l e a se) r e c o m m ended t hat f

i r s t r e spon d ers “ back a w a y ” f r om a 6

scene (o n ce a ha z ardo u s m a t e r i a l s i n c i de n t h a d oc c ur re d) u n t i l ap p ro p r i a t e che m i c al p ro t ec t i v e c l o t h i ng 7

and r es p i r a t ory p r o t e c t i on i s donn e d ( H u ff,1 9 91). P r e v en ti ng con t a m i na t i on p r o t ec t s p e rson n el and 8

reso u r c es ( e. g ., a m bu l ance s , e m

er g ency depar t m

en t s ) f rom second a

ry con t a m i n a t i on ( K i rk e t

. a l , 19 9 4). 9

O ccup a ti o n al he a lt h and s a f e t y pr i n c i p l e s a l so j u s t i fy gu i da n ce t o i mm ed i a t e l y de c rea s e ex p os u re a m ong 10

pa t i e n t s. When e v a l u a ti n g m e t hods of c on t

ro ll i ng hu m an exp o su r es i n a w o r k p l a c e from w or k

p l ace 11

ha z ards, t he p a t h w ay for t h e ha z ard t o t ra v el from t he s o ur c e t o t h e r e c e i v er ( i .e., pa t i e n t

, f i r s t res p ond e r, 12

hosp i t a l f

i r st re c e i v e r ) r e qu i res e xa m i na t i on. I n a che m i c a l i n c i d en t

, t h e so u rce i s u ncon t ro l l ed ( a t l ea s t 13

i n i t i a l l y ) and m e t hods such as i so l a t i on o r ph y s i c al en cl osur e s a re n o t n e ce s sa ri l y pra c ti c al i n t he sho r t

14

t er m

. T h us, t he n ext l o c a ti on t o c on t r o l hu m an expo s ure i s t he p a t h w ay f rom source t o r ec e i v er. 15

I ncreas i ng ph y s i c a l d i s t an c e be t w een t he re l ea s e so u r c e and p eop l e an d / o r p l a c i ng peop l e i n a s afe r e fu g e 16

(e. g ., sh e lt e r

- i n

- p l ace ord e r at ho m e or w or k , or e v acu a ti on up w i nd an d / or up s t r ea

m from t he sourc e ) i s an 17

ef

f ec t i v e co n ti n g ency ( P l o g

, B

. A

., N il a n d, J

., Q u i n l an, P .J, N a t i on a l S a f e t y C ounc i l (1 9 96 )

. No 18

deco n t a m

i na t i on p ra c t i ce i s of u s e i f p e rf o r m ed i n an e n v i ron m

ent i n w h i ch p a t i e n t s wi l l c o n ti n u e t o be 19

expos e d. 20

21

D e t er m

i n i ng t h e s i z e of a n af

f ec t ed a rea, or t he e v acu a

ti on d i s t a n ce, i s m

ost o f t e n based on a g u i d el i ne 22

s uch a s t h e su gg es t ed e v ac u a t i on r ad i i r ef e re n ced i n t he 2012 DO T E m er g ency R e s ponse G u i deb o o k

. I n 23

an a t t e m

pt t o i ll u s t

ra t e t h e i nf

l u ence of t he n a t u re of a con t a m i na n t ( l i qu i d or v ap o r) on t he s i z e o f t h e h o t 24

z one, w h il e e s t a b l i sh i ng t h e F ren c h e m er g ency respon s e p l a ns, L a ure n t e t a l

. ( 19 9 9) e s ti m a t ed t h e l i k e ly 25

af

f ec t ed h o t z one b a sed o n t he ph y s i c a l pr o pe r t i es o f a che m

i cal t h r e a t

. I

t w as no t ed t h at a l i qu i d ha z ard 26

area ex t end e d 350 ft. d i a m e t er. O n t he o t h e r h a

nd, a v a por ha z a r d a

r ea

– w it h w i n ds <1 m

/ s

– r a r e l y 27

exce e ded a ra d i us of 1 700 f t. and ex t ended do w n w i nd i n a 2 0 o a rc. 28

29

P re s t on e t a l

. ( 200 8 ) exa m i ned 2,930 che m

i c a l i n c i d e n t s i n w h i ch d e con t a m i na t i o n w as i n f

r equ e n t

, 30

occu r

r i ng dur i ng on l y 1 0 % of t h e i n c i d e n t s. O f t he 2, 9 30 i n c i d e n t s , 7. 7 % r es u lt e d i n e v acu a t i on. W hen 31

con t

ro l l ed f o r de c on t a m

i na t i on, i t wa s d e t er m

i ned t h a t t hose i n c i de n t s i n w h i ch t h e re w as an e v ac u a t i on 32

res u l t ed i n fe w er patients p e r e v ent t han t h o se i nc i de n t s for w h i ch t h e re wa s n o t e v acu a ti on ho w e v er, t he 33

d i f

fe r en c e i n nu m

ber of patients w as o n l y s i g n i f i ca n t ( p <0.05) f

o r i n c i d en t s i n v o l v i ng g asses or v apo r s 34

(sp e c i f

i c a l l y , ch l o r i n e, a mm on i a, and a c i d g as s es). 35

36

Wh i l e re m o v al from on g o i ng exposure i n t he hot z one i s s uppo r t ed by se v eral ex i s t i ng g u i dance 37

docu m

en t s, i n c l ud i ng DO D T S WG (20 0 4), O S HA / E M S (200 9 ), and ECB C (200 9 ), t h e i d ea o f e v acu a t i on 38

as a d eco n t a m i na t i on s t ra te gy i s not d es c r i bed. S p e c i fi c r e fe r en c e i s m ade t o m o v i ng pa ti e n t s out o f t he 39

hot z one, p re f e r ab l y up w i n d of t he re l ea s e, t o a s afe r e fu g e w h i l e a d e c i s i on on d e con t a m i n a ti o n and 40

prep a

r a ti o ns f or d eco n t a m

i na t i on a re m ade ( ECBC , 2 0 09). 41v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

35 1

P a t i en t s m ay e v acua t e t h e m se l v es t o a l o c a t i on t hey fe e l i s s a fe a nd t h i s m ay occur pr i o r t o t h e a r r i v al of 2

f

i r st r e spond e rs. O n ce p a t i e n t s a re d i s t a n ced from t he p oss i b i l i t y of on g o i ng expo s ure, d e t e r m i na t i on o f 3

t he n eed for add it i on a l d e c o n t a m i na t i on m ay co m men c e. 4

5

H a v i ng pa ti e n t s g u i d ed t o w ards a l o ca t i on m ay ease t he e v a l u a t i on of l a

r g e nu m bers t o a sc e r t a i n t he ne e d 6

for d eco n t a m i na t i on, i s sua n ce of i n s t r uc t i o n s, and t o c o nduct dec o n t a m i n a ti on pr o c ess es

. H o w e v er, 7

expe r t s a l so con v e y ed t h e c once r n of i n c re a s i ng s e co n dary con t a m i na t i on w hen p a t i en t s a

re g roup e d 8

t o g e t h e r i n a l oc a ti o n b e fo r e dec o n t a m i n a ti on i s cond u c t ed. 9

10

L as t l y , as s e l f

- e v acua t i on i s li k

e l y , and s i n ce a p rop o r ti on of t ho s e r e t a i ned at t he s cene m ay u lti m a t e l y be 11

t o l d t hey do n o t req u i re de c on t a m i na t i on, co m m

un i ca ti on i s c r i t i c a l

. I

ns t r u c t i ons t

o pa t i e n t s w ho are not 12

deco n t a m

i na t e d, b u t h e l d a t t he s ce n e, m ust e m phas i z e appro p r i a t e f

o l l o w

- up m

easures. C o mm

un i ca t i on 13

t o t h ose w ho m ay h a v e a l r e ady l e f t and w ho su b sequ e n tl y e i t h e r ( 1 ) de v e l op s y m p t o m s, (2) beco m

e 14

w orr i ed a b out t h e i r o w n h e a l t h, or ( 3 ) a r e co n c e rned a bout e xpo s i ng fa m

il y m e m bers, i s j u s t a s i m

por t an t

, 15

s i n c e t h ey m a y request de c on t a m i na t i on o r o t h e r a s s i s t a nce from any nu m ber of d i ff

e re n t h e a l t h c are 16

fa c i l i t i es. T he s e and o t h er r i sk co m m un i ca t i on i ss u es a

re a d dr e ssed m

ore ex t en s i v e l y i n F u n c t i on a l A r e a 17

18v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

36 

### G u ida n ce S tat e me n t 2.5

C l o t h i ng re m

o v al for p a t i e n t s w ho h a v e been v i s i b l y c o n t a m i na t ed or w ho a

r e s u s p e c t e d of ha v i ng been

con t a m i n a t ed i s an e s se n t ia l as p e c t of deco n t a m i n a ti o n

. F or p a t i en t s w ho c an r e m o v e t he i r o w n c l o t h i n g

, i t c an be a p a

rt of se l f

- care. E ff o r t s sho u l d b e m ade t o co l l e c t and ac c ount f o r c l o t h i ng and p e rso n al

i t e m s re m o v ed dur i ng pa t i e n t de c on t a m i na t i on.

Considerations:

• I f c l o t h i ng re m

o v al i s t o b e condu c t ed ou t s i d e, be m i n d ful o f en v i ron m

en t al r i s k s a nd, i f ap p l i ca

b l e,

ensu r e w ar m

i ng or co o l i ng m

e t hods a r e a v a i l ab l e ( e. g

., w ar m i ng t en t

, i ndo o r l o c a t i on, sha d ed a re a ).

• S o m e pa ti e n t s m ay requ i re ass i s t ance w i t h re m o v i ng c l o t h i n g

.

• E nsure pro p er l e v e l s of m odes t y (e. g

., s e pa r a t e l i n e s f o r m a l es and fe m a l es and c ov er from b y s t and e rs;

cu l t ur a l a nd r e l i g i ous p ra c t i ces s hou l d be t a k en i n t o c o ns i d e r a ti o n d u r i ng p l a nn i n g ).

• C l o t h i ng and p e rso n al i t e m s sho u l d be han d l ed i n such a m anner t o ad d re s s t h e f o l l o w i ng p r i o r i t i e s :

o P ro t e c t i ng t he he a lt h and sa fe t y of p a t i e n t s, re s pond e rs and r ec e i v er s ;

o E v i dence c o l l e c ti o n f

o r l aw enf

o rce m en t ;

o C ons i s t e n cy w it h l o g i s t i c a l capa b i l i t i e s;

o Allo w patients to retain essential personal items (e.g., prescription eyeglasses, hearing

aids, canes);

o R e t ur n i ng v a l ua

b l es t o p a ti en t s i f pos s i b l e a nd s a f e ;

o A na l yz i ng c l o t h i ng for c on t a m i nan t s t o c o n f

i rm expos u re a n d / o r p r o v i de an e s ti m a t e o f

de g ree of ex p osu r e.

• B e a w are of t he p o t e n t i a l f o r co n ce a l ed seco n dary i m p r o v i sed ex p l o s i v e de v i c e s or o t h e r w ea p ons t h a t

m a y be h i dden i n c l o t h i ng or o t her pe r son a l i t e m s.

• P a t i en t s sh o u l d be a ll o w ed t o r e t a i n a f o rm of i de n t i f

ic a t i on t h at can w it h s t a nd t he deco n t a m

i na t i on

proc e ss (e. g

., l a m

i na t ed I D card or d

r i v e r ’s li c en s e, M e d i c

- a l e r t b r ac e l e t , “dog t a g s”) a n d w i l l n o t

re t a i n co n t a m

i na t i on i f a d e qua t e l y deco n t a m i na t ed.

• P ro v i s i o ns s h ou l d be i n p l a ce t o ac c o m m oda t e l aw en f

orce m ent e qu i p m

en t / w eap o ns.

• I f t he i n c i de n t i s s u spe c t ed t o be an i n t e n t i on a l a c t

, c l o t h i ng and p e rso n al i t e m s m a y beco m e e v i dence;

l aw e n fo r ce m

ent sh o u l d b e i nc o rpo r a t ed i n t o re s pon s e p l an n i ng t o d e v e l op S O P s f or c o l l ec t i ng

con t a m i n a ted m a t e r i a l a nd ensu r i ng ch a i n o f cu s t ody i n acc o rda n ce wi t h ( I A W) j ur i s d i ct i on a l

g u i dance

Level of Confidence: II

1

D i sc u s s i o n : 2

Q uan t i t a ti v e c l a i m s ha v e been m ade fr e que n t l y i n t he l i t e r a t u re a bo u t t h e e f

f i cacy of c l o t h i ng re m

o v al i n 3

redu c i ng co n t a m i nan t s on a pa t i e n t

. I

t i s o f t e n s t a t ed t

h at r e m o v i ng c l o t he s m ay reduce c on t a m i na ti o n on 4

a pe r son by ap p rox i m a t e l y 80

- 90% ( C ox, 199 4 ; K oe n i g , 2003). R e f er e nc e s a r e s o m

e ti m es i nc l u d ed a n d 5

au t h o rs seem t o i m p l y t hat t here i s e v i den c e t o supp o rt t h i s qua n t i t a ti v e c l a i m

. H o w e v er, c i t ed re f er e nc e s 6

usua l l y re p eat t he sa m e es ti m a t ed per c en t a g e of c o n t a m i nan t s r e m

o v ed t hrou g h d i sr o b i ng w i t hout 7

des c r i b i ng any e v i dence. I n fa c t

, t h e re i s c u r r en t l y no pub l i sh e d s t udy t h a t d i re c t l y e v a l ua t es t he que s t i on 8

of how m

uch con t a m

i na t i o n can b e re m

o v ed from a p e rson a f

t er che m i c a l e xp o su r e by re m

o v i n g t he 9

pers o n’s c l o t h i n g

. S uch a s t udy cou l d be p er f or m ed by expo s i ng hu m an su b j e c t s t o a che m

i c a l s i m u l an t

, 10

or by expo s i ng m annequ i ns or l abo r a t o ry an i m a l s t o a t ox i c che m i ca l

, and m

eas u r i ng con t a m

i nant l e v e l s 11

bef

o re a n d a f t e r c l o t h i ng r e m

o v a l

. T he S t a

nd a rd T e s t Me t h od f

or Man

- I n

- S i m u l ant T e s t ( M I S T ) f

or 12

P ro t e c t i v e E nse m b l es ( A S T M F 258 8

- 06) co u l d p ro v i d e a u s ef u l s t a rt i ng po i nt f

o r such s t u d i es. T he 13

res u l t s a

re l i k e l y t o v ary d e pend i ng on t he spe c i f i c ch e m i ca l

, i t s ph y s i cal s t a t e ( i .e

. , s o l i d, li q u i d, v ap o r or 14

g as), t he m e t hod of d i s pe rs a l , a n d t h e c l o t h i ng be i ng w orn. 15

16

T h e re i s co m pe l l i ng i nd i re c t e v i de n ce t o su gg est t h at c l o t h i ng shou l d be r e m o v ed from a pa t i ent w h o has 17

been e xpos e d t o a c h e m i cal i n o r der t o m

i n i m i z e t he a m

ount of co n t a m

i nant t h a t m a y po t en t i a l l y be 18

abso r

bed. S e v eral s t

ud i es h a v e de m

ons t r a t e d t h a

t c l o t h i ng abso r

bs a n d r e t a

i ns ch e m i ca l s t o w h i c h i t h as 19

been e xpos e d. I n an i n v i tr o s t udy t h at m

eas u red t he a

m ount of l i qu i d co n t a m

i na n t ab s or

b ed by fa b r i c

- 20v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

37 co v ered hu m an s k

i n, C s i s za r et a l

. (19 9 8) rep o r t ed t hat t he fa b r i c s a b sor b ed m

ost o f t h e ap p l i ed 1

con t a m

i na n t ( 8 5

- 95%) and re t a i n ed i t f or at l e a st e i g ht hours, r e su l ti ng i n abs o r p t i on t h rou g h t he s k

i n of 2

on l y a v ery s m a l l a m ount of t h e co n t a m

i na n t (0.1

- 0.2%). F e l d m an (2 0 10) a l s o p ro v i ded e v i d ence t h a t 3

c l o t h i ng ab s or b s and r e t a i n s che m

i c a l s, b u t a d d i ti o na l l y d e m ons t r a t ed t h a

t s i g n i f i c ant o ff

- g ass i ng can 4

occu r

. I

n t he F e l d m an ( 2 0 1 0) s t ud y , a v ar i e t y of c i v il ia n c l o t h i ng ar t i c l es we re ex p osed t o t he c h e m i cal 5

a g ent s i m

u l a n t m e t h y l s a li c y l a t e, w h i ch h as s i m il ar p hy s i cal p ro p e r ti e s t o s u l f u r m us t ard, i n v apor f

or m. 6

7

A f

t e r t h e ex p os u re w as t er

m i na t ed, m e t h y l s a li c y l a t e v apor w as d e t e c t ed ne a r ea ch a r t i c l e of c l o t h i n g

. 8

O ff

- g ass i ng con t i n u ed f

o r s e v eral m

i nu t es l on g er f

o r h ea v i er c l o t h i ng (e. g

., j ac k e t s and s w ea t e r s) t han 9

t he few m

i nu t es no t ed f

or li g h t er c l o t h i ng (e. g

., j eans and t

- sh i r t s), su gg es ti ng t h a t p ati en t s and 10

res p ond e rs m a y rece i v e ad d i t i o n al ex p osure f r om c l o t h i ng t h a t i s not r e m o v ed and i s o l a t ed af

t er 11

exp o sur e

. T w o o t her s t u d i es supp o rt t he co n ce p t t h a t c l o t h i ng pro v i d e s so m e pro t e c ti on f

o r i t s we ar e r 12

by red u c i ng che m i c a l abso r p t i on t hr o u g h hu m an s k

i n; ho w e v er, so m

e s k i n absor p t i on s t i l l o cc u rr e d 13

f

r o m t he con t a m

i n a t ed fab r i c s ( c o t t on s he e t s a nd f abr i c o f m

ili t ary un i for m s) i n t h i s i n v i t ro 14

e xp e r i m

en t a l s y s t e m

. T h i s add i ti o na l l y supp o r t s t h e p o t e n ti a l b e ne f i t of co m p l e t e c l o t h i ng re m

o v al as 15

o p pos e d t o o v er

- re l i an c e on s t r eet c l o t h i ng t o p ro v i de si g n i f i c a nt p r o t e c ti o n f

rom che m i cal e x pos u re 16

(W e s t er e t a l ., 199 6 ; W e s t er et a l

., 2 0 00). 17

18

S i m

u l a t ed sec o nd a

ry expo s ure o f ho s p i t al

- based re c e i v ers t o c h e m i cal v apo r s a n d dust from c l o t h i ng on 19

che m

i ca l l y con t a m

i n a t ed m anneq u i ns pro v i d e s e v i de n c e t h a t r ec e i v ers can b e a t r i s k of rec e i v i ng 20

dan g erous d os e s of che m i c al c o n t a m

i na n t s d u r i ng p a t i ent d eco n t a m i na t i on ( S ch u l t z et a l ., 19 9 5). 21

C oncen t

r a t i ons o f v apor o r par t i c u l a t e che m i cal co n t a m i nan t s i n t h e b r ea t h i ng z ones o f t w o re c e i v ers per 22

“pa t i e n t ” we re m easu r ed b e fore and d

u r i ng c l o t h i ng r e m

o v al from a con t a m

i na t ed m annequ i n. W hen t he 23

m

eas ured l e v e l s o f t h e r e l a t i v e l y har m

l ess c h e m i ca l s u sed i n t h e s t udy w ere e x t r a po l a t ed t o h i g h l y t ox i c 24

che m

i ca l s

, t h e e s ti m a t ed c o ncen t r a ti o ns we re h i g h en o u g h t o cau s e se v e r e h e a l t h ef f ec t s i n r e c e i v ers n o t 25

w ear i ng appro p r i a t e PPE

. T h e se res u l t s su gg est t h a t c l o t h i ng on co n t a m

i na t ed p a ti e n t s can p ut p a t i e n t s, 26

resp o nd e rs a n d r e c e i v ers a t r i sk of t o x i c i t i es from che m i c a l co n t a m

i na n t s. 27

28

R epor t s o f s e cond a ry con ta m i na ti on o f r espo n de r s or r ece i v e r s a l so i n d i r e c t l y su p port t he reco mm enda ti on 29

t h a t c l o t h i ng be re m o v ed from con t a m

i na t ed p a t i en t s. I n one of t he m ost c i t ed c ase s , 13 of t h e 15 30

p h y s i c i ans w ho t r ea t e d p a t i en t s i n a T o ky o e m er g ency depar t m

en t , a f t e r t he s a r i n re l ea s e on sub w ay t r a i ns 31

i n 1 995, e xp er i enc e d s y m p t o m s of s a

r i n expos u re. S i n c e no n e of t h e pa t i e n t s we re deco n t a m i na t e d, i t h a s 32

b e en dedu c ed t h at t he ph y s i c i a n s w ere exp o sed t hr o u g h of f

- g ass i ng of sa r i n from t he p a t i e n t s’ c l o t h i ng 33

( N o z a k

i et a l ., 199 5 ). 34

35

E x i s ti ng g u i dan c e docu m e n t s r e v i e w ed i n t he c ro s s w a l k ana l y s i s r eco mm end t he r e m

o v al of c l o t h i ng f

or 36

any person sus p e c t ed o f h a v i ng been expo s ed t o a c h e m i cal ( HH S A T S D R

- E D , 2000; HH S A T S D R

37

E M S

, 200 0 ; DO D T S W G

, 2004; O S H A

- FR , 2005; C A L

- O ES , 2006; ECBC , 2 0 09; O S H A

- E M S , 2009). 38

S o m

e of t he d o cu m

en t s, s u ch as t he ECB C ( 200 9 ) g u i dance, a l so p r o v i de s p e c i f i c i n s t r u c t i ons on how 39

c l o t h i ng sho u l d b e r e m o v e d

. T h e r e i s s t

rong exp e r i m

en t a l w ork and o t h e r i n d i re c t e v i dence t h a t s uppo r t s 40

t he c onc e pt t h a t c l o t h i ng r e m o v al m a y e li m

i na t e a s i gn i f

i ca n t a m ount o f a c he m

i c a l co n t a m

i nant f rom a 41

pa t i e n t

, t h er e by redu c i ng t h e po t en t i a l f o r a d d i ti o n al a b sor p ti o n by t he p a t i e n t , as w e l l as t he p o t e n t i al for 42

secon d ary co n t a m i na t i on o f res p ond e rs, re c e i v ers, o t h e r peo p l e, eq u i p m ent or fa c i l i t i es. T he d a t a, cu r re n t 43

pra c t i ce, a

nd S ME con s en s us j u s t i f

i es a L O C r a ti ng of II

. We l l d e s i g ned and c on t ro l l ed c l i n i cal t

r i a l s 44

and / o r f

i e l d r es e ar c h t o d i r e c tl y t e st t he e f f i cacy of c l o t

h i ng re m o v al i n r e du c i ng pa t i ent co n t a m i na t i on, o r 45

on o t h er o u t co m es, a re n e e ded t o sub s t a n t i a t e co mm o n l y m ade asse r

ti o ns. I n t he m ean ti m e, t h i s g u i d an c e 46

doc u m

ent end o rs e s c l o t

h i n g re m o v al as an i m

por t a n t deco n t a m

i na t i on s t ep t h at c an be p e r for m ed w it h out 47

equ i p m

ent o r su p p l i es and i n m any cases, w it h out t he a ss i s t a nce o f r esp o nde r s. 48

49v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

38 

### G u ida n ce S tat e me n t 2.6

P r i v acy for p a t

i e n t s sho u l d be i n cor p or a t ed t h rou g ho ut t he d eco n t a m i na t i on p ro c e s s, w i t h i n t he re s ou r ce

li m it a ti o ns o f t h e r espon d i n g or rec e i v i ng or g an i z a t i on, t o i nc l ud e :

• P r i v acy dur i ng c l o t h i ng r e m o v al

• S e g re g a ti on o f m a l es a nd fe m a l es du r i ng deco n t a m i na ti on

• Ma t e r i a l s f

or red r es s i ng f

o l l o w i ng dec o n t a m i n a ti on

Considerations:

• R espon d i ng and r ec e i v i ng or g an i z a t i ons m ust b a l a n ce conc e rns su r

roun d i ng pa t i e nt p r i v acy and t h e

ur g ency of dec o n t a m

i n a ti o n nee d s.

• F a m ili es, i n c l u d i ng ca r e t a k

ers, sho u l d be per m

i t t ed t o re m a i n t o g e t h er d u r i ng t he d eco n t a m

i na t i on

proc e ss.

• P a t i en t s an d

/ o r t h e i r f a m il y m e m bers m a y not be co m

f o r t a b l e w it h t h e p a ti e nt b e i n g decon t a m i na t ed

by s t a f f of t he oppo s i t e g ender.

• A ll o w a n ces for t h ese conc e rns m ay not be ap p ro p r i a t e i n a l i fe o r d e a t h s i t u a ti o n.

Level of Confide nce: IV

1

D i sc u s s i o n : 2

P r i v acy i s n o t d i r e c t l y re l a t ed t o a p a t i en t ’s m ed i c a l o u t co m

e; ho w e v er, e f

f o r t s t o pro v i de p r i v acy m a y 3

enhan c e p a t i ent co m p li a n ce w it h reco mm

ended deco n t a m

i na ti on pr a c t

i c e s, w h i ch can i n f

l ue n ce p a t i ent 4

ou t co m

e. A n a s se s s m

ent of s i m u l a t ed p a t i e n t s ’ p e rce p ti o n s d u r i ng f i e l d ex e r c i s e s i n v o l v i ng m ass pa t i e n t 5

deco n t a m

i na t i on i n t he U n i t ed K i n g dom re v ea l ed t h a t l ack of p r i v acy w as a co m m on con c ern. I

n 6

feed b ack from a t o t a l of 4 0 2 pa r t i c i p an t s i n f i v e e x e r c i ses, req u es t s f

o r g re a t e r p r i v acy dur i ng v ar i ous 7

aspe c t s of t he d eco n t a m i na t i on p roc e ss we re s ub m itt e d

. S o m

e par t i c i p an t s ex p l a

i n ed t h at t hey f

e l t 8

e m

barras s ed d u e t o t he l a ck of p r i v acy and one pe r son ref u sed t o b e de c on t a m

i na t ed be c ause of m

odes t y 9

( C a r t er et a l

., 201 2 ). 10

11

E v i dence from ac t u al i n c i d en t s

– ba s ed on ne w s rep o r t s , a f t e r a c t i on r epo r t s, and a

necd o t es

–

de m ons t ra t es 12

t h a t w hen p a t i e n t s p er c e i v e t h a t t h ey ha v e not b e en a ff o rded su f f i c i e n t p r i v ac y

, t h e y m a y expre s s 13

d i s s a t

i s fa c ti o n w i t h t h e d ec on t a m i na t i on p ro c ess or t he o v er a l l w ay t hey w ere t r ea t ed by resp o nd e rs o r 14

rec e i v ers. I n t he sus p ec t ed b i o l o g i cal and che m i cal i n c i de n t a t B ’ n ai B ’ r i t h He ad q uar t e r s i n W a sh i n g t o n

, 15

D C i n 1997, so m e po l i ce o f

f i c ers w ho w e r e i n s t

ru c t ed t o und e r g o deco n t a m i na t i on i n i t i a l l y ref

u sed, and 16

t en s io n s en s ue d b e t we en p o li c e and E MS p er s onn e l , d u e t o t he li v e b road c a s ti ng of p i c t u r es o f t h e 17

i n c i de n t s c ene from ne w s c a m eras on t op of a n e ar

b y b u il d i ng ( U n i t ed S t a

t es F i r e A d m

i n i s t r a t i on, 1 9 97). 18

I n s o m

e cases, l a w s u i t s ha v e been f i l ed a g a i n s t e m

er g ency respo n se o r g an i z a t i ons a l l e g i ng t hat pa t i e n t s ’ 19

pr i v acy and o t h e r r i g h t s we re v i o l a t e d du r i ng deco n t a m i na ti on, for w h i ch t hey w ere req u es t ed t o d i sr o be 20

i n v i ew of re s pond e rs o f t h e oppo s i t e g ender an d / or b y s t an d e r s ( G ong et a l

., 199 6 )

. A necd o t es su gg est 21

t h a t p a ti e n t s m ay bec o m e upset i f se p ar a t ed f

r om fa m il y m e m bers du r i ng deco n t a

m i na ti o n

. F u r t her m

ore, 22

pare n t s m ay fear t h a t t he p r i v ac y , saf e t y and w e l fa

r e of t h e i r c h i l d r en a

re n o t a d e q

ua t e l y pro t e c t ed i f t hey 23

are c a r ed f

o r by r e spond e rs of t h e opp o s i t e g end e r d u r i ng decon t a m i n a ti o n

. D u r i n g a dr i n k

i ng w a t er 24

con t a m

i n a ti o n i n c i d ent i n S penc e r, MA i n 2 0 07, l oc a l f i re dep a r t m en t s on l y con du c t ed dec o n t a m i n a ti on 25

w it h res p onse pe r sonn e l o f t he s a m e g ender as t he p a ti en t s. H o w e v er, an i ns u f f i ci ent nu m

ber o f f e m a l e 26

pers o nn e l w e r e de p l o y ed t o t he i n c ide n t

, res u l t i ng i n d e l a y s i n d eco n t a m i na t i on o f fe m a l e p a t i en t s and 27

fe m a l e p e rson n el ha v i ng t o w ork l on g er s h i f t s t han m a l e pe r sonn e l ( FE M A , 20 0 7). 28

29

P ro v i d i ng f o r p r i v acy dur i n g decon t a m i na t i on req u i r es reso u r c es. C u r t a i ns or b a r r i e rs t o s e g re g a t e peop l e, 30

a t l ea s t by g ender i f not by i n d i v i du a l , c a n a ll o w for p ro t e c ti on of m odes t y

. I n a case s t udy of t

he 31

ef

f ec t i v ene s s of h os p i t al

- based p a t i ent dec o n t a m i n a ti o n du r i ng a s i m

u l a t i on, 83% of su b

j e c t s re p o r t ed t h a t 32

t hey f

e l t t hey w ere pro v i d e d a h i g h l e v el of m ode s t y pro t e c t i on w h i l e u s i ng a f i x e d deco n t a m

i na t i on 33

sho w er se t up wi t h m u lt i p l e cur t a i n s ( H o o d e t a l ., 201 1 )

. I f s o m e t y pe of s i m

p l e c l o t h i n g , such a s hos p i t al 34v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

39 g ar m en t s, or b l an k

e t s or s h ee t s

, w i t h w h i ch p a t i en t s c a n c o v er up a

re a v a il a b l e

, t h i s m ay not on l y he l p t o 1

m a i n t a i n p r i v acy but a l so p ro v i de so m e co m for t

, pos si b l y m

iti g a ti ng ne g a ti v e ps y cho l o g i c al conse q uen c es 2

res u l t i ng fr o m a pa ti e n t ha v i ng been i n v o l v ed i n a t rau m a ti c m ass e xposu r e i nc i de n t ( H o l l o w a y , 1997; 3

D i G i o v a nn i , 1 9 9 9; F e t t e r , 200 5 ). 4

5

D ocu m

en t a t i on o f t h e i m

por t a n ce o f p ro t ec t i ng pa t i e n t pr i v acy du r i ng deco n t a m i na t i on i s i n ade q

ua t e. 6

T h e re i s l i t t l e e v i den c e i n t he s c ie n t i f i c l i t er a t u r e de m

ons t ra t i ng t h a t p ro t e c ti on of pr i v acy i n f l u e nc e s 7

pa t i e n t ou t co m e or co m p li a nce. H o w e v er, f

i n d i n g s f r o m ac t ual i n c i de n t s a nd e x e r c i s e s su gg est t hat t h e 8

l e v el o f p r i v acy pro v i ded t o pa t i e n t s d u r i ng decon t a m i na t i on c a n s i g n i f

i ca n tl y i n f

l u ence t h e i r co m

fort a nd 9

ps y cho l o g i c a l we l l

- be i ng and po t en t i a ll y t h e i r co m p li a nce wi t h t he p roc e ss. S e v en of t he e i g ht c u r r ent 10

g u i dance d ocu m en t s i n c l u d ed i n o ur cro s s w a l k an a l y s i s re c o m m end t hat pa t i e n t s ’ pr i v acy be m a i n t a i ned 11

as r e so u rc e s a l l o w

. S M E s unan i m ous l y supp o r t ed t h i s g u i dance s t a t e m ent w h il e e m

phas i z i ng t he 12

i m

por t an c e of not de l a y i ng ur g en tl y n e e ded d eco n t a m i na t i on f or t he p urp o se o f w a i t i ng for m a t e r i a l s or 13

equ i p m

ent t o p ro v i de p r i v a c y

. 14v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

40 

### G u ida n ce S tat e me n t 2.7

I n t he absen c e of sp e c i f

i c i nfor m a ti o n ab o ut t he con ta m i nan t

, w a t er i s t he p re f

e rr ed de c on t a m

i nant i n t h e

case t h a t g ross pa t i e n t a nd / o r t ech n i c a l p a t i ent de c on ta m i na ti on i s d ee m

ed appr op r i a t e.

Considerations:

• D epend i ng on t he deco n t a m i na ti on s y s t e m

, w a t er p a

r a m e t ers (e. g

., pr e ss u r e, f

l o w and t e m

per a t u re)

m a y or m a y not be e a s i l y m an i p u l a t ed.

• Wa t er

- based d e co n t a m i na ti on m ay be con t r a i n d i c a t ed or d e l a y ed due t o con c erns for we a t h er

- re l a t ed

and / o r en v i ron m

en t al i n j u ri es, s u ch as c o l d w e a t h e r i n j ur i e s a n d he a t i l l ne s s ( see a l so G u i da n ce

S t a t e m ent 2.11 for a l t e r na ti v e prac t i c e s).

o F or a m b i ent t e m per a t u r es b e t w een 36

- 64° F

, i ndoor m e t hods f o r w a t er

- based

d e con t a m i n a ti o n shou l d be c on s i d e red a nd i n door p o st

- decon t a m i na t i on ac t i v it i es s hou l d

be i m p l e men t e d 11

.

o F or a m b i ent t e m per a t u r es a t and b e l ow 35° F

, w a t e r

- based d e co n t a m i na t i on s h ou l d on l y be

condu c t ed i nd o ors (e. g ., s h o w ers a nd s w i m m i ng poo l s at g y m s, schoo l s or o t h e r f ac i l i t i es)

and

i ndo o r po s t

- decon t a m

i n a ti o n ac t i v i t i es sho u l d be i m p l e m en t ed.

• Wa t er u sed for dec o n t a m i n a t i on m ay be su b

j e c t t o l o c al o r s t a t e en v i r on m ental r e g u l a ti o ns r e g ard i ng

s t o r a g e and d i sp o s a l ( s ee G u i da n ce S t a t e m

ent 5. 8 ).

• T he e f f i cacy of d eco n t a m

i n a t i on m ay be i m

pro v ed by t he ad d i t i on o f m il d s o ap t o w a t er ( S ee

G u i dan c e S t a t e m

ent 2.9).

• Wa t er

- based d e co n t a m i na ti on sho u l d be a v o i ded w h en w a t e r

- reac ti v e c h e m i ca l s a re i n v o l v ed.

Level of Confidence: I

1

D i sc u s s i o n : 2

A v ar i e t y of d eco n t a m i na ti on so l u t i ons ha v e been de m ons t ra t ed t o e it h er s i g n i f

i ca n tl y re d uce t he a m

ount 3

of a c on t a m

i nant on s k

i n or m iti g a t e ad v e r se h e a l t h e f

f ec t s and t h e r e for e , be u se f u l as d eco n t a m

i na n t s. 4

Many of t he s e s o l u t i o n s a r e w a t e r

- based but con t a i n an add i ti o nal i n g re d i e n t s u ch as s o ap. S t ud i es t h a t 5

ha v e ass e ssed w a t e r a l one a s a d e con t a m i nant are r e l a t i v e l y li m

it ed. N e v er t he l ess, a s i g n i f i c a n t a m ount of 6

d a t a d e m

ons t r a ti ng t h e e ff

i cacy of wa t e r a l one as a deco n t a m i nant has b een pu b l i shed . A l a r ge prop o r t i on 7

o f t h e d a t a h as b een co m p i l ed f rom che m i cal bu r n c a ses, usu a ll y an ac ci den t a l e xpos u re o f a pers o n t o a 8

c a us t i c che m i c a l i n t he w o r

k p l a c e or ho m

e. R e t r o sp e c t

i v e an a l y ses of such c as e s ha v e f o und t h a t p a ti e n t s 9

w hose s k

i n wa s r i nsed w i t h co p i ous w a t e r w it h i n m i nu t e s of exp o su r e exp e r i enc e d l ess se v ere i n j u r i es a nd 10

n e eded l ess e x t e ns i v e m ed i c a l c a re t han p a t i en t s w ho w e r e n o t deco n t a m i na t e d wi t h w a t er sh o r t l y af t er 11

e xpos u r e ( L e o nard et a l

., 198 2 ; M o ran e t a l ., 1 9 87). H a l l and Ma i b ach (2 00 6 ) condu c t ed an e x t e n s i v e 12

r e v i ew of t he l i t e r a t u re o n w a te r de c on t a m i na ti o n of che m

i cal b ur n s, i n c l u d i ng occup a t i on a l r epo r t s, 13

ep i d e m

i o l o g i cal s t u d i es, ca s e r e p or t s and an i m al e x pe r i m en t s. T hey con c l ud e d t h at ea r l y w a t er 14

deco n t a m

i n a ti o n red u ces t he se v e r it y o f c h e m i cal b u rn i n

j u r i es, a l t ho ug h i t do e s not pre v e n t a l l har m ful 15

e f

fe c t s a nd a d d i ti o n al d eco n t a m i na t i on so l u ti o n s an d

/ o r s t r a t e g i es a r e n eeded. 16

17

I n t w o s t ud i e s u t i l i z i ng h u m an sub j e c t s, a w a t e r s h o w er s i g n i f i ca n tl y r e duc e d l e v e l s o f s i m u l at e d che m

i c a l 18

con t a m

i na n t s o n t h e su b

j e c t s. A w a t e r

- on l y sho w er i n t he f i r s t s t a g e of a ho s p i t a l d econ t a m i na t i on s y s t em 19

a l m

ost co m p l e t e l y re m

o v ed t he re l a t

i v e l y w a t e r

- so l ub l e e t h y l l a c t a t e (a s i m u l ant f or s a r i n) a nd a l so g rea tl y 20

r e duced t h e a m ount of t h e l ess wa t e r

- so l ub l e me t h y l s a l i c y l a t e (a s i m u l a n t for su l fur m

us t a r d ) on su b j e c t s 21

( T o rn g ren et a l

., 1 998). Mo f f e t t et a l

. (201 0 ) found t h a t an o i l

- based s i m

u l a n t ap p l i ed t o su b

j e c t s’ 22

fo r ear m s w as co m p l e t e l y re m

o v ed from a l l s ub

j e c t s by a wa t er sho we r of 90 se c onds d ur a t i o n and f rom 23

90% of su b j e c t s w it h a sho we r of on l y 30 se conds d ur a t i on. T h i s res u l t i s c o n t rary t o t he h y po t he s i s t hat 24

o i l y che m

i cal a g en t s r equ i re soapy w a t er or an o t h e r s o l u t i on f o r e f fe c ti v e deco n t a m

i na t i on. H o w e v e r

, t he 25

app l i c ab i l i t y of ex p e ri m en t s on dec o n t a m

i n a ti o n of s i m

u l an t s t o i n c i de n ts i n v o l v i ng t ox i c i nd u s t r i al 26

11 T h e t e m

p era t u re ra n g e s list ed i n t h i s G u i d a n ce St a t e m e n t a r e b a s ed o n e x ist i n g E C B C ( 2009 ) gu i d a n ce, t he lit era t u re

re v i e w

, a n d S u b

j ect Ma tt er E x p ert ( S ME) i n p u t du r i n g t h e 201 2 s ym po s i u m.v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

41 c he m i ca l s o r c h e m

i cal wa r fa re a g en t s i s n o t c l e a

r. 1

2

A se r i es o f i n v i v o s t u d i es of d e con t a m i na t i on e f f i c i e n cy for se v e r al d i f

f e re n t i n d u s t r i a l c h e m

i cal 3

con t a m

i na n t s app l i ed t o t he s k

i n of rhes u s m

on k e y s s u g g est t h at wa sh i ng wi t h wa t er a l o ne c an 4

r e m

o v e a s i g n i f

i ca n t p rop o r t i on o f t h e i n i t i a l a m ount of co n t a m

i nant ( W es t er et a l

., 1 991; We s t er 5

et a l

., 199 2 ; We s t er et a l

., 199 9 ). D ec o n t a m i na t i on e f f i c i e n cy w as depen d ent on t h e s p ec i f i c 6

c he m

i cal c o n t a m

i na n t and t h e t i m

e af t er c he m i cal expos u re. G l y phosph a t e, a re l a t i v e l y w a t e r 7

so l u b l e h e r

b i c i de, wa s t h e m

ost a m enab l e t o re m

o v al w it h w a t e r

, w h i l e a l a c h l o r ( a l so an 8

h e rb i c i d e) a nd m e t h y l e n e b i s phen y l i soc y an a t e, w h i ch a re m uch l e ss wa t e r

- so l u b l e, we re m ore 9

re s i s t a n t t o wa t e r d e co n t a m i na t i on. T h e e f

f i c i ency of w a t er dec o n t a m i n a ti o n of e ach o f t h ese 10

t h r ee c he m i ca l s de c re a sed a s t he d e l ay f o l l o w i ng che m

i c a l expos u re i n c re a sed, a l t hou g h m ore 11

t han o n e

- t h i rd o f t h e i n i t i a ll y app l i ed a m ount w as s t i l l r e m

o v ed w it h deco n t a m

i na t i on c ondu c t ed 12

se v er a l ho u rs a f t er e xpos u r e. I

t shou l d b e n o t ed t h a t d econ t a m i na t i on w as condu c t ed i n t he s e 13

s t u d i es by w ash i ng t he s k i n w it h c o tt o n t h at h ad b e en we tt e d w it h wa t e r; s k i n w as w i ped m

u lt i p l e 14

t i m

es w it h t he w et co t t on. T h i s pr o ce d ure d i f fe r s f rom t he sho w e r i ng used i n so me o t h e r s t u d i es. 15

16

F i n a ll y

, t he r e su l t s o f s e v e r al i n v it r o s t ud i es, u s i ng d if fe r ent exp e r i m

en t a l s e t u p s, l end supp o rt t o wa t e r as 17

an e f

fe c ti v e d eco n t a m

i nan t

. F or m a l deh y de w as reco v e red f rom hu m an cada v e r s k

i n by w ash i ng wi t h 18

w a t er w i t h an e f f i c i e n cy t h a

t w as h i g h at o n e m

i nu t e p o s t

- exposure but de c li n ed wi t h i n c r ea s ed 19

deco n t a m

i na t i on d e l ay ( Z

hai e t a l ., 20 0 7). Us i ng a m odel d eco n t a m

i na t i on sho we r, R e i fe n

r a t h and 20

co l l ea g ues ( R e i fe n r a t h, 19 8 0; R e i fe n

r a t h e t a l ., 19 8 4) a ch i e v ed s i g n i f i c a nt d eco n t a

m i na ti on o f p i g and 21

hu m an cada v er s k i n t hat h a d been con t a m

i na t ed w i t h d i e t h y l m a l ona t e, t h i c k ened d i e t h y l m a l ona t e

, so m an 22

or t h i c k

ened so m an, by sho w er i ng t h e s k i n wi t h w a t e r a l one. De co n t a m i n a ti on e f f i c i e ncy v a

r i ed 23

depen d i ng on se v e r al fa c t o r s, i n c l u d i ng w a t e r p r es s ure and t e m pera t u re, s ho w er d u ra t i on, and t he s pe c i f i c 24

con t a m

i na n t

. 25

26

T o g e t h er, t he s t u d i e s d e sc ri bed abo v e b u il d a c ase t h a t w a t er has g ood e f

f i c acy i n r e m

o v i ng con t a m

i nan t s 27

from s k

i n and m iti g a t i ng c h e m

i cal co n t a m

i na n t

- i nduc e d i n

j u r i es. T he d a t a a r e ba s ed on a v a r i e t y of 28

che m

i cal con t a m

i nan t s and spe c i f

i c d eco n t a m

i na t i on me t ho d s, s u ch as t h e p a ra m e t ers d e t er m

i n i ng how 29

w a t er i s ap p li e d t o s k i n. W a t e r h a s se v er a l a dd i ti o nal a d v an t a g es t h at m a k e i t t he pre f

e r red deco n t a m

i nant 30

f

o r g ross a n d t e c hn i cal pa t i e n t d eco n t a m i na ti o n : w i d e a v a i l a b i l it y

, l ow c o s t

, s t a b i l i ty under a w i d e r a n g e 31

of en v i r on m en t al c o nd i ti o ns, e ase o f s t ora g e, a n d s a f e t y

. A l l o f t he e x i st i ng g u i dance docu m en t s i nc l uded 32

i n t he cro s s w a l k an a l y s i s reco m m ends wa t er as a de c on t a m i na t i on s o l u t i on. 33

34

When con s i d e r i ng u s i ng w a t er as a dec o nta m i na n t

, f i r st res p ond e rs a nd f

i r st re c e i v ers n eed t o be co g n i z ant 35

of t he r i s k s. W at er

- based de c on t a m i na ti o n c onduc t ed o u t do o rs m ay i n t r oduce r i sk from w ea t h e r

- re l a t ed 36

i n

j u r i es i n c l ud i ng co l d w e a t h e r i n j u r ie s ; h e at i l l n e ss m ay a l so be a conc e rn i f p a t i e n t s r e m a i n ou t s i d e, 37

u n sha d ed o n a hot day for pr o l on g ed p er i o ds fo l l o w i ng de c on t a m i na t i on. T h e A m

er i can C onfe r en c e of 38

G o v ern m

en t al I ndus t r i a l H yg i en i s t s ( A C G I H ) pu b li s hes annu a l T h resh o l d L i m i t V a l u es ( T L V ) g u i d e li n es, 39

w h i ch i n c l ude g u i dan c e on c o l d i n j u ry pre v en t i on p r a c ti c es ( A C G I H , n.d. )

. H y po t her m i a i s a s e r i ous c o l d 40

i n

j u r y ; t he r i sk of w h i ch i nc r ea s es w h e n peo p l e are e xposed t o wa t e r and l e f t t o re m a i n we t ( e v e n i n f a i r l y 41

t e m

pera t e co n d i ti o ns s uch as 75 o F ). T h i s i s p a r t i cu l a r l y t rue o f c e r t a i n pa t i e n t s

– such as t he v ery y oung 42

and v ery o l d

– w ho m a y be susce p t i b l e t o h y p o t her m i a e v en w hen hea l t hy adu l t s t y p i c a ll y w o u l d n o t be 43

due t o t he i r b o dy co m pos it i on ( i n fa n t s) and i m

pa i red t her m

ore g u l a t i on ( t he e l d e r l y ). T he U S D ep a r t m ent 44

o f t he A

r m y has pub l i s h ed M ed i c al T ech n i c a l B u ll e t i n on P re v en t i on a n d Mana g e m ent of C o l d

- Wea t her 45

I n

j u r i es ( T B Med 508, 2005 ) ; t h e i r s t u d i es su gg est t h a t con v e c ti v e he a t l o ss i s a b o ut 25 t i m es g re a t er i n 46

wa t e r t h an a i r. F or e x a m

p l e, w et c l o t

h i ng and i mm

ers i on i n w a t e r i n c rea s e h e at l o s s su b s t a n t i a ll y

, 47

i n c re a s i ng t h e l i k e li h ood o f h y po t h e r m

i a. C he m i cal i n c i d en t s o c cu r

r i ng i n co l d t e m

per a t u r e co n d i t i ons 48

re q u i re p l an n i ng t o care f o r p a t i en ts su b

j e c t ed t o w a t er

- based d e con t a m i n a ti o n. P l ans sho u l d i n c l ude 49

ca p ab i l i t i es t o p r ov i de w arm she l t e r s, dry b l an k e t s, dry t o we l s, d

r y c l o t h i n g , and / o r i mm

ed i a t e re m

o v al 50

from t he s ce n e 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

42 G u i dan c e f

rom t he U S A r m

y S o l d i er and B i o l o g i c al C he m i cal C o m m an d 12 (2002) su gg es t s t h a t 1

f

i r e f i g h t e r s c a n de c on t a m

i na t e t he g en e r a l pop u l a ti o n u t i li z i ng w a t e r w hen t he a m bie n t t e m per a t u re i s a t or 2

abo v e 6 5 o F wi t h a m i n i m al r i sk of i nc u r

r i ng co l d w ea t h e r r e l a t e d i n j u r i e s, p r o v i ded t h at p a t i e n t s a re n ot 3

req u i r e d t o s t and o u t s i de u n pro t ec t ed from t he en v i ro n m ent for e x t e n ded l en g t hs o f t i m e. T he sa m

e 4

g u i dance reco mm ends w a t e r de c on t a m

i na ti o n o u t doo r s from 36 o F t o 6 4 o F i f t he p a ti e nt i s t hen d i r e c t ed t o 5

a he a t ed en c l os u re a f t er d e c on t a m

i na t i on. B e l ow 3 5 o F

, w a t e r de c on t a m i na ti o n i n a hea t ed e n c l o su r e or a 6

form of dry dec o n t a m i n a ti o n i s reco mm

ended. 7

8

12 T h e US A r m y S o l d i er a n d B i o l o g i cal C h e m i cal C o mm a n d w a s re n a m ed t h e R e s earc h

, D e v e l o p m e n t a n d

E ng i n eer i n g C o mm a n d ef f ec t i v e 9 Oc t ob er, 2 003

.v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

43 

### G u ida n ce S tat e me n t 2.8

I n t he absen c e of sp e c i f

i c i nfor m a ti o n ab o ut t he con ta m i nan t

, t h e f

o ll o w i ng par a m

e t ers a re r eco mm

ended

for wa t e r

- based dec o n t a m i n a t i on:

• L ow pre s su r e ( ~50

– 6 0 p si )

• H i g h v o l u m e

• T e p i d ( s li g h tl y w ar m

, not h o t ) t e m per a t u r e

• D ura t i on n o l on g er t h an t h r ee m i nu t e s ; e nsu r e t hor o u g h soa k i ng

Considerations:

• O p ti m al p a

ra m e t e r s f o r w a t er

- based de c on t a m

i na ti o n h a v e not b e en u n i f o r m l y es t a b l i shed.

• T h e re i s so m

e e v i dence t h a t i n c re a sed p re s su r e, d u ra t i o n, and / or t e m per a t ure can l ead t o i n cr e as e d

abso r p t i on o r pe n e t

r a ti on of so m

e che m i ca l s ; t h i s i s kn o w n as t he w a s h

- i n eff e c t

.

• Wa t er p re s su r e f

o r p e d i a t ri c and g e r i a t

r i c pop u l a t i ons m a y need t o b e a d

j u s t ed t o m

i n i m i z e add i ti o n al

har m

.

• B ased u p on t h e c l a s s, c h ar a c t e r i st i cs, and a m ount o f t h e che m

i c a l co n t a m

i na n t

, t h e du r a t i on o f t h e

sho w er m ay v ar y

. Level of Confidence: III

1

D i sc u s s i o n : 2

S y s t e m a ti c i n v e s ti g a t i on o f t he i n f l ue n ce o f t he v ar i ab l es t h at d e t er m i ne how wa t e r i s de l i v ered t o p a t i e n t s 3

for d eco n t a m i na t i on o n t h e ef

f i c a cy of de c on t a m

i na t i o n has b een li m

it e d

. R e i fe n

r a t h (198 0 ) co n du c t ed 4

t he m

ost e x t e n s i v e s t ud y , var y i ng w a t er pr e ss u re, no zz l e t y pe, sho w er du r a t i on, d e con t a m i n a ti o n s o l u t i on 5

t e m

pera t u re, a nd t he add i t i on of a d e t er g ent t o wa t e r. P res s ure had t he g r e a t e st e f fe c t on d e c o n t a m

i na t i on 6

ef

f i c a cy i n an i n v i t

ro m odel of a p a

t i ent deco n t a m

i n a t i on s y s t em i n w h i c h hu m an cada v er s k i n wa s 7

con t a m

i n a t ed w it h one o f tw o ra d i o l ab e l ed c he m i cal s i m u l an t s. E f

f i c acy w as d et er m

i ned by m easur i ng 8

t he a m

ount o f s i m

u l ant re m o v ed from t he s k

i n s u r face by t he dec o n t a m i n a ti o n sh o w er. T he v a r i ed 9

deco n t a m

i na t i on s o l u t i on te m

pera t ur e s, no zz l e t y pes, a nd ad d i t i on o f T r it o n X

- 100 de t er g ent d i d n ot af f ect 10

dec o n t a m

i n a ti o n e f f i cac y

. L on g er sho we r d u r at i on i m pro v ed e f f i cacy but o n l y at t he l o w e s t w a t er 11

pre s su r e s t ud i ed. 12

13

O t her s t u d i e s ha v e su gg es t e d t h a t i nc r ea s i ng sho w er or w ash du r a t i on b e y ond a m i n i m a ll y ef

f ec t i v e l en g t h 14

o f t i m

e has l i t t l e or n o ef

f e c t on d eco n t a m

i na t i o n ef f i c ac y

. I n a s t udy of a m ass pa t i ent deco n t a m i na t i on 15

s y s t e m , doub l i ng sho w er d ur a t i on fr om t hree t o s i x m i nu t es d i d not r es u l t i n a ch a n g e i n t he e f f ec t i v ene s s 16

of t he sh o w er i n re m o v i ng a f l uo r op h ore f

rom t he s k

i n o f v o l u n t eer p a t i e n t s ( A m l ôt et a l ., 2 0 10). A n o i l

17

based f

l u ore s ce n t s i m

u l ant a p p l i ed t o a f

o re a rm of v o l un t e er p a

ti e n t s w as co m

p l e t e l y re m

o v ed, or at l e a st 18

u n de te c t a

b le, i n 9 0 % o f p a t i en t s a f

t e r a 3 0

- second sho we r a n d i n 1 0 0% o f p a t i en t s af t er a 9 0

- second 19

s h o w er ( Mo f fe t t e t a l ., 2 0 10). A re c ent c o m par i son of a ne w l y reco mm ended m e t hod for m ass p a t i ent 20

dec o n t a m

i na t i on ( t he O RC H I D S pro t oco l ) wi t h a p re v i o u s s t an d ard m e t hod s u gg es t s t h at an i n cr e ase i n 21

s ho w er du r a t i on f rom 1.5 t o t h r ee m

i nu t es do e s n o t en h ance e f f i ca c y as m

easured by sur v i v al and 22

re d uc t i on of cl i n i cal e f fe c t s i n p i g s expo se d t o a su p ra l e t h al d ose of V X ( M i s i k et a l

., 201 2 ). T he 23

O RC H I D S pro t oc o l

, w h i ch i n c l ud e s t he s h o r t er 1

. 5 m i nu t e d u ra t

i on sho we r, w as s i g n i f

i ca n tl y l e s s 24

ef

f ec t i v e t h a n t h e s t an d ard pro t o co l

, w h i c h i n c l u des a t hree m i nu t e sho w er, i n p r e v en ti ng a re d uc t i on i n 25

cho l i ne s t e ra s e a ct i v it y , a l t h ou g h t he u n

re l i a b i l i t y of c h o li n e s t e r ase a c ti v it y i n p re d i c t i ng c l i n i c a l e f fe c t s has 26

b e en d o cu m en t ed p re v i ous l y

. T h e re we re a d d i ti o n al d i f fe r enc e s b e t w een t h e s e t w o d e co n t a m i na t i on 27

pro t o co l s a n d t h e r e s u lt s of v ar y i ng sho w er dur at i on fr om t h i s s t udy a l one sho u l d be i n t e rp r e t e d w i t h t hem 28

i n m

i nd. B y con t r a s t

, an an a l y s i s of p a t i e n t de c o n t a m i na t i on e f f i c acy dur i ng a s i m

u l a t ed m ass che m

i cal 29

expo s ure fou n d t h at a sho we r of > s i x m i nu t e s du r a t

i on r es u l t ed i n re m

o v al of a s i g n i f

i c an t l y g rea t e r 30

a m

ount of a s i m

u l an t

, w h i ch c o u l d b e v i su a li z ed and q ua n t i t a t ed u n der a b l ack l i g h t

, f rom pa ti e n t s t han a 31

sho we r o f < four m i nu t es du r a t i on ( H ood e t a l

., 2011). T he a u t h o rs con c l u ded t h at sho we r du r a t i on 32

shou l d be a t l e a st f i v e m i nu t es. 33

34v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

44 O t her w i se, li m

i t ed i n f o r m a ti on c an be g l e aned from s t u d i es t h a t p ro v i de a sin g l e d a t a p o i n t f o r a w a t e r 1

para m

e t e r t h at i s ass o c i a t ed w it h e f f e c ti v e de c on t a m

i na ti on. F or exa m

p l e, i n t h e st

udy by Moffe t t a n d 2

co l l ea g ues (201 0 ), wa t er at 35 ° C and a p r ess u re b e t wee n 60 and 70 p s i a p p l i ed t o p a t i en t s f o r 30

- 90 3

secon d s r es u lt e d i n co m p l e t e re m o v al of an o i l y con t a

m i nan t . A hos p i t a l

- based d econ t a m i na t i on s y s t em 4

u t i li z i ng w a t e r a t 30 ° C s i gn i f i ca n tl y r e duc e d che m

i c a l s i m u l ant con t a m

i na t i on on pa t i e n t s a f

t er a t h ree 5

m

i nu t e sho we r and f

u r t h er r educed co n ta m

i na t i on a f t er an ad d i t i on a l f

i v e t o t en m

i nu t e sho w er w i t h so a

p; 6

w a t er pr e ss u re wa s not r e p o r t ed ( T o rn g ren e t a l ., 1 9 98). T h ese s t u d i e s p r o v i de su p port f o r p a r t i c u l ar w a t er 7

t e m

per a t u r es, p r e ssu r es and du r a t i ons i n e f f e c ti v e l y deco n t a m

i na t i ng pa t i e n t s. H o w e v er, i t m ust be 8

assu m

ed t h a t s u ch res u l t s m a y be depend e nt on o t h er fa c t o r s wi t h i n ea c h of t he s pec i f i c de c on t a m

i na t i on 9

s y s t e m s or m e t hods a n d c o m

par i son b e t w een s t ud i es s hou l d b e m ade w it h ca u ti on

. T h e b e st appr o ach t o 10

es t i m a ti ng t he o p t i m al pa ra m e t ers f o r wa t er

- based d e c on t a m

i na t i on i s t o v ary t he para m e t e rs o f i n t e re s t 11

one a t a ti m e w h i l e co n t r o l l i ng as be s t a s po s s i b l e for a l l o t h e r v ar i ab l es, u s i ng t h e sa m e s y s t em or m

e t hod 12

fo r d eco n t a m i na t i on

– m

ore such s t u d i es a r e ur g e n tl y needed. I t shou l d a l s o be n o t ed t h a t t h e o p ti m al 13

w a t er pa

r a m e t ers m ay dep e nd on t he s p e c i f i c c h e m i cal con t a m

i nan t ; s t ud i es s h ou l d be co n du c t ed u s i ng a 14

ran g e of t y pes of che m i c a l a g ent and s i m

u l a n t co n t a m

i n an t s

. 15

16

S e v eral o f t he a u t h o rs c i t ed abo v e m

en ti oned t he i m

por t a n ce o f i de n t i f

y i ng t he m

i n i m al con d i t i ons t h a t 17

w il l l e ad t o e f f e c t i v e pa t i e n t de c on t a m

i na ti o n i n or d er t o (1) m ax i m i z e t he p a t i e n t t

hrou g hput r a t e f

or a 18

m ass exposu r e i nc i de n t ( Am l ôt et a l ., 20 1 0; M i s i k et a l ., 201 2 ) a n d ( 2 ) m i n i m i z e t he po t en t i a l f

or w a s h

- i n 19

of co n t a m

i na n t s ( R e i fe n

ra t h, 1980 )

. T he r i sk of w ash

- i n, w h i ch i s d e f i n ed by M o ody and M a i ba c h (2 0 06) 20

as “ a n en h ance m ent o f p e r c u t an e ous abs o rp t i on e l i c i t e d spe c i f i c a l l y by s k

i n deco n t a m

i na t i on,” has l ong 21

been a con c ern. H o w e v er, da t a su gg es ti ng t h a t s k i n d e con t a m

i n a ti o n can ca u se w as h

- i n co m es m os tl y 22

from i n v it r o s t ud i es a n d t h e m echan i s m s are not und er s t ood. I ncreased hu m

i d it y and t e m

pera t u re h a v e 23

been s ho w n t o pro m o t e p e r cu t a n eous abs o r p ti o n of ac e t y l sa l i c y l i c a c i d t h r ou g h e x c i s e d hu m an s k i n 24

( F r i t s ch a n d S t ou g h t on, 1 9 63) a n d h i g h r e l a ti v e hu m i d it y (abo v e 8 5 %) s i g n i f

i ca n t l y i nc r ea s ed a b sor

p t i on 25

of p a

r a t h i o n t h rou g h ex c i s e d p i g s k i n ( C hang and R

i v i ere, 1 993). P e r cu t ane o us a bsor p t i on of c a ff

e i ne 26

t hrou g h e x c i sed hu m an s k i n cou l d a l so b e en h anc e d b y app li c a t i on o f p r es s ure t o t he s k i n, w h i ch w as 27

m

eant t o m i m i c m assa g e ( T re f

f e l et a l

. , 199 3 ). S i nce h u m i d it y

, t e m pera t u re and p r ess u re a

re al l l i k e l y t o 28

be e l e v a t ed o n or ne a r a p a t i e n t ’s s k i n by w a t e r

- based deco n t a m i na t i o n ; so m

e ex p er t s ha v e su gg es t ed t h a t 29

w a t er

- based d eco n t a m i na ti on can p rod u ce a w as h

- i n e ff e c t

. T h i s h y po t he s i s, ho w e v er, has n ot b een 30

v a li d a t ed t hr o u g h i n v i v o expe r i m en t s. M ore r e se a

rch i s n e eded t o i de n t i fy con d i t i ons u nd e r w h i c h t h e 31

r i sk of wa sh

- i n m a y be s i g n i f i ca n t. 32

33

A m

ong t he pre v i ous g uida n ce do c u m en t s i n c l u d ed i n t he c r oss wa l k ana l y s i s, f ew spe c i f i c 34

recommendations are pro v i ded r e g ard i ng t h e p a ra m e t e rs f or wa t e r

- based d eco n t a

m i na ti on, r e f

l e c t i ng t he 35

l ack of d a t a i n t h i s a rea

. T h e U S A r m

y ECB C (2009) r eco m m

ends w a t e r d e li v e re d i n h i g h v o l u m e and 36

l ow p r ess u re (

∼ 60 ps i ) for 3 0 sec o nds t o t hr e e m i nu t e s

. T h e DO D T S WG (20 0 4) r eco m m ends h i g h 37

v o l u m

e, l ow pres s ure and l u k

e w arm w a t er. A n i n i t i a l r i n s e o f at l e a s t one m i nu t e w it h t e p i d wa t er 38

fo l l o w ed by a m ore t h orou g

h w ash i ng w it h s o ap a n d w a t e r a r e r eco mm ended by b o t h o f t h e HHS

39

A T S D R g u i dan c e do c u m en t s ( 200 0 ) and b o t h O S H A g u i da n ce d o cu m en t s ( 2005, 2 009). T h e O S HA 40

g u i dance d ocu m en t s a l so c i t e s e v eral o t h er s ou r ces t h a t reco mm end v ar i ed du r a t i o ns of d eco n t a m i na t i on 41

(2005, 2 009). 42

43

T he g u i dan c e p r o v i ded h er e i s a i m ed at ac h i e v i ng a b a l an c e b e t w een t he pa r a m e t e rs f or wa t e r

- based 44

deco n t a m

i na t i on t h a

t sh o u l d pro v i de for e f

fe c ti v e p at i e nt d e con t a m

i na t i on a n d t h o se t h at sho u l d m i n i m i z e 45

t he r i sk of pa t i e n t h a rm due t o w ash

- i n, b a sed on a l l o f t he a v a i l a b l e e v i den c e. T h ere m ay be 46

c i r cu m s t anc e s i n w h i c h sh o w er t i m e or use of a sp e c i f

i c dec o n t a m

i na n t i s ad v i s ed by a cre d i b l e so u rce 47

(e. g

., m anufac t u r e r M a t e r ia l S a f e t y D a t a S he e t [ M S D S ] or S af e t y D a t a S h e e t [ S D S ] or C h e m ical 48

T r ans p o r t a t i on E m er g ency C en t e r [ C H E M T RE C ] t e c h n i c i an )

. 49

50v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

45 

### G u ida n ce S tat e me n t 2.9

When wa t e r

- based dec o n t a m i na ti on i s i nd i c a

t ed, m il d soap, i f a v a il a

b l e, sho u l d b e added t o wa t er f o r

g ross p a ti e nt a nd t ech n i c a l pa t i e n t de c on t a m i na ti o n, e s pec i a l l y i f t he c on t a m i nant i s t h i c k , o i l y , or

o t h e r w i s e d i f

f i c u l t t o re m

o v e by w a t er a l o ne.

Considerations:

• D o not d e l ay dec o n t a m i n a t i on e f fo r t s i n o rd e r t o acq u i r e m il d soap.

• E xa m p l es of m il d soap i n cl ude i t e m s su i t a b l e for d a i l y con t a ct w it h s k i n.

• D o not u s e d i sh w a s her d e t e r g en t

, l aun d ry de t e r g en t

, cl ean i ng p r odu c t s, a br a s i v e cl ean e rs, o r an y t h i ng

not s u i t ab l e f

or d a i l y con t ac t w i t h s k

i n; con s u l t t h e M S D S (or S D S ) f o r p o t e n ti a l p rodu c t s.

Level of Confidence: II

1

D i sc u s s i o n : 2

T he e f

f i cacy of d eco n t a m

i n a t i on m ay be i m

pro v ed by t he ad d i t i on o f m il d s o ap t o t he wa t e r; ho w e v er, 3

s t u d i es co m

par i ng t he e f

fe c ti v ene s s of w a t e r a l one v er s us so a py w a t er are l i m

it ed. S oap c a n i n cr e ase t he 4

par ti ti o n i ng of o il y or v i s c o us co n t a m i nan t s a w ay f

r om t h e s k

i n be t t e r t han wa t er a l one. B j a rnson et a l

. 5

(200 8 ) n o t ed t h a t s o apy w a t er h a s b e en a t op “ dec o n t a m i nant of c ho i ce” i n c as e s of m ass che m i c a l 6

expos u re, c i ti ng t h e i n exp e ns i v e and u n i v er s al a v a il a b i l i t y

. B j ar n son e t a l

. (200 8 ) a l so sho w ed t h a t s oapy 7

w a t er w as e f f ec t i v e i n p re v en t i ng t he o n s e t of se v ere s y m p t o m s af t e r e x pos u re t o V X i n do m es ti c s w i n e. 8

9

S oapy w a t er i s p a r t i cu l a r l y ef f i c a c i o us w hen a t t e m

p ti n g t o deco n t a m

i na t e a r eas a f

fe c t ed by l i p i d

- so l ub l e 10

che m

i ca l s ( Ha l l & Ma i bac h , 2006). H o w e v er, t h e una v a i l ab i l i t y of s o ap s h ou l d n o t d e l ay w a t e r

- on l y 11

deco n t a m

i na t i on, n or s hou l d w a t e r

- on l y decon t a m i na ti on be c o ns i de r ed i nf

e r i or o r sub

- s t anda r d c a

re e v en 12

i f a co n t a m i nant i s k no w n t o be o i l y or w ax y

. 13

14

Wh i l e s e v er a l of t he s t u d i e s from t he l i t e r a t u re re v i ew w ere e x t r e m e l y w e l l d e s i g ned, t h ey d i d n o t p r o v i de 15

a hea d

- t o

- head co m par i son of w a t er t o s o apy w a t e r; t h e y on l y used co n t r o l g roups expos e d and not 16

deco n t a m

i na t e d

. W e s t er, et a l

. (199 2 ) d e con t a m i na t ed a l a c h l o r, an he r

b i c i d e

, w i t h e i t her a 5 0 % l i q u i d 17

so ap (1 : 1 v / v of s oap t o wat er), or wa t e r a l one, o n r h e s us m on k e y s. T he co m

b i na t i on o f so a

p and w a t e r 18

redu c ed t he p erc u t a n eous a bsor p t i on of a l ac h l or m

ore t han w a t er a l o n e a f

t e r t he f ir st w a s h (7 3 % v s. 3 6 %) 19

and a f

t e r t hr e e w as h es (8 2 % v s. 50 % ). I n a s m a l l s t u d y , Moff

e t t et a l

. (20 1 0), s h o w ed t h e e f fe ct i v eness 20

(as m

easu r ed by t he t i m

e nece s sary t o co m

p l e t e dec on t a m

i na t i on) of wa t e r a l one f

or an o il y ( e. g

., 21

v es i ca n t ) a g en t

. T h i s s t udy used a f l uo r es c en t l y

- l abe le d s i m

u l ant ( b aby o i l ) ap p l ie d t o v o l u n t e e r s ’ ar m s

, 22

af

t er w h i ch, a de c on t a m

i na t i on s h o w er (60

- 70 ps i , 3 5 o C ) w as e ff e c t i v e i n re m

o v i ng 100% of t he s i m

u l ant 23

af

t er 9 0 s e conds. T he s t udy by Wes t e r c l e a r l y de m ons t ra t ed t he e f

f i c a cy of so a

py w a t er i n a r h esus 24

m

o n k e y / a l ach l or m

ode l

, r e v ea li ng g rea t e r e ff e c t i v ene s s t h a n w a t er a l o n e. T he s m a l l s t udy by Mo f fe t t 25

us i ng a s i m u l ant s u gg es t s t hat wa t e r a l one i s e f f ec t i v e, e v en w it h an o i l y con t a m i nan t

, a nd s h ou l d not be 26

de l a y ed o r wi t hh e l d i n an e ff o rt t o a d d so a

p. 27

28

B raue et a l (2011 a / b ) de m ons t r a t ed an i n c r e ase i n t he LD 5 0 13 of V X u s i ng 1% s o a p y w a t er o v er no 29

deco n t a m

i na t i on i n g u i n e a p i g s. H o w e v er, m ost of t h i s i n c r e ase i n t he L D 50 w as l i k e l y due t o t he 30

per f

or m ance o f AN Y dec o n t a m i na t i o n ; t h e s t udy d i d not t e s t a wa t e r

- on l y con t r o l

. T hu s , be c ause t h e 31

s t udy d i d not t e s t for a w a te r

- on l y con t ro l

, t h e e f f i cacy of s o apy w a t er v e r sus wa t e r a l o n e co u l d n o t be 32

d i r e c t l y ass e sse d

. 33

34

A pre v i ou s l y re l ea s ed g u i d ance d ocu m ent ( DO D T S WG , 2004) h i g h li g h t s t h e i n c r ease i n deco n t a m i na t i on 35

e f

f i c acy t h at s o ap p ro v i de s : 36

a. S oap c a n a i d i n d i s so l v i ng s o m e of t he o i l i e r che m

i c a l a g en t s l i k

e V X o r b li s t e r a g en t s. 37

13 An i n cre a s e i n L D 50 i n d i ca t es t h at m o re c o n t a m

i n a n t i s re qu i red t o ca u s e l e t h a li t y i n 50 % o f s u b j ec ts

.v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

46 b. “ L i q u i d r a t h er t han s o li d s o aps s h ou l d be u sed b eca u se t hey are qu i c k er t o e m p l oy, red u ce t he n e e d 1

for m echa n i c a l s crub b i n g

, a

nd co u l d r edu c e s e cond a

ry con t a m i n a ti o n r i s k s.” 2

c. L i m

it a t i ons t o s oap i n c l ude t he n eed t o ha v e it i m m ed i a t e l y a v a il a b l e a nd t he ti m e req u i r ed f

o r 3

m

i x i n g ; decon t a m

i na t i on s hou l d n ot b e d e l a y ed w h i l e w a i t i ng for soap t o b eco m e a v a il a b l e. 4

5

O S H A G u i dance for P r o t e c ti ng E MS F i r s t R e s pond e rs (200 9 ) r e co g n i z es t he u t i l it y of soap a n d w a t er as 6

ef

f i c a c i o us i n d e con t a m

i na t i on: “s o ap and w a t e r re m a i ns t h e be s t p ra c t i ce for m ost co n t a m

i nan t s un d er 7

m

ost c i r c u m s t anc e s of m a s s dec o n t a m i n a ti o n ”. 8

9

ECB C (2009) g u i d ance su gg es t s t h at wa t e r i s o f t en us e d for i n i t i a l de c on t a m i na t i o n, but t h a t s o ap a n d 10

w a t er m ay be needed f o r a t echn i c a l de c on t a m

i na t i on, espe c i a ll y i n v o l v i ng t he r e m o v al of o i l y li q u i d 11

a g en t s. S o ap c a n i m pro v e deco n t a m

i na t i on e f f i c acy by i ncre a s i ng de g rad at i on o f a che m

i c a l a g ent and 12

“a i d s i n d i ss o l v i ng o il y su b s t a n ces li k e b l i s t e r a n d n e r v e a g en t s ”. 13

14

S ME i n p ut s t ron g l y suppo rt ed t h e ad d i t i on o f s o ap t o w a t e r f o r d e co n t a m

i na t i on w hen po s s i b l e and 15

spe c i f

i ed t h a t s o ap r ef

e rs t o a m il d, non

- abra s i v e, li q u i d soap and n o t a d e t er g en t

. T h ere sho u l d be no 16

de l ay of wa t e r

- b ased dec on t a m i na t i on i n an e f

fo r t t o p r ocure or p re p are soap and w a t er s o l u t i ons. N o 17

i de a l p e rc e n t a g e for a so a p and w a t er so l u t i on h a s b e en de t e r m i ned s c i e n t

i f i c a ll y n or i s w i d e l y acc e p t e d i n 18

pra c t i ce. S ub j e ct m a t t er e x per t s r eco g n i z ed t he l i m i t at i ons o f e x t r ap o l a t i ng t he r es u l t s of s t u d i e s b a sed on 19

an i m al m

ode l s t o hu m ans. 20

21v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

47 

### G u ida n ce S tat e me n t 2.10

T he use of a non

- abra s i v e spon g e, w ash c l o t h, or s i m il a r w ash i t em m ay enhance w a t e r

- based

deco n t a m i na t i on by i n cr e a s i ng t he ph y s i c a l re m o v al of a co n t a m

i nant t h rou g h li gh tl y rub b i ng

con t a m i n a t ed ar e as.

Considerations:

• T e chn i c a l p a t i ent d eco n t a m i n a ti on sho u l d n o t be d e l a y ed t o acq u i r e sp e c i f i c w ash it e m s.

• S uf f i c i ent qua n t i t i es o f w a s h i t e m s shou l d b e a v a i l a b l e t o a v o i d reu s e and co n t a m i na t i on t ra n s f er.

• T he w ash i t em used f

o r ru b b i ng w il l i t s e lf beco m e co n t a m i na t ed a nd m ay be d i sp o sed o f as h a z ardo u s

w as t e i n a cc o rda n ce wi t h j u r i s d i c t i on a l g u i dan c e.

• Wash i t e m s shou l d be d i f f e rent t h an i t e m s t h a t m ay ha v e been us e d f o r s e l f

- care ( e. g

., c l o t h s,

hand k e rc h i e fs, b a

by w i pes )

.

• S crub b i ng t oo h ard can ab r ade t he s k i n and l ead t o e n h anced che m i cal pe n e t ra t i o n

. Level of Confidence: I

1

D i sc u s s i o n : 2

T he use of a w as h i ng i t e m , such a s a s pon g e or wa sh cl o t h, m ay enhance d eco n t a m i n a ti o n ; u s e o f a 3

w ashc l o t h or s p on g e m ay i m pro v e t he m

echan i c a l r e m o v al of t h i c k , h e a v y con t a m i na n t s t h a t a re m ore 4

adhe r ent t o t he s k i n. H o we v er, t he u se o f a spon g e or w ashc l o t h i m m ed i a t e l y r a i s es se v e r al i s s ues, 5

i n c l ud i ng abra s i on o f s k i n due t o s c rub b i n g

, w h i ch ca n i n c re a se a

bso r p t i on

, and r i sk of t

ra n sf e r r i ng 6

con t a m

i n a ti o n b e t w een p a ti en t s i f t h e re i s i ns u f f i c i e n t a v a il a b i l it y of c l e an w ash i t e m s. A dd iti o n a l l y , use 7

of a wa sh i t em m a y t rans f er con t a m i nant t o a r e l a t i v e l y unco n t a m i na t e d body pa r

t

, such a s f

rom t he ha n ds 8

t o a c l e an t or s o. F u r t h e r, i n s t r u c t i o n s p ro v i d ed t o p a ti e n t s on t h e pr o per use o f a w ash i ng i t em req u i re 9

ti m

e, w h i ch i s a c r i t i c al fa ct or d u r i ng dec o n t a m i n a ti o n

. L as t l y

, a l l w ash i t e m s req u i re ap p rop r i a t e d i sp o s a l 10

f

o ll o w i ng t he i n c i d en t. 11

12

T he l it e r a t u r e on u se o f a w ash c l o t h or spon g e i s l i m it e d. A m l ôt et a l

. (201 0 ) co nd

uc t ed a hu m an s t udy of 13

deco n t a m

i na t i on e f f e c ti v e n ess u s i ng a t hr e e

- w a y i n t e ra c ti v e d e s i g n ( i .e., n o w as h c l o t h, w a s hc l o t h, and 14

w ashc l o t h w it h i n s t r uc t i o n s on i t s u s e) a f

t er ap p li c a t i on of a che m

i cal s i m u l a n t. T he exp o su r e m

odel and 15

unb i a sed m easu r e m en t s o f re s i du a l c o n t a m

i n a ti o n , u si ng i nfr a

red i m a g i n g

, w ere t he s t ud y ’s s t r e n g t h s. U se 16

of a w as h c l o t h r es u l t ed i n a 2 0% red u c t i on i n c o n t a m i na ti on v e r sus n o w as h c l o t h

. A s li g ht d e c re a se of 17

e f

f e c t i v eness wa s s e en w hen v erb a l and p i c t o r i a l i n st ruc t i o n s w e r e p r o v i ded on use o f t h e w as h c l o t h ; t he 18

s t ud y ’s au t h ors sub s eq u en t l y de t e r m i ned t h at t he d e cre a se i n e ff e c t i v eness w as due t o t w o fa c t o r s: (1) 19

su b

j e c t s s p ent so m

e of t h e i r ti m

e i n t he s ho w er re v i e w i ng t he i n s t ru c t i o n s i n s t ead of w as h ing and ( 2) a du l t 20

su b

j e c t s m i s i n t er p r e t ed t he p i c t o r i a l i n s t ru c ti o ns ( W i n fi e l d, 2 0 11 )

. 21

22

S e v eral ex i s t i ng g u i dance d ocu m en t s and m anu a l s a l so supp o rt t he u se o f an i m p l e m ent t o a s s i s t wi t h 23

con t a m

i na n t r e m o v a l

. D O D T S WG (200 4 ) e m phas i z ed t h e i m

por t ance of re p l a c i ng spon g es or 24

w ashc l o t h s b e t w een e v ery pa t ie n t

. I n add i t i on, ECB C (200 9 ) ac k no wl ed g es t h e u t i l i t y of a s o ft c l o t h or 25

spon g e and t h a t g en t l e f r i c ti on m ay ass i st wi t h t he re m o v al of c h e m

i cal v apo r s a n d ae r os o l s. H o w e v er, 26

t he r e i s t h e t he o re t i c al r i sk t

hat t he u se o f an i m

p l e m ent m a y spread o il y co n t a m i n a n t , s u ch a s m

us t ard 27

a g ent, and, t h u s, c a re m ust be ex e r c i sed t o u se o n l y g en t l e f r i c t i on i n t h e l o c a li z ed area of con t a m i na t i on 28

( ECBC , 2009). O S HA ’s B est P ra c t i ces f o r F i r s t R ec ei v ers (200 5 ) wa rned a g a i n s t us i ng a w ash i t e m

, 29

w h i ch c ou l d da m a g e t he s k i n and f a c i l it a t e che m

i c a l p e ne t r a t i on (e. g ., s t i f

f b rush, a bra s i v e pad )

. 30

31

S ME i n p ut wa s t h at use o f a w ash it em i m pro v es dec o n t a m

i na t i on e f f e c ti v ene s s w it h t he u nde r s t and i ng 32

t h a t de c on t a m i na ti o n sh o u l d ne v er be d e l a y ed i n o rd e r t o p r oc u re w a s h i t e m s. I ns t ruc t i ng pa t i e n t s i n 33

prop e r d e con t a m i na t i on t e c hn i que w i t h a w a s h i t em shou l d e m pha s i z e ( 1 ) g e n tl e r

ubb i n g , ( 2 ) a v o i d a nce o f 34

t rau m a t i z i ng t he s k i n, and ( 3 ) l o c a li z ed r ubb i ng w hen t here i s r i sk of s p rea d i ng v i scous o r o i l y 35

con t a m

i na n t ( e. g ., b l o t t i n g ). S uf f i c i e n t nu m

bers o f w a s h i m

p l e m en t s a r e n e eded i n ord e r t o a v o i d c ro s s

36

con t a m

i n a ti o n b e t w een p a ti en t s by us i ng t he sa m e it e m

. I t m ust be e m phas i z ed t h at i n t h e a

b sen c e of 37

w ash i t e m s, deco n t a m i na t i o n w it h wa t e r a l one sho u l d n e v er be d e l a y e d

. A d d i t i o n a ll y

, t h e u s e of 38v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

48 w ashc l o t h s or s pon g es for deco n t a m i na t i on i nc u rs t he i ss u e of w as t e d i spo s a l

. 1v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

49 

### G u ida n ce S tat e me n t 2.11

A lt e rn a ti v e p r a c ti c e s o r d ec on t a m i na n t s s h ou l d be i nc o rpo r a t e d i n t o t he d ec o n t a m i na t i on p roc e ss w h e n

w a t er

- based d eco n t a m

ina ti on i s co n t r a i n d i c a

t ed (e. g

., due t o w ea t

he r / en v i ron m

en t al con c er n s, c h e m

i cal

rea c ti v i t y ) or d e l a y ed (e. g

. , due t o r e sou r ce o r c a pa b i l i t y li m it a t i ons o r l o g i s t i c s ). T h i s p l an n i ng sho u l d

i n c l ude i de n t i f

y i ng pos s i b l e a l t er n a t i v e l o c a t i ons (e. g

., sho w e r s at a g ym or s w i m m i ng poo l ) for wa t e r

based deco n t a m

i n a ti on w h e n nec e ss a

r y

.

• A lt e rn a ti v e d e con t a m

i na t i o n pr a c t i c e s i n l i eu o f w a t er

- based deco n t a m i n a ti on i n c l ud e : Al t e rn a ti v e

pra c t i ces m ay i nc l u d e:

o D e l a y i ng w a t er

- based d ec o n t a m i na t i on

o N on

- w a t er b ased dec o n t a m i n a ti on t e chn i ques

• A lt e rn a ti v e d e con t a m i nan t s i n c l ud e :

o A ppro v ed ne u t

r a li z i ng a g e n t s ( e. g ., pa r t i ti o n i ng and c h e l a ti ng a g en t s )

o C he m i cal s p ec i f

i c d e con ta m

i nan t s ( e. g ., po l y e t h y l e n e g l y col for p h en o li c co m pounds)

o A bsorb e nt m a t e r i a l s (e. g

., s p i l l pa d s, o i l

- dr y

, k itt y li t t er

, F u l l e r ’s E a

r t h)

o A dsorb e nt m a t e r i a l s (e. g

., a c ti v a t ed c arb o n)

Considerations:

• R eac t i v e S k

i n D eco n t a m

i n a ti on L o t i on © ( RS D L © ) i s cl ear e d by F D A as a de v i c e o n l y for s pot

de co n t a m i na t i on a nd o n l y for u s e w i t h C W A s.

• B l each s o l u t i ons a r e n o t r ec o m m ended for c h e m

i cal d e con t a m

i n a ti o n i n a c i v il i an m ass

- exposure

i n c i de n t; t he co n t a c t t i m

e r e qu i r ed f

or e f f ec t i v ene s s i s t oo l ong t o b e p r a c ti c al and i s as s oc i a t ed wi t h

po t e n t i al i r

r i t a ti o n t o t he s k

i n w h i ch m ay i ncr e ase che m i c a l pe n e t r a ti o n

.

• C he m i cal ne u t r a l i z a t i on o f ac i d s or a l k a l i s o n s k i n o r e y es w it h a c i d i c o r b a s i c de c on t a m i na t i on

m i x t ures (e. g ., 1% ac e t i c a c i d f o r a l k a l i bur n s; sod i um b i c a rbo n a t e f o r a c i d b u rn s ) i s n o t

rec o mm ended.

Level of Confidence: IV

1

D i sc u s s i o n : 2

When t he d e c i s i on i s m ade t o p e rf o rm decon t a m

i na ti on

, i t sho u l d be cond u c t ed a t t he s c ene (pr e f

e ra b l y ), 3

as ex p ed i t i ou s l y as po s s i b l e t o r edu c e che m i c a l “ con t a c t ( re s i de n ce) t i m e”, and m ay i n v o l v e a ti e red 4

a ppr o ach i n c l u d i ng se l f

- care, g ross p at i e n t , and t e chn ic al p a t i ent dec o n t a m i n a ti o n. T h e c o rn e rs t one o f 5

ef

f ec t i v e dec o n t a m

i n a ti o n i s t he re m

o v al of c o n t a m

i n at ed c l o t h i n g , fo ll o w ed by decon t a m i n a ti o n w i t h 6

w a t e r , as we l l as w it h soap and a c l o t h o r spon g e, i f a v a i l ab l e. 7

8

R i sks P ro m

p ti ng C on s i der a ti on of A l t ern a t i ve P r

ac t i ce s or D e c on t

a m i na n t s 9

Water

- based d econ t a m i na t i on h a s t h e a

b i l it y t o c r e a t e ad v er s e ou t c o m es it s e l f. T hese ad v er s e o u t co m es 10

i n c l u d e: 11

 E x t en d i ng con t a m i na t i on t o c l e an p a

r t s of t he bod y : m

i n i m a ll y con t a m

i n a t ed p a t i e n t s w ho 12

u nd e r g o 13

g ross p a ti e nt o r t ech n i c a l p a t i ent dec o n t a m i n a ti on m ay i nad v e r t e n tl y w ash c on t a m i na n t o n t o an 14

uncon t a m i na t e d l i m b, i n t o t he i r e y e, or aer o so l i z e and s ubseq u en t l y i nh a l e c on t a m i nant d u r i ng 15

sho w e r i n g ; 16

 P a t i en t s d e con t a m i na t ed i n co l d we a t h er w ho r i sk t he d e v e l op m ent of h y po t h er m

i a

, i n a d d i ti on t o 17

t h e i r che m i cal

- spec i f

i c i n j u r i e s; 18

 P a t i en t s w ho s u s t a i n m ech a n i c a l i n

j u ry ( i

. e

., s li p s, t

r i p s

, and f

a l l s ); 19

 P s y cho l o g i c a l co n seq u enc e s i n p a t i e n t s i n v o l v ed i n a tr au m a ti c m ass exp o su r e i nc i dent m ay be 20

co m pounded i n p a t i e n t s for w hom a t echn i c a l p a t i ent deco n t a m i na t i on p ro c ess (w h i ch m ay 21

i nc l ude 22

s t r i p p i ng and sho w e r i ng i n v i ew of r e scu e rs and o t h e r pa t i e n t s) i s nec e ss a ry and i n w h i ch 23

re s pond e rs m ana g e casua l ti e s , wi t ho u t su f f i c i e n t co mm

un i ca t i on ( F e t t er, 2 00 5 ; C a r t e r, 201 2 ). 24

25v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

50 A lt e rn a ti v es t o I

mm e d i a t e G ross P a t i ent o r T e chn i cal P a t i ent De co n t a m i n a t i on i n C o l d W ea t her 1

D econ t a m

i na t i on i s s c a l a

b l e, and i f t he r i sk of w et de c on t a m i na t i on i n a n e x t

re m e l y co l d en v i ron m

ent i s 2

t oo g re a t

, d i s r o b i ng patients and p r o v i d i ng unco n t a m i n a t ed co v er i ng i n t h e sh o rt t e rm m a y be suf f i c i e n t t o 3

sub s t a n ti a ll y r e duce t he r i s k of che m i cal

- spec i f

i c he a l t h ou t c o m

es w it ho u t i ndu c i n g h y po t her m i a. 4

T e chn i c a l p a t i ent d eco n t a m i n a ti on m ay t hen o c cur i n d oors w h e n w arm r efu g e i s a v a il a b l e. Al t e rn a t e 5

deco n t a m

i na t i on p ra c t i ces s hou l d b e co n s i d e r ed w hen w a t e r

- based d eco n t a m i na ti on m i g ht be 6

con t

ra i nd i ca t ed. T h ese p r ac ti c es i n c l ude, but are not li m it e d t o: 7

 D e l a y i ng w a t er

- based d ec o n t a m i na t i on d u e t o un f

a v o r ab l e w ea t her con d i t i on s ; 8

 Forgoing water

- based decontamination in favor of evacuation and clothing removal for non

9

reactive gases; 10

 Or use of alternative decontaminants such as polyethylene glycol (PEG) for phenol water

11

reactive compounds 12

13

C ons i d er a t i on f o r ad v e r se o u t co m

e s of wa t e r

- based de c on t a m i na t i on, i n c l u d i ng e nv i ron m en t a l

, and 14

ph y s i cal and p s y cho l o g i c al i n j u ry t o p a t i en t s, h a s b e en pre v i ou s l y es t ab l i s h ed i n s e v eral e x i s ti ng g u i dan c e 15

docu m

en t s ( DO D T S W G

, 2004; O S HA / R e c e i v ers, 2 0 05; ECBC , 200 9 ; O S HA / E M S , 200 9 ). 16

17

A lt e rn a ti v e D ec o n t a m i na n t s W hen W a t er i s C on t ra i n d i c a t ed 18

U n i que con t a m i na t i on s it u a

ti o n s m ay requ i re co n s i d er a ti on of a n a lt e rn a ti v e d e co n t a m i na t i on s o l u ti o n. F or 19

e x a m

p l e, RS D L © i s c o ns i d e red m ore ef f i c ac i ous f or c h e m i cal wa rf a re a g e n t s ( i .e

. , n e r v e and m us t a r d 20

a g en t s) bec a use t he so l u t i o n i t se l f i s d e s i g ned t o s p e c i f i c a ll y ne u t

r a li z e n er v e a g e n t and p a r t i t i on s u l f u r 21

m

us t ard a w ay f

r om t he s k

i n

. I n cer t a i n n i che i nd u s t

r i es , a p a r t i c u l ar che m

i c a l or m i x t u re m ay ha v e an 22

espe c i a ll y e f fe ct i v e deco n t a m

inan t ; i t i s n o t c l e a

r how s uch u n i que s i t u a ti o ns m i g ht i nf o rm g eneral p at i e n t 23

deco n t a m

i na t i on g u i d el i ne s . W a t e r

- rea c ti v e c h e m i ca l s req u i r e co n s i d er a t i on of a lt ern a ti v e r e m o v al 24

proc e ss e s s u ch as dry m echan i c al re m

o v a l/ br u sh i ng ( f

o r w a t er

- reac t i v e m

e t a l s ) or an a l t e rn a ti v e s o l u ti on 25

t h a t has been sho w n t o p r ov i de be t t e r e f f i cacy ( i .e., po l y e t h y l ene g l y col so l u t i ons for p hen o l

, [ Mo n t e i ro

26

R i v i ere et a l

., 2 001; B ro w n, et a l ., 1 9 75 ] ). 27

28

C

he m i c a l N

e u t r a li z a t i o n o

f A c i d s / A l ka l i s Is C

o n t r a i n d i ca t ed 29

S o m

e w a t er

- reac t i v e or e xo t her m i c c he m i cal re a c t i ons ( i .e. a c i d o r ba s e) m ay be an abs o l u t e 30

con t

ra i nd i ca t i on t o wa t e r

- b ased d eco n t a m i na t i on. E a rl y exper i m

en t a l e v i de n ce s u ppor t s t he e f f i c a cy of 31

i m m ed i a t e wa t e r de c on t a m i na t i on o f a c i d a nd a l k a l i c h e m i cal b u rn s ; t h e sa m

e ex p er i m ent d e m ons t r a t ed 32

m

ore se v ere bu r ns i f c he m

i cal n eu t r a li z a t i on ( 5 % N a H C O 3 / ac i d b u rn s ; 1% ac et i c ac i d / a l k a l i b ur n s) wa s 33

a t t e m

p t ed i n l i eu o f w a t er d econ t a m i na t i on ( D a v i dson, 1927). S od i um h y drox i de burns t r e a t ed wi t h 0

. 35 34

M so d i um c i t ra t e i n a r at m odel sho w ed h i g her ( m ore a l k a li n e) s ubc u t a n eous pH at 1 m i nu t e o v er t hose 35

deco n t a m

i na t e d wi t h w a t er a l on e , su gg es ti ng t h at “ ne u t ra l i z a t i on” o f t he a l k a l i ne c he m i cal w a s (1) s l o w er 36

w hen an a c i d i c d eco n t a m i n a t i on s o l u t i on w as u s ed, a n d (2) ca u sed m

ore h a rm t h a n w a t e r w as h i ng a l o n e 37

( Y ano, 1 9 94). W a t e r de c o n t a m

i na t i on a l so r e su l t ed i n l ess s e v ere b u rns i n a 4 5 % s od i um h y drox i d e

38

expos e d r a t m odel t han d i d PE G ( B ro w n, 19 7 5). W h i l e ne u t r a li za ti on (c h e l a t i on, pa r ti ti o n i n g , ph y s i c a l 39

re m

o v al of a dry co n t a m

i n a n t ) m ay be m

ore appro p r i a t e t h a n w a t er d eco n t a m i na ti on i n se l ect 40

c i r cu m s t anc e s, a n eu t r a li z a t i on r ea c t i on ( ac i d bu r n / a l k a l i s o l u t i on; a l k a l i b u rn / ac i d i c so l u t i on) can cau s e 41

m

ore ex t e n s i v e i n

j ur y

. 42

43

C

he m i c a l S t

a t e M a y be A f fe c t ed by E

n v i r o n m en t

al C o n d i t i ons 44

T he a m

b i ent t e m per a t u r e of t h e s u r

roun d i ng a i r and we a t h e r c o nd i ti o ns m ay i m pact t h e ph y s i c al s t a t e of 45

t he re l ea s ed c h e m i ca l

. F re ez i ng po i n t s o f s e l e ct che m i c a l s m ay m a k

e t he m e t hod of de c on t a m

i na ti o n 46

v ar i a b l e, d e pen d i ng on t h e ph y s i cal s t a t e a t t h e t i m e of re l ea s e. C on v er s e l y , che m i c a l s i n i t i a l l y re l ea s ed as 47

l i q u i ds m ay e v apora t e, c aus i ng an i n c re a sed i nh a l a t i onal h a z ard for p a t i e n t s and res p ond e rs. 48

49

B l each i s N o L ong e r R e c o mm ended as an A l t e r na t i ve D econ t a m i na n t 50

F or t h e p u rpo s es o f m ass p a t i ent dec o n t a m i n a ti on i n a c i v i l i an p o pu l a t i on, d i l u t e b l ea c h s o l u t i o n s a r e n o t 51

reco mm

ended as an a l t er n a

ti v e de c on t a m

i na ti o n s o l u ti on. W h i l e b l each s o l u t i ons ha v e pro v en e f

f i ca c i ous 52v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

51 i n c e r t a i n s i t u a t i ons a nd wit h spe c i f i c che m i cal w a r fa r e a g en t s ( C W A s), no t ab l y s o m e ner v e a g en t s and 1

su l f

ur m us t a rd ( W o r m ser, e t

. a l ., 200 2 ; B j ar n son e t

. a l

. 2008; B raue, e t

. a l

. , 2011 a / b), t h e i r u s e i n c i v i li a n 2

popu l at i on wi t h a n un k no w n che m

i cal co n t a m

i nant i s not r eco mm

ended. R ese ar ch on t he u se o f b l each 3

so l u ti o ns i nd i c a t es t h a t t he conce n t r a t i on and

/ or c on t a c t t i m

e requ i red t o n eu t

r a li z e che m

i cal wa r f are 4

a g en t s e x cee d s t he c o n t a ct t i m e sho w n t o c au s e s k

i n or e y e i r r i t a t i on (W o r m ser, e t

. a l . 20 0 2). 5

6

A dd i t i on a ll y

, t h e f o l l o w i ng l o g i s t i c a l c on s i d e ra t i o n s w ere i de n t i f

i ed by S M E s d e m ons t ra t i ng t h a t a b l e a ch 7

so l u ti o n i s an i m prac t i c a l al t er n a t i v e so l u t i on for a c i v il i an m ass p a t i ent dec o n t a m i na t i on. T h ey i nc l ude 8

(but a r e not l i m it ed t o ) : ( 1 ) s t oc k

i ng and s t o ra g e of b l e ach f or m i x i n g , ( 2 ) e n su r i n g t he co r re c t r a t i o i s 9

m

i xed (0.5 % ) a n d m a i n t a i n ed t h rou g hout t he dec o n t a m

i n a ti on p ro c ess, ( 3 ) and t he t i m e requ i red t o e ns u re 10

t he c o r

re c t co n ce n t

r at i on o f b l e a ch s o l u ti o n. 11

12v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

52 

### F u nctio n al Ar e a 3: E v aluating the Eff e ctive n ess of Dec o n ta m i n ation 1

G u i dan c e s t a t e m en t s 3.1 a n d 3.2 r eco m m

end cr i t e r i a f

o r d e t er m i n i ng i f a p a t i e n t h a s been d ec o n t a m i n a t ed 2

suf

f i c i e n tl y

. D i s t i nc t

i o n s b e t w een e f

fe c ti v en e ss o f p a t i ent d eco n t a m i na t i on and ef

f i c i e n cy of 3

deco n t a m

i na t i on o p e r a t

i ons are a l s o p r ese n t ed. 4



### G u ida n ce S tat e me n t 3.1

D ec i s i ons on w h e t h e r co n t a m i na ti on h as b een redu c ed t o a l e v el t h a t i s s a fe a nd / o r add i ti o nal

deco n t a m i na t i on i s n ece s s a

ry can be g u i d e d by t he fo ll o w i ng i nd i ca t ors (a n d o t he r s as a ppr o p r i a t e ) :

• E li m i na t i on o f v i s i b l e co n t a m

i na ti on from t he s k

i n an d / or c l o t h i n g ;

• O bser v ab l e i m

pro v e m ent i n s i g ns and s y m

p t o m s w h i ch pro m

p t ed t he d e c i s i on t o p erf

o rm

deco n t a m i na t i o n ;

• P a t i ent pe r ce p ti o ns o f t h e e ff e c t i v eness o f d e co n t a m

i na t i o n ;

• R esu l t s from ap p ro p r i a t e d e t e c ti o n t e chn o l o g i e s ;

• G u i de l i n e s i n F un c t i on a l A rea 2 : O p t i m i z ed T e ch n i c a l P ra c ti c es we re f ol l o w e d;

• I f an effe ct i v e deco n t a m

i n a ti on m e t ho d

, w h i c h i s k

no w n t o be ap p rop r i a t e g i v en t h e na t ure of t he

i n c i de n t and che m

i c a l i n v o l v ed, i s p r ope r l y exe c u t e d, t hen a s u f f i c i e n t r edu c t i on i n con t a m i na t i on c an

be i m p li e d

. Considerations:

• T he e f fe c ti v en e ss o f d e co n t a m

i na ti on m ay no t be ob

j ec ti v e l y m

easura b l e wi t h c ur r ent c apa b i l i t i e s.

H o w e v er, t he abo v e can b e used a s su b j e c t i v e i n d i c a t o r s of a ch i e v e m ent of t h e g oa l s o f pro v i d i ng f i r s t

a i d t o p a t i en t s and pr o t e ct i n g respond e rs and r ec e i v ers from secon d ary co n t a m i na t i on.

• D e t e c ti o n t echn o l o g i es m u s t be a ppr o p r i a t e t o t h e ch e m

i ca l

, pro p e r l y ca l i b r a t ed, and t h e u s er p rop e r l y

t r a i ne d

Level of Confidence: III

5

D i sc u s s i o n : 6

W i t h i n t he a v a i l ab l e l i t er at ure, t h e re a re no w i d e l y ac c ep t ed g u i de l i n e s f o r d e t e r m i n i ng t h e e f

f e c t i v eness of 7

p a t i ent d eco n t a m i n a ti on. I n order t o d e v e l op and v a li d a t e t o o l s for e v a l u a ti ng t he e f fe c ti v en e ss o f a 8

proc e ss, ob

j e c t i v es m

ust be es t ab l i s h ed. S u c h o b j e c ti v es f o r p a t i ent dec o n t a m

i n a t i on ha v e not been 9

def

i ned n or a dop t ed by t he e m er g ency response co mm

un it y

. C o m

p l e t e l y e li m

i n at i ng con t a m

i n a ti on i s n o t 10

re a li st i c a n d m ay not be n e ces s ar y

. R edu c i ng con t a m i na t i on t o b e l ow a t h r esh o l d for c au s i ng ad v erse 11

hea l t h e f

f ec t s i s d i f f i c u l t t o i m

p l e m ent b eca u se f

or m any che m

i ca l s, t he a cce p t a b l e hu m an exposu r e l i m i t 12

i s n o t k

no w n. F u r t h e r, eq u i p m

ent w it h v a l i d a t ed s t a nd ards for i t s u s e i n d e t e c t i ng con t a m i na n t s o n a 13

pers o n i s not a v a i l ab l e f o r m a k i ng t he pre c i s e m

easur e m en t s nec e ss a

ry t o a s se s s w he t h e r s u ch o b j e c ti v es 14

ha v e been m e t

. T he ch a l le n g es of d e t e r m i n i ng “how c l ean i s sa f

e” h a v e been d i sc ussed i n t he l i t e ra t ure 15

( I O M, 1999; R ab e r e t a l

., 2 001, 200 4 ; V o g t & S or e ns e n, 2002 )

. I n t he ab s ence of es t a

b l i sh e d s t an d ar d s, 16

pa t i e n t de c on t a m i na ti o n g oa l s h a v e been p rop o sed h e r e (s e e D e s i r ed e n d po i n t s f o r p a ti e nt 17

deco n t a m

i na t i on s e c ti o n ). T h e se end p o i n t s a re b ased on he a lt h ou t co m es: i m pr ov i ng pa ti e n t s’ sh o rt and 18

l ong

- t erm hea l t h o u t co m es and p r o t e c t i ng t he h e a lt h o f res p ond e rs a nd r ec e i v ers. T he c r i t e r i a 19

reco mm

ended here for e v a l ua t i ng pa t i ent de c on t a m i na t i on e f f ec t i v eness a r e b a sed on t h o se h e a l t h 20

ou t co m

e

- focused g oa l s. 21

22

D ue t o t he l ack of es t ab l i s h ed g oa l s a nd s t an d ar d s up t o t h i s t i m e, t h e re i s l i tt l e s c i en t i f

i c d a t a o r o t h e r 23

pub l i sh e d e v i de n ce t o su b s t an t i a t e t h i s or o t h e r ap p ro ac hes t o e v a l u at i ng pa t i ent d e con t a m i n a ti o n 24

ef

f ec t i v ene s s. H o w e v er, t h e g u i dan c e p r ese n t ed he r e i s ba s ed on S ME o p i n i o n a n d cu r re n t p r a c ti c e, and 25

co m

p l e m en t s g u i dance s t a t e m

en t s on d e t e r m

i n i ng w he t her a p a t i ent ne e ds d e co n t a m i na t i on ( G u i d ance 26

S t a t e m

ent 1.1) and p r i o r it i z i ng a m o n g m u lti p l e p a t i e n t s w ho m ay need deco n t a m i na t i on ( G u i d a nce 27

S t a t e m

ent 4.1 a n d 4. 2 ). 28

29

L oo k

i ng for e l i m

i na t i on o f v i s i b l e co n t a m

i na t i on o n s k

i n an d / o r c l o t h i ng i s a co mm

on sense s t ep t o w ard 30

de t e r m

i n i ng t he ef

f e c ti v en e ss of dec o n t a m

i n a ti o n

. S i g ns and sy m

p t o m s of che m

i cal expo s ure w h i ch a r e 31v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

53 m an i fest be f

ore deco n t a m

i n a t i on m ay d i m

i n i sh d u r i ng t he co u rse of d eco n t a m i na ti on. I n s o m e case s

, 1

ho w e v er, su c h as w it h t he a bsor p t i on of a s i g n i f

i ca n t d ose o f t o x i c che m

i c a l p r i or t o d e con t a m

i na t i on, 2

ef

f ec t s m ay pro g ress and b e co m e s y s t e m i c. S i g ns and sy m

p t o m s of s y s t e m

i c ef fe c t s m ay not i m

pro v e 3

un t i l a n t i do t es a nd / o r o t h e r m ed i cal t r e a t m en t s a re ad m i n i s t e red. G i v en t h ese pos s i b i l i t i es, i t i s 4

reco mm

ended t hat i m

pro v e m ent in s i g ns a nd s y m

p t o m s be c o ns i de r ed i n co m b i n at i on wi t h o t h e r 5

i nd i c a t or s , r a t h e r t han by it se l f. 6

7

S o m

e pa ti e n t s m ay be qu i t e a w are of w h e re t hey a r e c o n t a m i na t ed and w he r e t h e l e v e l s a re g re a t e s t

. I f so, 8

t h ey m

i g ht a l so ha v e a s ense o f w h e t h e r t h e d e con ta m i na ti on p ro c ess red u ced t hat c on t a m i na ti o n or 9

m

i ssed i m por t a n t a re a s. M any pa t i en t s can po t en t i a ll y off e r feed b ack on w h e t her or n o t

, i n t h e i r 10

j ud g m

en t

, t he d e co n t a m

i na t i on p roc e ss wa s t h o rou g h a nd i f t hey f

eel any i m

pro v e m ent i n t h e i r con d i ti on. 11

12

T he g u i de l i n e s p r es e n t e d i n F unc t i on a l Ar ea 2 : O p t i m i z ed T e c hn i cal P r a c t i c e s r e p res e nt t he b e s t c u rr e nt 13

t h i n k

i n g , ba s ed on a v a il a

b l e s c i e n t i f

i c e v i den c e, e x pe r

t op i n i on, a nd co mm

on prac ti c es i n t he f

i e l d. 14

A lt hou g h t h e g u i da n ce s t at e m en t s do n o t d e sc r i be op e r a t i on a l s t e p

- by

- s t ep pra c t ic es, f o l l o w i ng t he 15

g u i de l i nes can h e l p t o e ns u r e t h a t d e s i red end p o i n t s ar e ac h i e v ed. F i na l l y

, i f spe c i f i c d e co n t a m

i na t i on 16

pra c t i ces ha v e been de m ons t r a t e d t o be e f

f i c a c i o us for k

no w n con t a m

i nan t s o r c er t a i n i n c i d ent t y pes, t h e n 17

t h e i r i m

p l e m en t a t i on sh o u l d con t

r i bu t e t o, and can b e used a s an i n d i c a t or of t he a ch i e v e m ent of p a t i e n t 18

deco n t a m

i na t i on g oa l s. 19

20

W i t h p a t i ent dec o n t a m i n a t i on g oa l s d e f

i ned, i t sho u l d be po s s i b l e t o m ore r i g oro u s l y ana l y z e t he c r i t e r i a 21

reco mm

ended here a s i nd ic a t o r s o f e f fe ct i v e deco n t a m

i n a ti on. 22

23v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

54 

### G u ida n ce S tat e me n t 3.2

T i m e li ne s s an d e f

f i c i e ncy are c r i t i cal e l e m

en t s of e f fe c ti v e p a ti e nt d eco n t a m

i na t i o n: an i n d i v i du a l p a t i ent

needs t o b e de c on t a m

i na t ed w it h m

i n i m al d e l ay and p a ti e n t s i n a m ass expo s ure i n c i de n t n eed t o be

deco n t a m i na t e d ex p ed i t i o u s l y i n o rder t o d o t h e g re a t e st g ood f o r t he g re a

t e s t n u m ber. H o w e v er, a ra

p i d

pace m ust be b a l an c ed wi t h qua l it y and con s i s t ency of pa t i e n t c a re t o a ch i e v e t he g oa l s of p ro v i d i ng f i r st

a i d t o p a t i en t s and pr o t e ct i n g respond e rs, re c e i v ers and hea l t h c are i n f r as t ru c t u r e fr om secondary

con t a m i n a ti o n.

Considerations:

 P a t i ent t h

rou g hput o r p roc e ss

- based endp o i n t s a l o n e, w it h o ut c on s i d e ra t i on of i m p act o n t h e

h e a l t h of pa t i e n t s, r esp o nd e rs a n d r ec e i v ers i s n o t a us e ful m easure of e f

fe ct i v eness o f p a t i e n t

de c on t a m i na ti o n.

 E v a l ua t i on o f t h e e ff

e c t i v eness o f d e con t a m

i na t i on m ust t a k e i n t o ac c ount t h e de s i r ed end p o i n t s,

w h i ch a re h e a lt h o u t c o m

e

- b ased.

Level of Confidence: V

1

D i sc u s s i o n : 2

T i m

e li ne s s and e f

f i c i e ncy of a p a t i ent de c on t a m i na ti o n oper a t i on a

re re l a t i v e l y ea s y t o m

easure. T he 3

de l ay b e t w een p a t i e n t ex po sure and c o m

p l e ti o n of de c on t a m

i na t i on sho u l d be e s t i m

ab l e i n m ost c a ses, and 4

p a t i ent t h

rou g hput i n a m ass exposu r e i nc i de n t sh o u l d be c a l c u l a b l e. Wh i l e m

i n i m i z i ng ti m e be t w een 5

expos u re a nd d e co n t a m i na t i on i s c r i t i ca l

, t h e t h orou gh ness o f d e co n t a m i na t i on w h i ch d oes i m

pro v e pa t i e n t 6

he a l t h o u t co m e(s) s hou l d n ot b e co m

pro m i sed for t he sa k

e of i n c re a s i ng p a t i ent t h rou g hput w h i ch i n

- an d

7

o f

- it s e l f m ay no t

. P ro t o co l s n e ed t o be c a r ef u l l y execu t e d and t he op e ra t i o n sh o u l d be m

on i t or e d for 8

q ua l it y co n t r o l

. A ra p i d pace w it h o ut p rop e r e xec u t i on wi l l not l e a d t o a t t a i n m ent o f h e a l t h o u t co m

e

9

based pa t

i e n t d e co n t a m

i na ti on g oa l s. T h er e f

o re, a co m

b i n a ti o n of fa c t o rs n e ed t o be i n c l u d ed i n an 10

e v a l ua t i on o f e f f ec t i v ene s s: (1) t he i n d i c a t o rs li s t ed i n G u i dan c e S t a t e m ent 3.1, w h i ch are t he be s t m eans 11

cur r en t l y a v a il a b l e t o d e t e r

m i ne, d i r e c t l y or i n d i re c tl y

, i f a nd t o w hat e x t e n t p a ti e n t co n t a m i na t i on h as 12

been redu c ed; and (2) t i m e li ne s s and e f

f i c i e nc y

. 13

14

R ap i d d eco n t a m i na t i on and h i g h pa t i e n t t h rou g hput a r e of t en d i sc u ssed i n t he l i t er a t u r e a n d be st

- prac t i ce 15

g u i des as m eas u res of e f

f e c ti v e p a ti e nt d eco n t a m

i na t i o n ( B r e nnan, 1 999; B ur g ess, 1999; DO D T S W G

, 16

2004; H o u s t o n & H end r i c k son, 200 5 ; ECBC , 200 9 ). P a t i ent t h rou g hput i s a l so fr equ e n tl y re p o r t ed i n 17

af

t er

- ac ti o n r e po r t s for ex er c i s e s. H o w e v er, t he S M E s w ho pa r t i c i p a t e d i n t h i s p r o j e c t ex p r e ssed an ur g ent 18

n e ed t o r e d i re c t a ss e ss m en t s of e f fe c ti v en e ss t o w ard i nd i ca t ors t h a t a re m ore c l o s e l y a l i g ned w i t h hea l t h 19

o u t co m

e

- based g oa l s , but wi t h ti m e li n ess and p a ti e nt t hr o u g hput s t i l l con s i d ered as m easu r es o f ef

f i c i enc y

. 20

T h i s g u i da n ce s t a t e m en t

, t h en, h a s an L O C of V

, s i nce i t i s ba s ed on S ME co n sens u s b u t i s no t

, t o o u r 21

k

no w l ed g e, c u r r ent p ra c t i ce a nd no p ub l i s h ed sup p o r ti ng e v i den c e i s a v a il a b l e. W i t h i nc r ea s ed acce p t a n ce 22

a nd a n a l y s i s of t he e f fe c t o f t h i s g u i d an c e o n pa t i e n t

, r esp o nder and re c e i v er h e a l t h o u t co m es, t he L O C 23

m ay i m

pro v e i n t h e f

u t u r e. 24

25v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

55 

### F u nctio n al Ar e a 4: P

a tient Pri o ritizat

i on for Deconta m ination 1

F or t h e c a se o f a m ass e x p o sure i n c i d e n t

, G u i da n ce S t a

t e m en t s 4.1 and 4

. 2 ad v i se on p r i o r i t i z i ng pa t i e n t s 2

for d eco n ta m i na t i on and c o ord i n a t i ng deco n t a m i na t i on w it h m

ed i c al c a r e. 3



### G u ida n ce S tat e me n t 4.1

Imm ed i a t e, l i fe s a v i ng m

ed i cal ca r e an d

/ o r a n ti d o t a l t h e rapy sho u l d i d e a ll y be a p ri or i t y , o v er pa t i e n t

deco n t a m i na t i on.

Considerations:

• R espond e rs m

ust b e ap p ro p r i a t e l y t r a i ned and h a v e t he prop e r PP E i n o r der t o i m p l e m ent m ed i cal c are

pr i o r t o p a t i ent d eco n t a m

i n a t i on.

• L i f e sa v i ng m ed i cal c are w i l l be d e f

i ned by t he A u t

ho r i t y H a v i n g J u r i s d i c ti o n 14

.

• T h i s g u i d a nce sho u l d be f o l l o w ed a s c l os e l y as p o ss i b l e w it h i n t he re s our c e a n d c apab il it y li m it a t i ons

of t h e or g a n i z a ti o n.

Level of Confidence: III

4

D i sc u s s i o n : 5

T he b a l an c e b e t w een t he n e ed f o r l i f esa v i ng m

ed i cal c a re a n d de c on t a m

i na ti o n i s t enuous and req u i r es 6

resp o nd e rs a n d r e c e i v ers t o per f orm a r i sk and ca p ab i l it

i es as s ess m

ent t o d e t e r m

i ne w he t h e r i t i s 7

appro p r i a t e and fe a s i b l e t o pro v i de m ed i c a l i n t er v en t

i o ns i n t he “ w arm z one” w h i l e pa t i e n t s a w a i t 8

deco n t a m

i na t i on. T he li t e r a t u r e su gg es t s t h a t t he r e i s an on g o i ng deb a t e r e l a t e d t o w hen m ed i c a l c a re 9

shou l d be g i v en f o ll o w i ng a che m

i c a l exp o su r e. O n t h e one h and, i n t he U S

, m ed i cal ca r e f o l l o w i ng a 10

che m

i cal expo s ure i s t y p i c a ll y cond u c t e d a f t e r p a t i ent deco n t a m

i na t i on ( H i ck et a l ., 2003 b ; H o r t on e t a l

., 11

2003; K o en i g et a l

., 200 8 ). P ers o nn e l t ra i ned t o p ro v i d e l i f

e

- sa v i ng m

ed i cal ca r e a

re n o t a l w a y s t r a i n ed t o 12

w ear a n d con d uct op e r a ti o n s i n PPE

, w h er e as p er s onn e l t ra i ned t o w e a

r PP E do n o t a l w a y s ha v e t he s k il l s 13

nece s s a

ry t o re n der m

ed i cal care t o pa t i e n t s. O n t he o t her h and, s e t ti ng up g ross p a t i ent or t ec h n i c al 14

pa t i e n t de c on t a m i na ti o n o p er a ti o n s t a k

es t i m e dur i ng w h i ch i t m

i g ht be nec e ssary t o ad m

i n i s t er 15

i m m ed i a t e, l i f e

- sa v i ng care pr i o r t o

– o r i n co n j un c ti o n w it h

– one o r m

o re t i e r s of pa t i e n t 16

deco n t a m

i na t i on. H o w e v e r , non

- li fe

- sa v i ng m easures, such a s d i a g nos t i c a nd a n c il l ary t e s t i ng and 17

on g o i ng v it al

- s i g n assess m en t s, a r e n o t ap p ro p r i a

t e un t i l de c on t a m

i na t i on op e r a t i ons a

re co m p l e t ed a nd 18

t he v i c ti m i s i n a c l e a n en v i ron m en t ( Ha ll

, 199 5 ; L a u r e nt e t a l ., 199 9 ; Ja g m i nas, 2008a; and R a m

esh & 19

K u m ar, 201 0 ). A s o n e e x a m p l e i n w h i c h a d e l ay i n l if esa v i ng care l e d t o an e x ce s s of m orb i d it y and 20

m

or t a l i t y : a f

t e r t h e O c t ob e r 2002 M o scow t he a t r e s i e g e, de l ay i n ad m i n i s t ra t i on o f an o p i o i d a n t i do t e w as 21

fe l t t o be re s pon s i b l e f o r a m a j o r it y of t he h os t a g e de at

hs ( Wax, B e c k

er, & C urr y

, 2003). T hou g h 22

deco n t a m

i na t i on wa s not p erf

o r m ed dur i ng t he M osc o w i nc i de n t , t h e r es u l t o f a d e l ay i n l i fe s a v i ng 23

m

ed i cal c are (ad m

i n i s t ra t i o n of a re v er s al a g en t ) re s u lt ed i n p re v en t ab l e d e a t h s f r o m resp i r a

t o ry arr e s t

. 24

25

I n o t her cou n t r i es, f o r e x a m p l e F ran c e, J a pan, I sra e l , a n d t he U n i t ed Ki n g do m , so m e ha v e r e co m m ended 26

a l l o w i ng pro p e r l y t r a i ned m ed i cal p ro v i de r s w e a r i ng appro p r i a t e PP E t o pro v i d e l i f e

- sa v i ng m

ed i cal c are 27

i n t h e w arm z one ( L a u re n t et a l ., 19 9 9; O k u m ura et a l

. , 2003; M a

r k el e t a l , 200 8 ; P i l li n, 200 8 ). 28

A dd i t i on a ll y , so m e U

. S

. g u i dan c e d o cu m

en t s co n t a i n p ro v i s i o ns f

or t he a d m

i n i s t r a ti on of l i fe s a v i ng 29

m

ed i cal c are i n t he wa

rm zone or con c o m

it an t l y w it h deco n t a m

i na t i on, i n c i r cu m s t a n ces w h ere t he 30

pa t i e n t ’s con d i t i on p oses a g rea t e r r i sk of d e a t h or m o r b i d i t y t han t he on g o i ng ex p osure i t s e l f ( A T S D R

– 31

E D , 2000; A T S D R

– E M S

, 2000; DO D T S W G

, 2 004). O S HA ’s B est P r a c t i c e s f o r F i rst R ec e i v ers a l s o 32

des c r i b es s t a b i l i z i ng t ho s e w it h l i fe t h r ea t en i ng cond i t i ons or i n j u r i e s , su c h as sh o ck and re s p i ra t ory 33

fa i l u r e, p r i o r t o e n t e r i ng d e con t a m i n a ti o n (2 0 05) B y ers (200 8 ) su gg es t ed ra p i d t r i a g e and l i f

esa v i ng c a

r e

, 34

such as a n t i do t es a nd t ra u m a care, co u l d b e ad m i n i s t er e d t o pa t i e n t s by f

i r e s er v i ce pe r sonn e l w e a r i ng 35

L e v el A PP E and m ed i c al p ro v i de r s on s ce n e w ear i ng L e v el C

. A n ob v i o us l i m it a t i on t o t he m

odel 36

14 T h e p u b li c a g e n c y o r it s d e l e g a t e t h a t h a s l e g al re s pon si b il it y a n d a u t h o r i t y f o r re s po n d i n g t o an i n c i d e n t

, b a s ed on po liti cal

o r g e o g ra p h i cal (e. g

., c i t y

, c o u n t y

, T r i b a l

, St a t e, o r F e d eral bo un d ary l i n e s ) o r f un c ti o n al (e. g

., l a w e nf

o rc e m e n t

, p u b li c h ea l t h )

ra ng e o r s p h ere o f a u t h o r i t y

. D e f i n ed b y t h e De p ar t m

e n t o f H e a lt h a n d H u m an S e r v i ces (HH S ) i n t h e P u b li c R ea d i n e s s a n d

E m er g e n c y P re p are d n e s s ( P R E P ) A c t

, Dec l ara ti o n f o r P a n d e m

i c F l u ( 2009 )v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

56 p ropo s ed by B y ers i s t h a

t t he use o f L e v el C PP E on any sce n e i n w h i ch t he n a t u r e o f t h e che m i c a l ha z a r d 1

has n o t b een fu l l y cha r ac t er i z ed m ay not a l l ow for a deq u a t e pr o t e ct i on o f m ed i cal p e rs o nn e l

. L a u re n t et 2

a l

. ( 199 9 ) a l so p rop o sed t h a t m ed i cal pe r son n el en t e r t he h o t z one i n PP E t o ad m i n i s t er l i f e

- sa v i ng 3

i n t e r v en ti ons ( t he F r ench “ R ed” P l a n ). L i f e sa v i ng i n t er v en t i ons a d m i n i s t e red b ef

o re o r d u r i ng 4

deco n t a m

i na t i on sho u l d be li m

it ed t o t ho s e l i k

e l y t o i n c r ea s e t h e ch a nc e s of s ur v i v al ( 1 ) t h rou g h t h e 5

de c on t a m

i na t i on p ro c ess and ( 2) w h i ch i n c r ease t h e li k e l i hood a p a

t i ent w i l l s u r v i v e t o rea c h d e f i n i t i v e 6

m

e d i c a l c are. F or exa m

p l e, i t m a y be poss i b l e t o ad m i n i s t er a ner v e a g ent a n ti d o t e t o p re v ent re s p i ra t ory 7

fa i l u re a n d t er m i na t e s e i z ures for a no n

- a m bu l a t ory p a ti e nt as t hey m o v e t hrou g h deco n t a m

i n a ti on, 8

t h ereby a ll o w i ng t hem t o s u r v i v e t o r each a H C F w here a v en ti l a t or a nd I C U l e v el ca r e a r e a v a i l a b l e for 9

d e f

i n i t i v e m ana g e m

e n t

. O n t he o t h e r han d

, it m a y not be p r a c ti c al t o p er f orm ex t en s i v e re s us c i t a t i on 10

( i n c l u d i ng CPR ) t h rou g h t he de c on t a m

i na ti o n proc e ss. ( T he li k

e l i ho o d of sur v i v i ng out

- o f

- hosp it a l ca rd i a c 11

a

rr e st i s v ery l o w

, re g ard l ess of t he cau s e) ( B erdo w s k i et a l

., 2010 )

. 12

13

I n cer t a i n s i t u a t i ons, a d m i n i s t r a t i on o f l i f e

- sa v i ng i n t e r v en ti ons can occur during any of the tiered 14

decontamination processes

. H o w e v e r : 15

 T h e re m ust b e ad e qu a t e P P E for any resp o nd e rs p ro v i d i ng i m m ed i a t e l i f e

- sa v i ng i n t er v e n ti o n s f

or 16

a po t en t i a ll y co n t a m i na t e d pa t i e n t , and t he i n t e r v en ti o n m ust be doa

b l e w h i l e w e a

r i ng PPE

. 17

 L i fe

- sa v i ng i n t e r v en ti o ns a re r eso u rce and cap a c i t y depende n t , a n d should only be performed if they 18

are likely to prolong su rvival to the next level of care; 19

o F or e x a m p l e, a p a t i ent w h o has p e rf o r m ed se l f

- care a f t er n e r v e a g ent e x pos u re a n d 20

subse q ue n tl y de v e l o p ed s eiz ures and re s p i ra t ory a r re s t

, m i g ht re c e i v e an an t i d o t e a

u t o i n j e c t o r 21

pr i o r t o und e r g o i ng non

- a m bu l a t ory t e ch n i c a l p a

t i ent d econ t a m

i na t i on 22

o A pa t i ent w i t h l i f e

- t hr e a t en i ng he m

orrha g e m

i g ht ha v e b l ee d i ng co n t

r o l ( d i r e c t p re ssu r e; 23

dre s s i n g ) a p p l i ed p r i or t o d econ t a m i na t i on 24

o A n uncon s c i o u s p a t i ent w hose a i r w ay i s co m pro m i sed by pos i t i on, v o m

it us, o r s ec re t i on s

, 25

m i g ht ha v e t h e i r a i r w ay re p os i ti o n ed, c l e are d , or an o r a l a i r w ay i n s e r t ed p r i o r t o 26

deco n t a m i na t i on 27

 T he l e t h a l i t y of m any che m i c a l w a r f a re a g en t s, e v en a t l ow l e v e l s of exp o su r e, su gg es t s t h at 28

m

i n i m al a m

oun t s of co n t a

m i na ti on m ay resu l t i n m

or t a l it y i rr e sp e c t i v e of any l i f esa v i ng 29

i n t er v en t i ons. 30

31v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

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57 

### G u ida n ce S tat e me n t 4.2

P r i o r i ti z e p a t i en t s f

or d eco n t a m

i na t i on by e s ti m a ti ng r e l a t i v e r i sk and g roup i ng pa t i e n t s i n t o i m m

ed i a t e

and d e l a y ed d e con t a m

i na t i on g roups. R i sk ass e ss m ent sho u l d t a k

e i n t o c on s i d e r a

ti on t he f o ll o w i ng

cr i t e r i a (a n d o t he r s as ap p r o pr i a t e ) i n p r ef e re n t i al o rd e r:

• N eed f o r i mm ed i a t e l i fesa v i ng care or a n t i d o t al t h e ra p y (see a l so G u i da n ce S t a te m ent 4.1)

• V i s i b l e e v i den c e of con t a m i n a ti on on p a t i en t ’s s k

i n or c l o t h i ng

• P a t i en t s d i s p l a y i ng s i g ns a n d sy m p t o m s of expos u re

• P rox i m

it y of p a t i e n t t o t he l oca t i on o f r e l ea s e

• C on t a m

i na t i on d e t ec t ed on pa t i e n t u s i ng appro p r i a t e d e t e c ti o n t e chn o l o g y

Considerations:

• P r i o r i t y shou l d be given to t hose p a t i e n t s w ho req u i r e d econ t a m i na t i on i n o r der t o r e ce i v e immediate

care f o r l i f e t h re a t e n i ng co n d i t i ons or i n j ur y

, i n c l u d i ng an t i do t al t h e rap y

.

• C h il d ren sho u l d be p r i o r

i t i z ed b e fore ad u l t s w i t h i n t he sa m e decon t a m

i na t i on p r i o r it y g roup.

• A g e, pre g nancy and ch r on i c m ed i cal con d i t i ons sho u l d a l s o be con s i d e red w h e n es t i m a ti ng re l a t i ve

r i sk and p r i o r i t i z i ng pa t i en t s f o r de c on t a m

i na ti o n.

• C oncer n ed c i t i z ens w ho are at l ow r i sk of co n t a m

i n a ti o n m a y reque s t t o und e r g o decon t a m i na t i on.

• I n a m ass expos u re c h e m

i cal i nc i de n t

, p a t i en t s n e ed i n g decon t a m i na t i o n m ost u r g en tl y m a y not be t h e

f i r st t o p re s en t ; a m

bu l a t ory pa t i e n t s m ay reach f i r st re s ponde r s or f

i r s t r ec e i v ers m

ore q u i c k l y t han

non

- a m bu l a t ory p a ti e n t s.

• S e l f

- repo r t i ng pa t i en t s a

r r i v i ng at a h e a lt h ca r e f

ac il it y shou l d a l so be p r

i o r i t i z ed a ccor d i ng t o t he s e

cr i t e r i a.

Level of Confidence: III

1

D i sc u s s i o n : 2

T h e re i s l i t t l e p ub l i s h ed e v i dence, e i t h e r ex p e r i m en t al or e m

p i r i c a l , su gg es ti ng t h e best m eans t o t r i a g e or 3

pr i o r i ti z e p a t i e n t s a cc o rd i n g t o t h e i r n eed for d eco n t a m i na ti on. A v a r i e t y of t r i a g e s y s t e m s are pro p osed i n 4

t h e l i t e r a t u re, m any bas e d on t ra d i t i on a l m ass c a su al t y i nc i d ent m ed i cal t r i a g e p ro t o co l s ( e. g

. S T A R T

, 5

S A L T

, S I

E V E ) ( C i e s l ak et a l ., 2 0 00; K e nar & K a ra y i la no g l u, 200 4 ; C one & K oe n i g , 2005; S ubb a rao et 6

a l ., 2 0 05; O k u m ura et a l

., 2 007; Ne al e t a l ., 2 0 10; R a m esh & K u m ar, 2010). W it h t he e xce p t i on o f 7

ass e ss m

en t s o f t w o t r i a g e s y s t e m s, no a t t e m p t s ha v e b een m ade t o e v a l u a t e t he s e pr i o r i ti za ti on sc h e m es 8

e m

p i r i c a ll y or v a l i d a t e t h e m as pro v i d i ng a de c re a se i n overall levels of m orb i d it y or m

or t a l it y ( B ond, 9

2008 C o ne e t a l

., 2008). 10

11

T he t

r i a g e s y s t em e v a l ua t e d by C one et a l

. (200 8 ) w as de v e l oped as a CBR N t r i a g e s y s t em w h i ch i n c l udes 12

r e co m m

enda ti o ns for b o t h p a t i e n t d e co n t a m i na t i on and m

ed i cal c a re ( C o ne & K o en i g , 200 5 ). T he 13

e v a l u a t i on of t h e s y s t e m w as conduc t e d i n co n j u n c t i on wi t h a d i s as t er d r il l a n d w as l i m

it ed t o o n ly t he 14

c he m

i cal and t r a u m a a l g or it h m

. D esp i t e r ec e nt t r a i n i n g

, t h e s t udy found a h i g h r a t e o f und er

- t r i a g e (or 15

p l a c i ng ca s ua l t i es i n a t r i a g e c a t e g ory t hat w as l o we r t h an w h e re t hey sho u l d h a v e been p l ace d ) a s w e l l as 16

a f

a il u re t o r eco g n i z e t o x i d r o m es. T h e r e s u lt s i nd i c a

t e t h a t t he s y s t em needs f

u r t h er re f i ne m ent and 17

t es t i n g

. 18

19

S ubba

r ao e t

. a l . ( 2 005) de v e l oped a s e t o f s y m p t o m

- based t

r i a g e a l g or i t h m s for C B R N i nc i d en t s b a sed o n 20

s i t ua t i o n al c ha r a c t e r i s t i cs (e

. g

. t y pe of a t t ack or r e l e a se) and p a t i ent pr e se n t a ti on. Wh i l e p a t i e n t 21

deco n t a m

i na t i on i s i de n t i f

ie d i n s o m

e of t he a l g o r it h m s, o t h e rs foc u s on p ro v i d i ng m ed i cal c are or o t h e r 22

pro t ec t i v e m easure s

. B ond e t

. a l

. ( 200 8 ) con d uc t ed a u s ab i l i t y asse s s m ent of t h i s s y s t em w it h f

i r s t 23

rec e i v ers ( a tt e nd i ng ph y s i ci ans, e m

er g ency m

ed i c i ne r e s i de n t s, and n ur s es) u s i ng 26 pa r a g raph l en g t h 24

w r i t t en sc e na r i os. A gg re g a t e s co r es f or a l l sc e na r i os a

nd a l l t e s ti ng g roups y i e l d e d a c o rr e ct t r i a g e r a t e of 25

45%, i n d i c a ti ng t h at add i t i o nal re v i s i on and s i m p l i f i ca t i on o f t h e a l g or i t h m s i s ne e ded. 26

27

I

t has a l so been no t ed t

hat t here i s n o co mm

on l y accep t ed e v a l ua t i on m e t hod. B e f

ore a n ap p l i ca

b l e t r i a g e 28

s y s t em can be e x a m i ned, a s t an d ard e v a l u a t i on m e t hod need s t o b e e s t a b l i shed ( R a m esh & K u m ar, 2010). 29v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

58 T he use of t r i a g e pr o t o c o l s or o t her m e t ho d s t o p r

i o ri t iz e pa t i en t s i s a l so we l l re p r ese n t ed i n b e s t

- pra c ti ce 1

g u i des

– s e v en of t he e i g ht docu m en t s e x a m i ned m en t i on p r i o r

i t i z i ng pa t i e n t s f

or deco n t a m

i na t i on. T h e 2

ass e r t i ons i n t h i s g u i da n ce s t a t e m ent w ou l d be d i f

f i cu l t t o e v a l u a t e i n a con t

r o ll e d hu m an t r i a l b u t c o u l d be 3

an a l y z ed t hrou g h r e t ros p ec t i v e s t udy of a c t u a l i n c i d en t s. 4

5

T he l i st of c r it e r i a p r opo s ed i n t h i s g u i dan c e s t a t e m ent i s an ex t en s i on o f t he c r i t e r i a l i s t ed i n g u i dan c e 6

s t a t e m

ent 1.1 u sed t o d e t er

m i ne i f a p a t i e n t r eq u i r e s d econ t a m i na t i on i n t h e f

i r st p l a c e. In this guida nce 7

statement, these criteria are used to prioritize patients who require decontami nation according to a resource 8

and/or time

- constr ained response, where some patients may require decontamination sooner than others. 9

U pon e v a l u a t i on, p a t i en t s sh o u l d be c a t e g o r i z ed i n t o i mm ed i a t e o r d e l a y ed ca t e g or i e s b a sed on t he 10

c r i t e r i a l i s t e d ; t h i s e v a l u a t i on i s i n ad d i t i on t o, a n d s hou l d t a k e i n t o a cco u n t

, t ra d i t i on a l m ed i c a l t r i a g e. 11

12

N

eed f o r m e d i c a l c a re or a n ti d

o t a l t her a py 13

P a t i ent dec o n t a m i n a ti o n s h ou l d n o t b e d e l a y ed w hen l i fesa v i ng m ed i cal c a re o r a n ti d o t a l t he r apy are 14

needed and a v a il a b l e. A l te rna t i v e l y

, i f r e sou r ces are a v a il a b l e, l i fesa v i ng m ed i cal care or an t

i d o t a l t he r apy 15

sho u l d n o t be d e l a y ed w h i l e wa i t i ng for d eco n t a m i na ti on. P ro v i d i ng m

ed i cal ca r e and an t

i d o t a l t he r apy i n 16

t he wa

rm z one w h i l e p a ti e n t s a r e a wa i t i ng decon t a m i na t i on r eq u i r e s p r ope r l y t r a i ned pe r son n el i n 17

ap p ro p r i a t e PP E ( L a ure n t et a l

. , 199 9 ; O k u m ura et a l ., 200 3 ; Mar k

el et a l

., 200 8 ). 18

19

V

i s i b l e 20

V i s i b l e i n d i c a ti o ns o f c h e m i c a l co n t a m

i na t i on on t he p a t i ent or t he p a t i e n t ’ s c l o t h i ng are an o t h e r f ac t or 21

t h a t can be u sed t o d e t e r m i ne t h e ne e d f

o r d e con t a m

i na t i on ( R a m

esh & K u m ar, 2 010). V i s i b l e e v i den c e 22

of co n t a m

i na t i on i n d i c a t e s an on g o i ng expos u re w it h i ncr e ased co n t a c t t i m e ( K i rk & D ea t on, 2 007). 23

24

Sy m

p t o m s 25

T o x i d r o m

es, or c l u s t e rs o f sy m

p t o m s, cou l d be u t i li ze d t o h e l p d i s t i n g u i sh b e t we en a f fe c t ed and 26

una f

fe c t ed i n d i v i du a l s (K i r

k et a l

., 1 994; M a

r k el e t a l

., 2008) and b e t w e e n p r i o ri t y l e v e l s ( i mm ed i a t e a n d 27

de l a y ed )

. H o w e v er, t he r e i s so m e res e ar c h t o su gg est t

hat i nd i v i d u a l s w ho ha v e a l ow pr o ba b i l it y of be i ng 28

co n t a m

i na t e d can s t i l l ex h i b i t s y m p t o m s t hat do not ha v e an or g an i c o r i g i n ( K ir k & D ea t on, 2 007), 29

i nd i c a ti ng t h a t a dd i ti o nal i n for m a ti on i s re q u i red t o d et er m i ne t h e i r ap p ro p r i a t e p r i or i ty l e v el f or 30

deco n t a m

i na t i on. 31

32

P rox i m ity 33

P a t i en t s who were i n c l os e r p r ox i m it y t o a r e l e a se a

re s usp e c t ed o f ha v i ng re c e i v ed a h i g her dose o f 34

co n t a m

i na t i on and t h e r ef

o re ha v e a h i g her need for d eco n t a m i na t i on t han a p a t i e n t who was f u r t her f r om 35

t he r e l e a se ( K i rk & D ea t on, 200 7 ). P r o x i m it y t o t he r e l e a se i s c i t ed i n v ar i ous a r t i c l es a s one of t he m a i n 36

fa c t o r s t o con s i d e r w hen d e t er m i n i ng de c on t a m

i na ti on n eeds ( R a m

esh & K u m ar, 201 0 ). 37

38

D e t e c ti o n 39

H i s t o r i ca l l y

, t h e re i s a l a ck of d i sc u ss i on i n t h e l i t er a t u r e re g ar d i ng t he u se o f d e t ec ti on and d i a g no s ti c 40

t ech n o l o g i e s t h at can b e u s ed t o d e t er m i ne d e co n t a m

i na t i on r equ i re m

en t s. A lt h o ug h t here are 41

en v i ron m

en t a l d e t e c ti o n t e c hno l o g i e s a v a i l ab l e and a r e used by f i r s t r espo n de r s t o cha r ac t e r i z e ha z ardo u s 42

en v i ron m

en t s, t h e re i s li t t l e m

en ti on of t he use of t he s e de v i ces i n d e t e r m i n i ng de c on t a m

i na t i on 43

pr i o r i ti za ti on. A nc il l ary t es ti n g , su c h as l ab o r a t ory co n f i r m a t i on o f co n t a m

i na n t s i n b i o l o g i c a l sa m

p l es, 44

has no ro l e i n t h e i mm ed i a t e de c i s i on t o d e con t a m i na t e or p r i o r i ti z e d e co n t a m i na ti on. W h i l e su b seq u ent 45

con f

i r m a ti o n of expo s ure t h

rou g h l ab o r a t ory t e s t i ng m a y i nform so m e aspec t s of a t

t r i bu t i on ( w ho w as 46

expo s e d v ersus w ho w as no t ), m ed i c a l m ana g e m

ent (on g o i ng an ti d o t a l t h e r ap y ), o r pro g no s i s, n o 47v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

59 l ab o ra t ory re s u l t co u l d re as onab l y be e xpe c t ed t o b e a v a i l ab l e, on sce n e, t o p r i o r i tiz e decon t a m i na t i on 1

dec i s i o n s. 2

3

A g e ex t re m

es, p r e g nanc y , and ch r on i c m ed i cal con d i ti ons, sh o u l d a l so be fa c t o red i n t o t h e p r i o r i ti z a t i on 4

fra m

e w or k

, w it h t he assu m

p ti o n t h at p a t i e n t s i n t he s e ca t e g o r i es m ay h a v e a h i g her r i sk of i n j ury due t o 5

t he c he m

i cal con t a m

i na t i o n

. H i s t o r i c a l e x a m

p l es i n d i c a t e t h a

t i n a m ass p a t i ent i n c i de n t

, t ho s e n e ed i ng a 6

h i g her l e v el of c a re a re n ot t he o n es t o r each r e spon d e r s and re c e i v ers f i r s t ( O k u m ura e t a l ., 1 9 96; S can l o n, 7

201 0 ). I

n t he s e c a ses, d eco n t a m

i na t i on sho u l d s t i l l be cond u c t e d u n t i l p a ti e n t s of a h i g her r i sk ca t e g ory 8

a r

r i v e f o r d eco n t a m

i na ti on a nd t

r e a t m en t

. 9

10v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

60 

### F u nctio n al Ar e a 5: S

y ste m

- wide Coordi n ati o n of Pati e n t Dec o n ta m ination 1

T he pu r

pose of F u n c t i on a l A rea 5 i s t o p ro m o t e p l ann i ng t hat i s c o or d i n a t ed t h r o ug hout t he en t

i r e 2

co m m

un it y and add r es s es t

he ne e ds o f a l l c o m m

un it y m e m bers. G u i da n ce p a r ti c u l a r l y e m phas i z es t h e 3

i m

por t an c e of co m m

un i ca ti on and c oor d i n a t i on b e t w e e n re s pond e rs at t he i n c i de n t sce n e and at h e a lt h 4

care f

a c i l i t i es. 5



### G u ida n ce S tat e me n t 5.1

I f decon t a m

i na t i on i s i nd ic a t ed, i t sho u l d b e p e rf o r m ed as s o on as po s s i b l e, p r e f e rab l y a t t h e s c ene i f n ot

con t ra i nd i ca t ed by s a fe t y c ons i d er a t i ons.

Considerations:

• T he l o ca t i on for on

- scene p a t i ent dec o n t a m i n a ti on sh o u l d be at t he pe r i m e t er of t h e w arm z one

up w i nd, u p h i l l and f

ar eno ug h a w ay from t he che m i cal re l ea s e l o ca t i on t o p re v en t r e

- con t a m i na ti on and

s e r v e as t he e g r e ss p o i n t t o t he co l d z one.

Level of Confidence: II

6

D i sc u s s i o n : 7

O nce t h e d e c i s i on i s m ade t o deco n t a m i na t e p a t i en ts

, t he be s t l oc a t i on f o r d e co n t a

m i na ti on i s a

t t he s ce n e 8

or a t an o t h e r s u i t ab l e l o c a t i on t h a t c an be ac c es s ed wit h m i n i m al de l ay i f t h e re are con t r a i nd i c a ti o n s t o on

9

scene deco n t a m i na t i on s uch as ex t

re m e w ea t h er, sa f

e t y conc e rns, or a r i sk of a d d i t i on a l r e l ea s e. T he 10

pre f

e r ence for de c on t a m

i na ti on at t he sc e ne i s b a sed o n se v er a l ob s er v a t i on s : 11

12

 D econ t a m i n a t i on a t a fa c i l i t

y i n t rod u ces a d e l ay and o ng o i ng absorp t i on o f c on t a m i n a n t s ; 13

 O n l y one dec o n t a m i n a ti on set u p i s r e qu i red. T h i s d e p e nds on h ea l t h ca r e f a c i l i t i es acce p t i ng t hat 14

deco n t a m i na t i on a t t he s ce n e i s su f f i c i e n t

, w h i ch i n t u r n, depe n ds on co o rd i n a t ed pre

- i nc i d e nt 15

p l a n n i ng and t ru s t b u il d i n g

. 16

 D econ t a m i na t i on a t a l l p o t e n t i al re c e i v i ng fa c i l i t i e s r e q u i r e s m ore r e so u rces and i n t rod u ces 17

cons i de r ab l e v ar i ab i l i t y i n t he t h o rou g hne s s of dec o n t a m i na ti o n ; 18

 Decontamination at a facility risks contaminatio n of transport assets; 19

 Decontamination at a facility increases the risk of secondary contamination of medical 20

infrastructure and personnel; 21

 First responders are for the most part more proficient in decont amination than first receivers, 22

based on their training and frequency of equipment use (Keim et al., 2003; Moffett, 2010): 23

o T hey a re m ore s k i l l ed i n t h e use o f PPE

, 24

o T hey a re m ore fa m i l i ar w i t h deco n t a m

i na t i on eq u i p m

en t

, 25

o T hey e x er c i se and re

- t ra i n f requ e n t l y

. 26

27

K i rk and D e a t on (200 7 ) c o n t en d ed t hat dec o n t a m i n a t i on i s a f

i r st a i d p ro c edu r e a

nd t h a t any d e l ay i n it s 28

exec u ti o n i n c r eas e s t he c on t a c t t i m

e pa t i en t s ha v e wi t h a che m i c a l

. C on s i d e ra b l e conc e rn e x i s t s w it h 29

re g ard t o s e cond a ry con t a m i n a ti on. O k

u m ura et a l

. (2 0 05) n o t ed t h a t 1 0 % o f f i r e s er v i ce p er s onn e l and 30

23% o f t h e s t a f f a t S t

. L u k e’s h o sp i t a l had exp o sure t o S a r i n v apor fo l l o wi ng t he 1 995 T o ky o sub w ay 31

a t t ac k ; ho w e v er, i t sho u l d b e e m phas i z ed t h at no d e co n t a m i na t i on

– e i t h e r on

- sce n e or a t t he h o sp i t a l

– 32

w as pe r f

o r m ed. B ur g ess ( 1 999 ) e xa m

i ned 11 E D s ec o ndary co n t a m i na t i on e v en t s and f

o und t h a t t he 33

res u l t i ng E D e v acua t i ons l a s t ed f r om 1

- 10 hours du r i n g w h i ch be t we en 0 and 50 E D pa t i en t s had t o b e 34

m

o v ed. I n add i t i on, up t o 1 5 m

ed i cal p er s onn e l w e r e tr ea t e d f o r e x pos u re. 35

36

S e v eral ex i s t i ng g u i dance d ocu m en t s d e sc r i be dec o n t a

m i na ti on on

- scene as t he p r ef e rr e d ap p roa c h ( DOD 37

T S W G

, 200 4 ; ECBC , 200 9 ) w hen n o t p re c l ud e d by c o n t r a i n d i c at i ons such as w e a t her or sa f

e t y con c er n s. 38

S u b

j e c t m a tt e r e xpe r t s as se r t ed t h at d eco n t a m i na t i on a t t h e s c ene, i f pos s i b l e, i s t h e pr e f e rr e d ap p ro a ch. 39

F i r s t

, ra

p i d r e m o v al of con t a m

i nant and pre v e n ti on of s econd a ry con t a m i na t i on a re ob v i ous ad v an t a g e s. 40

S econd, es t i m a ti on of res ou rces and p er s onn e l n e eded i s ea s i e r w hen b as e d on t he nu m ber of p a t i en t s 41

m arsha l ed at t h e sce n e, t h a n w hen d e con t a m

i na t i on i s per f

or m ed at m u l t i p l e a lt er

na t i v e s i t es o r r ec e i v i ng 42v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

61 fa c i l i t i es. T h i rd, t r i a g e of p a t i en t s t o ap p rop r i a t e m ed i c al f a c i l i t i es i s ea s i e r f

rom one l o ca t i on t h a n a m ong 1

se v eral d i ff

e re n t s i t es. F ou r t h, u n i for m it y of a ss e ss m

ent of t he ne e d f

o r d e con t a m

i n a ti on, qu a l i t y of t h at 2

deco n t a m

i na t i on, and d e t er

m i na ti on o f t

he n e ed f or m ed i c a l e v a l u a t i on i s e a s i er f r om t he scen e

. I

t i s 3

pos s i b l e t h at m ed i c al res ou rces m ay be m ore rea d il y a v a il a b l e f

or t ho s e p a t i en t s m

ost i n ne e d i f 4

dec o n t a m

i na t i on i s p er f

or med at the s c en e ; e f

f e c t i v e decon t a m

i na t i on a t t he s cene cou l d e l i m i na t e t he 5

need t o t

ra n spo r t a pro p o r t i on of p a t i e n ts t o a h e a lt h c a re f ac il it y

, t h e reby p r es e r v i ng t rans p o r t and hosp i t a l 6

a c ce s s f

o r t hose w ho m

ore ur g en tl y r e qu i re i t

. I

n such i ns t an c es, s o m

e pa ti e n t s m ay not require 7

d e con t a m

i na t i on a n d thus, r e l e as e d, and so m e pa t i e n t s m ay under g o deco n t a m i na ti on a nd be re l ea s ed 8

f

o l l o w i ng a p e r i o d of as y m p t o m a ti c obs e r v a t i o n

. 9

10

P ro v i s i o n of fo l l o w

- up i ns tr uc t i ons i s ea s i er on

- scene w h ere pa t i e n t s are a l l i n one p l a c e. A dd it i on a ll y

, 11

pro v i d i ng l i m it ed s p e c i al r e sour c es for pa t i e n t c are (e. g

., t r an s l a t i on, beha v i o r a l h e a l t h / p s y cho l o g i c a l 12

suppo r t

, s pe c i a l a c ce s s eq u i p m en t ) i s ea s i e r a t t h e s c e n e (o n e l o ca t i o n ) t han p ro v i d i ng t he s a m e reso u rc e s 13

at m

u lt i p l e r e ce i v i ng f

a c i l i t i e s

. M ana g e m

ent of d eco n t a m

i na ti on w as t e w a t er (co n t a i n m ent and d i spos a l ) i s 14

a l so ea s i e r a t t h e one l o ca ti on. 15

16

S u b

j e c t m a tt e r e xpe r t s re c og n i z e se v eral li m it a ti o ns t o t he g u i d a n c e p ro v i ded i n t h i s s t a t e m en t : m any 17

pa t i e n t s m ay se l f

- e v acua t e and d e con t a m

i na t i on a t f ac i l i ti e s m ay be s t i l l req u i r ed (O k u m ura et a l

, 1998a

/ b; 18

V o g t & S o r en s en, 2002; U S C h e m i cal S a f e t y and H a z ard I

n v es ti g a ti o n B oard [ CSB ], 20 0 8). A t t he s a m e 19

ti m

e, so m e pa ti e n t s w i l l s t i l l i n s i s t on m ed i c al e v a l ua t i o n e v en i f t he po ss i b i l i t y of ex p os u re h a s been ru l ed 20

o u t ; t hey t oo m ay be requ i red t o f i r s t und er g o decon t a m

i n a ti on at t he f

ac i l i t y at w h i ch t

hey seek such 21

e v a l u a ti on. F i n a l l y , so m e fac i l i ti e s m ay per f

orm a second d eco n t a m

i na t i on d e sp i t e ass u ra n ces t h a t 22

p a ti e n t s ha v e a l r e ady been d e co n t a m i na t e d at t h e s cene. 23

24

T he he a l t h o u t co m e bene fit s of red u c i ng co n t a c t t i m e sooner r a t h e r t h an l a t er

– i f w ea t h e r o r s a f e t y 25

conc e rns d o n o t r e qu i re c o n s i d e r a ti on of an a l t ern at i v e appr o ach

– are ap p are n t. D econ t a m i na t i on a t t he 26

scen e , or as s oon a s po s s i b l e t h e re a f t er, i s op t i m a l , e v en i f n ot co m p l e t e l y ach i e v ab l e. 27

28v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

62 

### G u ida n ce S tat e me n t 5.2

A n ti c i p a t e se l f

- e v acua ti on f

rom t he sc e ne p r i o r t o de c o n t a m i na t i on a nd de v e l op a coor d i n a t ed w h o l e

co m m un it y respon s e p l an t o m ana g e t he en t i r e s p ec t r u m of pa ti e n t s, w h i ch i n c l u d e:

• A t sc e ne: A m

bu l a t ory and non

- a m

bu l a t ory p a ti e n t s w ho re m a i n a t t he s cen e ; i nd i v i dua l s o t h e r t han

resp o nd e rs w ho a

r r i v e at t h e sc e ne a f

t er t he re l ea s e a n d beco m e e x po s ed ( e. g ., n ew s rep o r t er s

, b y s t and e rs).

• S e l f

- e v acua t e d : P a t i en t s w ho t r a v el wi t ho u t t h e a s s i s ta nce o f r e spon d ers t o a he alt h ca r e f ac i l i t y (e. g.

, hosp i t a l , ph y s i c i a

n’s o f f i c e, or ur g e n t c a

re c en t e r ).

• L eft sc e ne: P a t i e n t s w ho l e a v e t he s cene and do not s e ek care (e. g

. r e t urn ho m e or t o w or k

, t

ra v el

e l se w h e r e), o r s eek care l at er d u e t o de l a y ed ons e t o f s i g ns and s y m p t o m s.

Considerations:

• T he r e spon s e co mm

un it y shou l d b e p r ep a

red for a s p e c t rum of p at i e n t s w ho m ay seek de l a y ed ca r e,

i n c l ud i n g :

o t hose w ho r e m a i n w it h out s y m p t o m s but w ho p re s ent o ut of con c ern ba s ed on m ed i a

r ep o r t s ;

o t hose w ho m ay be espe c i a ll y suscep t i b l e t o l ow l e v e l s of s e cond a ry con t a m i na t i on

i n t rod u ced t o t he ho m

e by an as y m

p t o m a ti c pa t i e n t w ho l e ft t he sce n e.

• P a t i en t s sh o u l d re m a i n a t t h e sc e ne o r m ed i cal f a c i l i t y for ob s er v a t i on a nd / o r t r e a t m ent as l ong as

su gg es t ed by resp o nde r s a n d / or r e ce i v e r s.

Level of Confidence: III

1

D i sc u s s i o n : 2

D ur i ng an i nc i de n t , p a t i en t s w il l use v a r i o u s ro u t e s t o r each m ed i c a l c a r e. S c a n l on (201 0 ) d e sc r i b e d t h e 3

m

eans by w h i ch pa t i e n t s s e l f

- e v acua t ed a nd s e l f

- t ra n s p or t e d t o r e ach m

ed i c a l c are af

t er t he 1 943 B a

r i

, 4

I t a l y b o m

b i ng w it h m

us t ard g as and a f

t e r t he 1 9 95 sub w ay S ar i n a t t a ck i n T o ky o, J a p an. I n B ar i

, pa t

i e n t s 5

s e l f

- e v acua t ed t h e sea s i de and rep o r t e d t o t h e hosp i t a l t o s e ek t re a t m ent f or b u rns a nd r es p i r a t o ry i n j u r i es. 6

I n T o ky o, J a pan, m a n y pa ti e n t s wa l k

ed or u s ed a t axi t o g et t o t he c l o se s t hos p i ta l

. T o k uda, et a l

. (200 6 ) 7

de s c r i bed t h e s e l f

- t r ansp o rt o f p a t i en t s a f

t e r t he 1995 sub w ay a tt a c k : 3 5 % of t h e i n j u red wa l k

ed t o t he 8

h o sp i t a l , 2 4 % we re t ra n spo r t ed by t a x i

, and o n l y 7% w e r e t ran s po r t ed by a m

b u l an c es. We n ck et a l

. (200 7 ) 9

re v i e w ed t he Janu ar y 2005 li q u i d t an k er c ar de r a il m

ent t h a t c a used t he r e l e ase o f c h l o r i ne i n G ran i t e v i l l e, 10

S C and i n t er v i e w ed t h e p a t i ent pop u l a t i on w h i ch s ou g ht m ed i c a l t re at m en t

. T r ans p o r t a t i on da t a w as 11

c o l l e c t ed for t he 5 7% o f p a ti e n t s t h at we re t r e a t ed w it h i n t he f

i r s t 24 h o u r s: 6 3 % s e l f

- t ransp o r t ed i n a 12

p r i v a t e l y o w ned v eh i c l e t o a m ed i cal ce n t e r; o n l y 35% we re t ra n sp o r t e d by E MS and 2 % we re t ra n sp o r t e d 13

by t he p o l i ce ( Wenck et a l

., 200 7 ). T h e se res u l t s i nd i ca t e t h at m any pa t i e n t s wi l l not wai t f o r E MS and 14

w i l l l ea v e t he s ce ne, po s s i b l y de l a y i ng dec on t a m i na t i on. T h ese pa t i e n t s m a y s ti l l be con t a m i n a t ed and 15

c o u l d po t en t i a l l y spr e ad t he c on t a m i na t i on t o o t he r s. M any m a y t ra v el a c ro s s a c it y t o t h e i r p r e fe r red 16

sou r ce o f m ed i c a l c en t er for t r ea t m

en t

. B ecau s e of t he t e n dency t o se lf

- e v acua t e and se l f

- t ra n sp o rt t o 17

r ea c h m

ed i cal c are, S c i s l o w s k

i ( 199 7 ) and A uf der H e i d e ( 1 989, 2 0 06) des c r i b e t h at i n n ea r l y a l l m ass 18

c as u a l t y i nc i de n t s a m bu l a t ory p a ti e n t s a

r r i v e f i r s t w h i l e t he m

ost se r i o u s l y i n

j ur e d a r r i v e l a s t f o r m ed i cal 19

t

r e a t m en t

. 20

21

Med i c a l p e rson n el sho u l d b e pr e pa r ed and a b l e t o m ana g e con t a m i n a t ed p a t i e n t s. I

n bo t h t he B a

r i

, I t a l y 22

and T o ky o, J a p an i nc i de n t s

, t he m

ed i c al s t a ff d i d n ot i n i t i a ll y deco n t a m i n a t e t he p a t i en t s. I

n t he T o ky o 23

a t t ac k , 39% of n u r s i ng as si s t a n t s, 27% of n u r s es, 2 6 % of v o l un t e e rs, 2 2 % o f ph y s i c i a n s and 18% of c l e r k s 24

beca m

e i l l wi t h s y m

p t o m s ( O k a m

ura et a l ., 19 9 8; S ca n l on, 201 0 ). B y be i ng pre p a r ed, t h e p a t i en t s wi l l 25

rec e i v e t he be s t c are and f ir st r esp o nde r s / f

i r s t r ec e i v ers w il l be p ro t e c t ed. 26

27

S i nce some pa t i e n t s may l e a v e t he s c e ne and re t u r n ho m e pr i or t o seeking and/or receiving m ed i cal c a r e

, 28

i nf

o r m a ti on sho u l d be a v a il a b l e t o ad v i se t hem on prop e r s e l f

- decon t a m

i na t i o n pro c edu r es. T h i s i n c l u d e s 29v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

63 re c o m m enda ti o n s t h at c l o t h i ng be re m o v ed, sea l e d i n a bag and t hen s e a l e d i n t o a n o t h er b ag ( i .e., dou b l e 1

b a gg ed). S ho w er i ng w it h t he u se o f s o ap and wa shc l o t h sho u l d be ad v i sed. T h e se i n d i v i dua l s sh o u l d b e 2

fu r t h er i n s t r u c t e d t o seek med i cal c a r e i f ex h i b i t i ng any of t he s i g ns a nd s y m p t o m s as des c r i bed by l o c al 3

a u t h o r i t i es resp o nd i ng t o t he che m i c a l i n c i de n t

. 4

5v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

64 

### G u ida n ce S tat e me n t 5.3

R espon d i ng and r ec e i v i ng or g an i z a t i ons sho u l d p l an f or b o t h a m

bu l a t ory and n o n

- a m

bu l a t ory pa t i e n t s

s i m u lt a n eou s l y

.

• A m bu l a t o ry pa t i e n t s s h ou l d be a b l e t o f o l l ow v erba l

, w r i tt e n or p o s t ed d i r ec t i o n s w it h no ph y s i c a l

ass i s t ance f

r om f i r s t r espo n ders or f

i rst r e ce i v e r s.

o May be h e l ped by “b u dd y ” or fa m il y m e m ber.

• N on

- a m

bu l a t ory pa t i e n t s w i l l ne e d ad d i t i o n al p er s onn e l t o as s i s t t hem t hrou g h t he proc e ss.

o S pec i a l i z ed eq u i p m

ent wi l l be ne e ded (e. g ., bac k boa r d s , ra i sed w o r k

i ng sur f ac e / r o l l er

ta b l e s).

Considerations:

• P l an n i ng for a m

bu l a t o ry and non

- a m

bu l a t o ry p a t i en t s s hou l d o cc u r f o r a l l t i e r s of deco n t a m

i na t i on

(non

- a m bu l a t o ry pa t i e n t s m ay not be a b l e t o condu c t se l f

- care).

• A s i g n i f

i ca n t nu m ber o f a m bu l a t ory p a ti e n t s a r e ex p ec t ed t o l ea v e t he s ce n e p r i or t o deco n t a m i na t i on

and m ay se l f

- present at a h ea l t h c are f a c i l i t y

. Level of Confidence: IV

1

D i sc u s s i o n : 2

T he ne e d t o pre p a r e f o r b o t h a m bu l a t o ry and non

- a m

b u l a t ory pa t i e n t s i s h i g h li g h t ed i n ex i s t i ng g u i dance 3

docu m

en t s a n d i s t y p i c a l l y based on i n c i d ent re p o r t s f o ll o w i ng re a l

- w or l d e v en t s. T he m ost no t ab l e 4

exa m

p l e of t h i s p l an n i ng n e ed i s t he 1995 sa r i n a t t ack i n T o ky o. I n re v i e w i ng a r e port f

r om S t

. L u k e’s 5

H osp i t al ( i n T o ky o), T o k u d a, et a l

. de t er m

i ned t h a t 3 5 % of t he i n

j u r ed wa l k

ed t o t he hos p i t a l

. I

n add it i on 6

24% we re t

ra n sp o r t e d by t a

x i , and on l y 7% w ere t

ran s por t ed by a m

bu l anc e s w h i c h m a y ha v e i nc l u d ed 7

bo t h a m

bu l a t ory and non

- a m

bu l a t ory patients ( T o k

u da et a l

., 200 6 ). T h u s, g i v en any i nc i de n t

, t he 8

expe c t ed r a ti o of a m bu l a t o r y t o non

- a m

bu l a t ory i s d i f

fi cu l t t o pre d i c t a n d co n t i n g enc i e s a re n e eded t o 9

prep a

re for bo t h s e t s o f p a t i en t s. 10

11

N on

- a m

bu l a t ory pa t i e n t s w i l l co n su m e t he m ost r eso u r ces i n t er m s of p e rs o nn e l m ana g e m ent (e. g

., t r i a g e, 12

m a i n t a i n o bs e r v a ti o n, su pp or t i v e ca r e, m ed i c i nal d i s p e ns i n g ) o v er a m bu l a t ory p a t i en t s. T h e ref o r e

, 13

con t i n g ency p l a n s f o r a m bu l a t ory pa t i e n t s u r g e i s t o r e duce p re s su r e on t he h ea l t h care f a c i l i t y t o a ll ow 14

conce n t r a t i on o f r eso u rc e s t o w ards n on

- a m bu l a t o ry pa t

i e n t s ( H i ck et a l

., 2 004 )

. D educ t i v e l y

, 15

deco n t a m

i na t i on o f non

- a m

bu l a t ory p a ti e n t s w i l l r eq u i r e ad d i t i on a l r eso u rc e s w e l l abo v e req u i r e m en t s f o r 16

a m

bu l a t ory p a ti e n t s

. 17

18

T i e r ed d e co n t a m i na t i on ( i

. e ., se l f

- care, g ross pa t i e n t a n d t e c hn i cal pa t i e n t d eco n t a

m i na ti o n ) m

us t

, 19

t he r ef

o re, acc o unt f

o r r e so u rce

- i n t e n s i v e r e qu i re m en t s t o ca r e f

o r no n

- a m

bu l a t ory pa t i e n t s. I

n fac t , s e l f

20

ca re i s as s u m ed as not ap p r opr i a t e and i n s t e a d, s k i pp e d t o g ross an d

/ or t e c hn i cal ti ered app r oa c h es. 21

A m

bu l a t o ry pa t i e n t s, on t h e o t h e r ha n d, sh o u l d be a b l e t o f o l l ow co m m ands and s h ou l d b e s e l f

- suf f i c i e n t 22

i n co n du c ti ng dec o n t a m i n at i on, i n c l ud i n g , se l f

- care; f o l l o w i ng i n s t r uc t i o n s f

o r a l t e r na t i v e deco n t a m

i na t i on 23

( i

. e., e v a c ua t i on / m ars h a l i ng t o an a l t e

rna t i v e s i t e, d i s ro b i n g , and spot dec o n t a m i n a ti o n ). A m

bu l a t o ry 24

pa t i e n t s s h ou l d a l so be a b l e t o as s i s t o t h er a m

bu l a t ory and n on

- a m

bu l a t ory p a t i en t s, i f nece s s a r y

. T he 25

u t i l i z a t i on of a b u ddy s y s t e m , such as a pa r ent or c a r e t a k er as s i s t i ng a ch il d or t he e l d e r l y t hrou g h t he 26

d e co n t a m

i na t i o n pro c ess, m ay fac i l i t a t e t h ose w ho req u i r e m i n i m al a s s i s t an c e t o u t i l i z e t h e a m bu l a t ory 27

ro u t e. I

n fa c t

, i n a he a l t

hc a re fa c i l it y

- based sur g e c a

pa c it y

, t h e use of so l i c i t ed v o l u n t e e r s (e. g ., for m er 28

e m

p l o y ees a n d r e t i re e s) a nd un s o l i c i t ed v o l u n t e e rs (e. g ., b y s t and e rs a nd pos s i b l y a m bu l a t ory pa t i e n t s w ho 29

a

re “ w e l l e n o ug h”) are re c o m m ended co n s i d e r a ti o n s ( H i ck et a l

., 2 0 0 4). 30v. 1 7



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65 

### G u ida n ce S tat e me n t 5.4

A t

- r i sk popu l a t i o n s 15 re q u i re add i ti o nal as s i s t a n ce. R e s p onder and rec e i v er o r g an i z a ti o n s sh o u l d

i m p l e m ent p l an n i ng and t

r a i n i ng t o as s i s t a t

- r i sk popu l a t i ons t hr o u g h t he d eco n t a m i na ti on p ro c ess.

• A t

- r i sk i nd i v i du a l s ha v e n e eds i n one or m o re of t h e f

o ll o w i ng fun c ti o n al ar e a s : c o m m un i ca ti on,

m ed i cal c are, m a i n t a i n i ng i ndepen d en c e, s u p er v i s i on, and t ra n spo r t a ti o n.

• A t

- r i sk popu l a t i o n s m ay i nc l ude i n fa n t s, ch i l d r en, t he e l d e r l y

, and pre g na n t w o m en, as we l l as p e op l e

w ho ha v e fun c t i on a l or m ob i l it y i m pa i r m en t s, li v e i n i ns t it u ti o na l i z ed or con g re g a t e s e t ti n g s, ha v e

li m it ed E n g li sh p r o f

i c i e n cy or a

re non

- E n g li sh s p ea k

i ng , or ha v e co g n iti v e i m

pa i r men t s.

Considerations:

• P l an n i n g

, t

r a i n i ng and co mm

un i ca ti o n w i t h m

e m bers of a t

- r i sk popu l a ti o n s s h ou l d be p r a c ti c ed p r i o r

t o an i n c i d e n t

.

• E nsure r e spon s e p l ans i n c l u de i n t e g r a ti on of add i t i on a l pers o nn e l t o as s i s t p a t i en t s t hrou g h

deco n t a m i na t i on a nd / o r p ai r i ng non

- a m bu l a t o ry pa t i e n t s wi t h a m bu l a t ory p a ti e n t s t o a s s i s t

.

• Ma k e e v ery eff

o rt t o k eep a ch i l d wi t h a pa r ent or t r u s t ed ad u l t b ut i f a c h il d i s a l o ne, a

resp o nd e r / rec e i v er s hou l d m a k

e e y e con t a c t and t

ry t o exp l a i n w h at i s g o i ng t o h a ppen a n d, i f

po s s i b l e, ass i st t he c h il d t h r ou g h de c on t a m i na t i on.

• A m e t hod t o h o l d or c a

rry a n i n f ant t h rou g h dec o n t a m

i na t i on m ust be i n p l a c e ( e. g

., l au n dry bas k e t

, baby ba t h ).

• C er t a i n i n d i v i dua l s m ay ha v e i ncr e ased su s ce p ti b i l it y t o co l d or h e a t i n j u r i e s ( e

. g

., i n f

an t s, y oung

ch i l dr e n, s e n i o r i nd i v i d u a l s

, pa t i e n t s wi t h h i s t ory of co l d or h e at i n j ur y ) a n d sho u l d be c l os e l y

obser v ed by f

i r s t r esp o nd er s and h o sp i t a l f i r st re c e i v e r s.

• H a v e a p l an for s e r v i ce a n i m a l s; i n t e g ra t e p e rso n nel tr a i ned i n an i m al t r i a g e (as r e sour c es al l o w ) a nd

deco n t a m i na t i on i n t o t h e p r oces s ; e ff o r t s s h ou l d be m ade t o k

eep an i m a l wi t h p a ti en t

.

• P a t i en t s wi th d e cr e as e d m ob i l it y (e. g

. i n w h e e l ch a i r s) m a y need t o b e t ran s f e rr e d t o a b ac k

board or

g urney and t r ea t ed a s a n on

- a m bu l a t ory pa t i e n t

.

• P a t i en t s sh o u l d r e t a i n, t o t h e g rea t e st ex t ent pos s i b l e, a l l m a t e r i a l s req u i r ed f or “ n o r m a l ” fu n c t i on a l i t y

(e. g ., pro s t h e t i cs, h e a

r i ng a i ds, e y e g l ass e s).

• P ro v i de wr i t

t en and p i c t o g raph i c i n s t

ru c ti o n s f o r the d e con t a m

in a ti o n pr o ce s s; t r a n s l a t e t o t he m ost

co m m on l y used l an g ua g es w it h i n t h e po p u l a t i on ( see a l so F u n c t i on a l Ar ea 6 : C r i si s an d E m er g ency

R i sk C o m m

un i ca ti o n ).

• I n t e g ra t e i n t e r

pr e t e rs i n t o a resp o nse p l an or h a v e pre

- recor d ed m essa g es i n t h e m ost fr e que n tl y used

l an g ua g es w i t h i n t he pop u l a t i on, as r e sou r ces a l l o w

.

• I n t e g ra t e beha v i o ral he a l t h pro f es s i on a l s ea

r l y i n t he r e spons e t o add r ess po t en t i a l se v ere r ea c t i ons o f

pa t i e n t s, a s r eso u rc e s a ll o w

.

• E v ery effo r t sh o u l d b e m ade t o k eep at

- r i sk pa t i e n t s wi t h a t r u s t e d p e rso n / c a r e t a k e r.

• D ur i ng t he p l a

nn i ng p r oce s s, i d e n t i fy at

- r i sk g roups wi t h i n t he co m m un it y and i n c l ude m

e m be rs of

t he s e g roups as ad v i s ors t o t he d eco n t a m i na t i on p l a n n i ng t eam and as p a r t i c i pa n t s i n d e con t a m

i na t i on

exe r c i s es.

Level of Confidence: IV

1

D i sc u s s i o n : 2

S c i e n t i f

i c s t ud i es are l a c k

i ng for sp e c i f

i c s of how t o a s s i s t a t

- r i sk popu l a ti o ns t hr o u g h t he deco n t a m i na t i on 3

p ro c ess. S e v eral ex i s t i ng g u i dance d ocu m en t s c it e t h e ne e d f

o r add i ti o nal p l a nn i ng f

o r at

- r i sk popu l a t i ons. 4

T h e D O D T S WG (200 4 ) a l so re c o m m ends an esc o rt be p ro v i ded for una c co m pan i ed ch i l dr e n and, i f 5

po s s i b l e, t o k eep ch i l d r en wi t h an ad u l t fa m il y m e m ber. A no t h er r eco m m

enda ti o n f rom rec e nt e v e n t s i s t o 6

15 N o t e t h at t h i s t e r m i s u s ed t h r o u g h o u t t h e do c u m

e n t a n d i s re p re s e n t a t i v e o f a l l s i m i l ar t er m s t o i n c l u d e: s p ec i al n ee d s

,

v u l n era b l e pop u l a ti o n s

, a n d acce s s o r f u n c ti o n al n ee d s

. T h e u s e o f t h i s t e r m i s c ons ist e n t w i t h t h e d ef i n i ti o n i n t h e P a n d e m i c

a n d A l l

- Haz a r d s P r e p are d n e s s A c t o f 200 6 ( P A H P A ), P u b

. L

. N o

. 109

- 4 1 7 (Dec 1 9

, 2 0 06 ). T h i s d e f i n i ti o n c a n b e f

ou n d i n

t h e g l o ss a r y a n d o n t h e HH S / A S P R w e b sit e a t: h tt p :/ / ww w

. p h e. g o v

/ P re p are dn e s s/

p l a n n i ng / a b c / P a g e s/ a t r i sk .a s p x

.v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

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66 g roup u n acco m

pan i ed c h il d

ren t o g e t her u n der t he sup e r v i s i on o f t w o o r m ore ad u l t s w ho can a ccou n t for 1

t he ch i l dr e n’s w e l l

- be i ng t hrou g h o ut t h e i nc i de n t and deco n t a m i na ti on p ro c ess (W i l e y , 200 6 ; C e n t e rs f or 2

B i o t e rr o r i sm P repa r edn e ss, 2008). 3

4

T a y l o r e t .a l ., ( 2 009) de s c r i b es t h e r es u lt s of a de c on t a m i n a ti on ex e r c i se u t i l i z i ng peop l e w it h d i s ab i l i t i es as 5

b o t h ad v i s o rs t o t he p l a n n i ng pro c ess and a s ex e r c i s e pa r t i c i p an t s. T h i s p a r ti c u l ar ex e rc i se i n v o l v ed: (1) 6

d eaf pa rt i c i pa n t s w ho u s ed A m er i can S i g n L an g uage ( A SL ) t o co mm un i ca t e ; ( 2) S pa n i sh

- spea k i ng 7

par t i c i pa n t s w it h l i m it ed E ng li sh p r o f

i c i enc y ; a n d ( 3 ) p ar t i c i pa n t s w it h ph y s i c a l d i sab i l i t i es (e. g . req u i r i ng 8

a w he e l ch a i r or o t h e r de v i c e for fu n c t i on a l m ob i l it y ). I n an effo r t t o m eet t he n ee ds of t h e se g roup s

, t h e 9

p l an n i ng t eam added t he f o l l o w i ng pe r sonn e l t o t he d ec on t a m i na t i on t ea m : i n t e rp re t e r s f o r S p a n i s h

10

spea k

i ng and A S L p a t i en t s, and ph y s i c al t h e ra p i s t s t o a ss i st i n t

ra n sf e r r i ng pa t i e n t s

. D i f

fe r ent eq u i p m

ent 11

w as a l so u t i li z ed, i n c l u d i ng acc e s s i b l e sho we r t en t s ( l o w w a l l s t a l l s) and s h o w er c ha i r s, w h i ch we re u s ed 12

i n l i eu of t

r a ns f e r r i ng w he el cha i r p a

r t i c i pa n t s t o b ac k

boards or g urne y s. 13

14

T h ree m a i n t he m es e m er g ed from t he i n t er v i ew a nd f o cus g roup d a t a : ( 1) co m m u n i c a t i on s ; ( 2 ) d i sa b i l i t y 15

a w are n es s ; a n d ( 3 ) d i f f e r i n g expec t a t i ons. F o r c o m m u n i c a t i on, d e af p a r t i c i p an t s i nd i c a t ed t h at m ore 16

d i r e c t i on wa s n e eded t o i n st ruct p a r t i c i pa n t s how t o m

o v e t hrou g h dec o n t a m

i n a ti o n. O t h e r su gg es ti o ns 17

i n c l ude d : m a k i ng e y e con t ac t , u s e o f body l an g ua g e or g es t ur e s, and po s ti ng s i g ns t o t e l l and show w h a t 18

par t i c i pa n t s sho u l d do. I t i s i n t er e s t i ng t o n o t e t h a t t he co m par i son g roup ( f

l u ent E n g li sh s p ea k

i ng 19

par t i c i pa n t s w it h out a d i sa b i l it y ) w as a l so co n fu s ed a bo ut w h e r e t o g o and how t o c onduct 20

deco n t a m

i na t i on. W i t h re g ards t o d i s a b i l i t y a w are n es s

, i t wa s n o t ed t h a t d e con ta m i na ti on t eam m

e m bers 21

shou l d ask pa r t i c i p an t s i f t h ey ha v e a d i sa b i l i t y ra t h er t

han j u st assu m

i ng and w h et

her t he p a r ti c i p a nt 22

ac t u a l l y needs as s i s t an c e, p ar t i c u l a r l y w hen t

ra n s f er r i n g f r om a w hee l ch a i r t o t he s ho w er c h a i r. 23

P ar t i c i pa n t s w it h d i s ab i l it i e s i n d i c a t ed a f ear t h at t h e i r aux i l i ary de v i ces ( w h e e l c h a i rs, ca n es, wa l k

ers, e t c ) 24

w ou l d be t a k en f rom t he m

, w it h o n e p a

r t i c i pa n t s t a ti ng “When t h ey t a k e a w ay y our w ay of m

o v i n g

, t hey 25

s t r i p y ou of e v er y t h i n g ! ” ( T a y l or e t a l ., 200 9 ). Ac ti o ns t h a t a ll ow a t

- r i sk popu l at i o ns t o m a i n t a i n s e l f

26

con t

rol sho u l d be t a k

en i n t o con s i d e ra t i on (e. g

. m a i n t ai n i ng e y e g l asses, red u ce a n x i e t y by s t a ti ng t h e 27

proc e ss b ef o re t he p a t i e n t e n t e r s). 28

29

T a y l o r e t a l ., ( 2 009) as s e r t e d t h a t by “ad d re s s i ng t h e n e eds o f peo p l e w it h d i s ab il i ti es, t h e n e eds o f o t h e r 30

i nd i v i d u a l s a r e o f t en m et, pro v i d i ng a u n i v ers a l b e ne f i t ”. I ncorpor a ti ng pe o p l e f

r o m a t

- r i sk popu l a ti o ns i n 31

t he p l an n i ng pro c e ss f o r d e con t a m

i n a ti o n op e r a ti o n s, a s w e l l as i n c l u d i ng t hem as par t i c i pa n t s i n 32

exe r c i s es, p er m it s p l a n ne r s an opp o r t u n i t y t o i d en t i fy n ew i s s ues and a s opp o r t u n it y t o i m pro v e t he 33

deco n t a m

i na t i on o p e r a t

i on s

. 34

35

I n add iti on, t h i s g u i d a nce r eco m m ends add i t i on a l p r e p ar a ti on t a k e i n t o a c c ount t h e exp e c t e d pop u l a ti o n 36

cha r ac t e r i s ti c s l i k e l y enco u n t e r ed

– t h e i r de m o g raph i c s, e t h n i c m a k

e

- up, l an g uage ba r

r i er s , and 37

soc i o eco n o m i c s t a t us and r esou r ce s / r e s i l i ency

– wi t h i n a j u r i s d i ct i on a l a rea. S u b j e c t m a tt e r ex p e r

ts 38

i nd i c a t ed t h a t t h e i r ex p e r i e nce s h o w s t h at o w n e r s wi l l br i ng t h e i r a n i m a l s ( i n c l ud i ng househo l d p e t s a nd 39

ser v i ce a n i m a l s) wi t h t he m

. T h er e f o re, i t i s b ene f

i c i a l for a co m m

un it y t o b u il d t h i s co m

pone n t i n t o t h e ir 40

p l ans and t o i de n t i fy capa b i l i ti e s p r i o r t o an i n c i de n t

. 41

42

A dd i t i on a l i nf o r m a ti on o n s pec i f

i cs for co m m

un i ca t i on w it h t he a t

- r i sk popu l a t i o n s can b e f o und i n 43

G u i dan c e S t a t e m en t s i n Fu nc t i on a l A r e a 6: C r i s i s and E m er g ency R i sk C o m m

un i ca t i o n

. S t a t e a n d l o c a l 44

pub l i c h e a l t h e m er g enc y

, m ed i c al cou n t er m eas u re d i s t r

i bu t i on, d i s a s t er e v acu a ti o n , and o t h e r d i sa s t e r 45

resp o nse and reco v ery p l a n s m ay pro v i de add i t i o n al r e co m m enda ti o n s f

o r a c co mm

oda ti ng a t

- r i sk 46

popu l at i ons u n i q u e t o y our spe c i f i c l oc a t i ons. 47

48v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

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67 

### G u ida n ce S tat e me n t 5.5

A for m al r a

p i d co m m un i ca t i on p roc e d ure sho u l d b e u ti li z ed t o pro v i d e ad v ance n o ti c e t o a r ea h e a l t h c a r e

fa c i l i t i es of a ha z ard o us c h e m i cal i n c i d e nt and t o s p ec if i c a ll y a l e r t f

a c i l i t i es t o t he pos s i b i l i t y of s e l f

e v acua t e d p a ti e n t s ne e d i ng ass e ss m ent of co n t a m

i na t i o n and a

r r i v i ng unannou n c e d t o h e a l t h c a r e

fa c i l i t i es.

Considerations:

• F i r s t r esp o nde r s a n d f

i r s t r e ce i v ers sho u l d h a v e on g o i ng c o m m un i ca t i ons t h rou g hout t he i n c i de n t

.

• C o m m un i ca ti on s y s t e m s s h ou l d b e r e dund a n t

, i n t er o p e rab l e, m u lt i

- d i r e c t i on a l a n d i n c l ude

no t i f i c a ti o n s t o a l l e m

er g ency respon s e p a

r t ne r s.

• A pre

- scr i p t ed t e m

p l a t e i n d i c a ti ng c r i t i c al i n f or m a ti on req u i re m

en t s sho u l d b e pr o duced d u r i ng

p l an n i ng be t we en f

i r st re s p onde r s and f

i r s t r ec e i v ers ( s ee F un c t i on a l A r e a 6 : C r i s i s and R i sk

C o m m un i ca ti o n ).

o I n iti al c o m m

un i ca t i ons sh o u l d i nc l ude t he fo l l o wi n g : i n i t i a l s c ene a ss e ss m en t ; i d e n t i t y of

t h e i n v o l v ed che m

i ca l ( s ) ( and t he i r t o x i c it y i f k no w n), c o m m

on l y obser v ed s i g ns a n d

sy m p t o m s; pa t i e n t de c on t a m

i na ti o n e f f or t s und e r w ay at t he sce n e.

o U pda t e s f

rom t he s c ene t o he a l t h c are f a c i l i t i es s hou l d i n c l ude t he co n f i r m ed i de n t i t y of

ha z ard o us che m

i ca l (s ) ; e s t i m a t ed p a t i ent nu m bers re q u i r i ng t

ran s por t ; t he i r t r

i a g e

c a t e g or i es; es t i m a t ed t i m

es of a rr i v a l ; a nd t he s t a t us o f pa t i e n t de c on t a m i na ti o n.

o U pda t e s f

rom rece i v i ng he a lt h ca r e f ac i l it i es t o t he s c e ne sho u l d i n c l ud e : t he s t at us of

fa c i l it y

- based pa t

i e n t d e co n t a m

i na ti on e f fo r t s ( i f an y ); e f

fe c ti v e ness o f d e co n t a m

i na t i on

a n d m ed i cal t r e a t m ent f rom t he s cen e ; e xpec t ed h o sp i t a l c a pa c it y ; r e

- rou ti ng of t

r a f f i c

a round hosp i t a l s o r a m

bu l ance d i v er s i on s ; i n f

o r m a t ion on c h e m

i cal i de n t i f

i ca t i on a nd

t ox i c i t y (e. g

., t h r ou g h hosp i t al l ab o ra t ory t e s t i n g ); d e l a y ed sy m p t o m s obser v ed

o R e g i onal p o i s o n ce n t e rs c a n ser v e a s an a u t h o r it a ti v e i nfor m a ti o n r eso u rce for bo t h

re s pond e rs and rec e i v ers re g ar d i ng t he hu m an hea lt h e f fe c t s o f t ox i c che m

i cal expo s ure. A

ce n t ral po i n t o f i nf

o r m a ti on w i l l p r e v ent c o nf l i c ti ng r e co m m

enda ti o n s.

• A l l co mm

un i ca ti o n p a t h wa y s shou l d b e p r e

- es t ab l i s h e d

, f r eque n tl y r e he a

rs e d

, and i n c l ude w r i t t en

pro t o co l s f

or t he m ost e f f e c ti v e use of res o ur c es. C l e ar l y es t a b l i sh e xpe c t a ti o ns a n d c r i t i c a l

i nf o r m a ti on n ee d s a m

ong a l l res p onse s t a k

eho l d e rs re g ard i ng i nf

o r m a ti on s ha

r i n g

.

• T he v o l u m

e of i n for m a ti o n t o be exp e c t e d on c o m m un i ca t i on s y s t e m s i n m ass ca s ua l t y e v en t s i s o f t en

unde r es t i m a t ed. I

t i s i m por t ant t h a

t r e spo n se p l a n s i n c l ude p r o v i s i o n s t o r a p i d l y aug m

ent

co m m un i ca t i ons c ap a c i t y and pe r sonn e l

. Level of Confidence: III

1

D i sc u s s i o n : 2

Wh i l e t h e re i s a l a r g e a m o u nt of an e cdo t al l i t e ra t ure c o ncer n i ng t h i s t op i c ( O k u m u ra, 19 9 8a

/ b; A u f d e r 3

H e i de, 1 989, 2 0 06), H o o d e t a l . (2 0 11) d es c r i bed a n e x er c i se w h ere a t eam pro v i ded bo t h deco n t a m i na t i on 4

a nd m

ed i c al c are du r i ng a s i m

u l a t ed m ass casu a lt y e v en t

. O ne o f t h e s t ud y ’s f i n d i ng s w as t h a t f

i r s t 5

r ec e i v ers t ook 4 0 m i nu t es t o s e t up t he d eco n t a m i na ti on f a c i l i t y and eq u i p m

ent as w e l l a s don appro p r i a t e 6

PP E b e fo r e ha n d li ng t h e f i r st p a t i e n t

. T h er efo r e, any w ar n i ng g i v en t o f i rst r e ce i v e r s p r i o r t o rec e i v i ng t he 7

f

i rst p a ti e n t s w il l a i d i n red u c i ng s e t up t i m e and a ll ow for immediat e c are. 8

9

I n add iti on, T o k uda and co l l ea g ues ass e r t ed t h a t t h e a b i l i t y of t h e E D t o p ro v i de t i m e l y and effe c ti v e 10

t r e a t m

ent i s e n han c ed by t h e i n for m a ti o n co m i ng from HA Z M A T t ea m s at t he sc e ne (2 0 06). T h i s 11

e m

phas i z es t h e ne e d f

o r r a p i d and e a

r l y co m m un i ca t i o n from t he f

i e l d t o t he m

ed i cal ca r e c e n t e rs. S uch 12

ea r l y co m m un i ca ti o n wi l l a ll ow re c e i v ing hea l t h ca r e f ac i l i t i es t o p r ep a

re for t he s e l f

- e v acua t i ng pa t i en t s 13

w ho, m any t i m es, show up bef

o re f i r st re s pond e r

- t ran s por t ed p a t i en t s. A d d i t i on al l y

, t h i s co m m un i ca t i on 14

a l l o w s h e a l t h c a re fa c i li ti e s t o co o r d i n a t e t ra n sp o rt o f n o n

- cr iti c al pa t i e n t s t o n e i g hbor i ng ho s p i t a l s; 15

i nc r ea s e s t a f f i ng l e v e l s ; i d e n t i fy and c o l l ect m a t e r i a l s ; identify m ed i ca t i on and r e f

e ren c es needed t o t r eat 16

i n co m

i ng pa t i e n t s; and p os s i b l y co o r d i n a t e p a t i e n t l o ad b a sed o n a v a il a b i li t y of r e sou r ces at a g i v en 17v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

68 i ns t i t u t e, as w e l l as c o or d i n a t e i n t he e v ent a hos p i t al m ust b e e v a c ua t ed due t o s econ d ary co n t a m i na ti on. 1

I n m ass casu a lt y i n c i d en t s of a l l t y pes, co o r d i n a ti on of p a t i e n t d i s t r i bu t i on i s o f t en l ac k i ng ( K i rk and 2

De a t o n, 2007). I n fa c t

, K i rk and De a t on (200 7 ), d e s c r i b e t h e p e r i od w h ere f i r s t r ec e i v ers a

r e l e ft i n 3

u n c e r t a i n t y as t he “ s i l e n t g ap” o r w he r e t h ere i s l i t t l e i nf o r m a ti on t h a

t has b e en s h a

r ed on t he n a t ure o f t h e 4

e v ent from t he s ce n e. A t l e a st i n l ar g e par t

, t h i s i s b eca u se patients s e l f

- t ra n spo r t ( A uf d e r H e i de, 1989, 5

2 006; Z oras t e r e t a l ., 200 7 ). O k u m ura et a l . (1 9 96) su gg es t e d t h a t i f l ar g e nu m

bers o f p a t i en t s r equ i r i ng 6

m

echan i c a l v en t i l a ti o n e x c e eds t he nu m ber o f v en t i l a t o rs a v a i l a b l e a t a pa r t i cu l ar h osp i t a l

, t h en t he r e i s a 7

need for p re

- hosp i t al co o rd i na t i on t o d e t e r m i ne pa t i e n t d i s t r i bu t i on. 8

9

Many co m m un iti e s r e qu i re f

i r st r e spond e rs t o n o t

i fy f ir st r ec e i v ers o f any t

ran s po r t t o t he i r f

a c i l it y

. T he 10

co m m

un i ca t i on b e t w een o n

- sce ne f i r st re s pond e rs and f

i r st r e ce i v e r s i s a c r i t i c a l o n g o i ng requ i re m ent 11

( A uf d e r He i de, 1 989). D e s p i t e t h i s req u i r e m en t

, m any su b

j ect m a t t er exp e r t s b e l i e v e that t h i s 12

coor d i n a ti o n do e s n o t o c cur m ost of t h e t i m

e becau s e o f i n e f

fe c ti v e co mm

un i ca ti o n ne t w o r k s be t we en f i r st 13

r e spond e rs, f i r s t r ec e i v ers, p o i s on c e n t e rs, and o t h er e m er g ency respo n se e n ti ti e s. F o r exa m p l e, ce l l u l ar 14

and t e l epho n e s y s t e m s are unr e l i ab l e i n d i sa s t e rs b e cau s e i f t hey are not d a m a g ed, t hey qu i c k l y beco m e 15

o v er l oa d ed a n d n o n

- func ti on a l ( A uf d er He i d e, 200 7 ). Ce l l p h ones m ay p l ay a v it a l r o l e in 16

co m m

un i ca t i ng t o bo t h f

i r s t res p ond e rs a nd p o t e n ti a l patients t h rou g h ne w l y i m

p l e m en t ed e m er g ency t ext 17

m

essa g es s y s t e m s such as FE M A ' s I n t e g ra t ed P u b li c A le r t W ar n i ng S y s t em ( I P A W S ) and t h e C o m m

erc i al 18

M ob i l e A l e r t S y s t em ( C M A S ). A po t e n ti a l a p pr o ach t o t he i ss u e of co m m un i ca t i on n e eds i n a c he m i cal 19

i n c i d e nt i s t o be g i n t o a da p t t h ese co mm un i c at i on p roc e dur e s a n d n e t w or k s f o r m ore r o u t i ne e m

er g enc i es 20

t o i n c r ease r es ponde r s’ fa m il i a r it y w it h t h e m and t o i d en t i fy pro b l e m s w it h t h e co m m un i ca t i on s y s t em 21

i t s e l f ( l a ck of i n t e rop e ra b i l it y ; l ack of r e dunda n c y ). A no t her i ss u e t o con s i d er i s t he a cc u racy of 22

i n f

or m a ti on be i ng con v e y ed be t we en o n

- scene res p ond e rs a nd r e c e i v i ng m ed i cal fa c i l i t i es. H o w e v er, 23

l i t er at ure s u gg es t s t h a t m ost s e c o ndary co n t a m

i na t i on o c cu r s beca u se t he h ea l t h ca r e fa c i l it y i s not re a dy 24

t o r e c ei v e pa ti e n t s ( O k u m ura et a l

, 1998a

/ b). T hus, i t i s b e t t e r for a ny a v a il a b l e i nf o r m a ti on re g ar d i ng 25

ch e m

i cal i d e n t it y , ro u t e / d u ra ti on / se v e r it y of co n t a m i na t i o n, t o x i d r o m

e or s y m p t om co m p l ex, and ex t ent o f 26

d ec on t a m

i na t i on e f fo r t s t o be c o m m

un i ca t ed wi t ho u t d e l a y

. F or p l an n i ng purpo s es, o t h e r su gg es t i ons 27

i n c l ude es t a b li s h i ng a f

i l l

- i n

- t h e

- b l ank form t hat w o u l d he l p f i r s t r espo n de r s no t i fy hea l t h ca r e f a c i l i t i es of 28

p e r t i ne n t i nf o r m a ti on (e .g ., che m

i cal su b s t a nce, i f k

no w n; s t a t e o f che m

i c a l ; s i g n and s y m

p t o m s pa ti e n t s 29

are p r e se n ti n g ; p at i e n t ’s r e sponse t o an t i d o t es, i f g i v en; nu m

ber of p a ti e n t s ; and w h a t t y pe of 30

de c on t a m

i na t i on, i f a n y

, i s b e i ng pe rf or m ed at t h e s cen e ). 31

32v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

69 

### G u ida n ce S tat e me n t 5.6

N o ti f i c a t i on, by v i s i b l e

, w r i tt e n, or v e r bal m eans, and i dea l l y a co m

b i na t i on o f a l l t hr e e, s h ou l d be u sed

t o rec o rd s cene dec o n t a m i n a t i on pr a c t i c e s f

o r c l e a r co m m un i c at i on a n d co o rd i na t

i on w it h h ea l t h ca

r e

fa c i l i t i es.

Considerations:

• I f a ph y s i cal d o cu m

en t a t i on s y s t em i s used, i t sh o u l d b e du r ab l e and t a m per p roof.

• N o ti f i c a t i on s y s t e m s shou l d be r edun d ant, i n t e r op e ra b l e, a n d m u lt i

- d i re c t i on a l a n d i n c l ude

no t i f i c a ti o n s t o a l l e m

er g ency respon s e p a

r t ne r s

.

• I f a ph y s i cal n o t i f

i c a ti on s y s t em i s u s ed, t he a m ount o f ti m

e t he n o t i f

i c a t i on t o ol i s v a li d a f

t e r t he

i n c i de n t i s o v er s h ou l d be d e t e r m i ned.

Level of Confidence: III

1

D i sc u s s i o n : 2

T r

i a g e c a t e g o r i es are l a

r g e l y d i scus s ed t hrou g ho u t t h e l i t e r a t u re w it h m any of t he cro s s w a l k ed d o cu m en t s 3

reco mm

en d i ng t he u t i l i z a t i on of s uch t o o l s t o h e l p o r g an i z e p a t i en t s. G i v en t h i s, c l e a r g u i d e l i nes n eed t o 4

be s e t f

o r l an g ua g e used i n cor r e l a t i on wi t h t he t r i a g e t oo l s. T he s e g u i de l i n e s c an s t an d ar d i z e 5

co m m

un i ca t i on b e t w een r e spond e rs a nd r e c e i v ers, m a k i ng t he deco n t a m

i na t i on c onduc t ed by r e ce i v i ng 6

hosp i t a l s m

ore e f f i c i ent and a v o i d i ng dup l i c a t i on o f e ff or t s . W h en l ar g e nu m

bers of patients a

r r i v e a t t he 7

E D i n a s ho r t a m ount o f ti m e, d i f

f i cu l t y a r i s e s i n t h e ab i l i t y of E D s t a f f t o d i f fe ren t i a t e b e t we en t hose t h a t 8

a r e co n t a m

i na t ed a nd t hose w ho h a v e been d eco n t a m i na t ed i n t he f

i e l d ( C l a r k e et a l

., 200 8 ). T he m ar k

et 9

p l ace h as d e v e l oped nu m erous t r i a g e t a g s t h a t c on v ey s i m il ar i n for m a t i on i nc l u d i ng bas e l i ne v i t al s i g ns, 10

m

ed i c a l cou n t e r m

easure or a n t i do t es g i v en, i f a nd how m uch deco n t a m

i na t i on h a s o c cu r

red, l oc a t i on of 11

i n

j ur y

, e t c. H o w e v er, o t h e rs such as O k u m ura et a l . (2 0 07) are de v e l op i ng a s y s t em for t he i n i t i al t r i a g e 12

and d eco n t a m i na t i on o f patients of a c h e m i c a l r e l e a se. T h i s s y s t em w i l l use c o l o r ed c l o t h es pe g s w here 13

red i n d i c a t es t h e need f o r e m er g ency care, y e ll ow f

o r se m i

- e m er g ency car e

, g reen for non

- e m er g ency 14

care, b l ack for e xpec t an t

, w h i t e for d ry de c on t a m

i na t i on, and b l ue for w et d e con t a m i na t i on. O k

u m ura et 15

a l

. ( 2 007) de t e r m i ned t hat t w o c l o t hes pe g s w ou l d be used p e r p e rson. O nce t h e p a t i ent had co m p l e t ed 16

we t d e co n t a m i na t i on, t he p a t i en t s w e r e s w i t ched back t o con v en t i on a l paper t

r i a g e t a g s. 17

18

Many E MS and HA Z M A T pers o nn e l u t i l i z e t h e S T A R T ( S i m p l e T r i a g e & R a p i d T r e a t m en t / T r ansp o r t ) 16 19

m

odel for c a t e g or i z i ng pa ti en t s ’ i n j u r i es a t t he s cene. F i r s t r esp o nde r s a n d r e c e i v ers c an u t i li z e t oo l s such 20

a s t h e HH S C he m i cal E m er g ency Med i cal Ma n a g e m ent I n t e lli g ence S upp o rt T o o l ( C H E MM

- I S T ) or t h e 21

N a t i o n al L i b r ary of Med i c i n e ’ s W i r e l e ss I nfo r m a ti on S y s t em for E m er g ency R espond e rs (W I SER ) t o 22

r eco g n i z e t o x i d ro m es a n d i de n t i fy t he g en e r a l c l ass of c h e m i cal a g ent to w h i ch t he p a t i e n t s we re expos e d. 23

T h i s a d d i ti o n al i n for m a ti on w i l l a i d i n S T A R T

, p a r ti c u l a r l y i n p r i o r i t i z i n g pa ti e n t s for res u sc i t a ti o n, 24

a n t i do t al t h er ap y , decon t a m i na t i on, a n d t hen t

ra n spo r t o r r e l e ase fr o m t he scene. 25

26

H o w e v er, Z oras t e r e t a l. ( 2 007) found t h a t t he c u r r ent t r i a g e s y s t em ( S T A R T ) has cha l l en g es. I

n 27

par t i c u l a

r, t he r e i s t h e p o t e n t i al for t he m is d i s t r i b u t i on of p a t i en t s t o he a l t h c a re f a c i l i t i e s. T h i s p o ses 28

co m m

un i ca t i on c h a l l en g es i n r e l a y i ng dec o n t a m i n a ti o n pr a c t

i c e s oc c ur r i ng at t he scene w i t h t h e v ar i o us 29

hea l t h c are f a c i l i t i es. F o r e xa m

p l e, i f so m

e pa t i e n t s ( w it h v ar y i ng expo s ur e s) we re ade q u a t e l y 30

de co n t a m

i na t e d wi t h s e l f

- care o r g ross pa t i e n t d eco n t a m i na ti on p ro c es s es w h i l e o t hers we re t e c hn i ca l l y 31

deco n t a m

i na t e d, co mm

un i ca t i ng w hat has ( o r h a s not ) o ccu r red i n t er m s of d eco n t a m

i na ti o n m ay be 32

16 De f

i n ed as a t ra u m a

- b a s ed sy st e m u ti l i zed f o r t h e t r i a g e o f a d u l t a n d p e d i a t r i c m e d i cal p a ti e n t s re s u l ti n g i n a

re p r od u c i b l e t r i a g e p r o ce s s s o t h at d i f f er e n t E m e r g e n c y Me d i cal S er v i ce (EM S ) p r o v i d ers c o m e t o t h e s a m e t r i a g e

ca t e g o r y c o n c l u si o n w h e n a ss e ss i n g p a ti e n t s b a s ed o n s e v er it y

. (G o n za l ez, D. ( 2011 )

, Tri ag e Ove r v i e w : M od ifi ed

S

. T .A.R. T

. , C o n ti n u i n g Me d i c al E d u ca ti o n

– N e w s & I n f o r m a ti o n

, F DNY O f

f i ce o f Hea l t h A ff

a i r s

, N o v 2011

, V ol 17

, I ss u e 11

, Re tri eved fr o m h tt p :/ / ww w

. n y s v ara. o r g / n e w s / 2011 / n o v / 1111 2 2b

. p d f o n 3 J a nu a r y 2013.v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

70 d i f f i c u l t i f n o t a l m

ost i m poss i b l e i n a m ass c as u a l t y even t

. T h e co mm un i ca ti o n c ha l l en g es a

re fu r t h e r 1

co m

pounded by pa t i en t s e v acu a ti ng t h e s c ene q u i c k l y and sho w i ng up at t he he a l t h ca r e f ac i l i t y on t h e i r 2

o w n, or p o s s i b l y as s i s t ed b y g ood S a m ar it a n s ( n ot k n o w i ng t hat t he pa t i e n t s we re pos s i b l y co n t a m i n a t ed 3

fu r t h e r ex a c e rb a ti ng t he m ed i c a l p rob l e m s) ( O k

u m ura, 2007). 4

5

T w o

- w ay c o m m un i ca ti o n s hou l d o cc u r b e t w een t he h e a l t hc a re f a c i l i t i es and f

i r s t r espon d ers o n

- scene. 6

I dea ll y , f

i r s t resp o nd e rs s ho u l d r e l ay t o sup p o r ti ng he al t h c a re fa c i l i t i e s of t he dec o n t a m

i na t i on p ro c ess 7

used on t he p a ti e n t s ( i .e., se l f

- care, g ross p a ti e nt a nd te chn i c al pa t i e n t). I n t urn, h e a l t h c a

re fa c i l it y 8

ba s ed f

i r st r e ce i v e r s sh o u l d send f eedb a ck t o f

i e l d f i r s t res p o n ders on d e con t a m ina t i on ef fe c ti v ene s s and 9

ef

f ec t i v ene s s of i n i t i al e m

er g ency m

ed i cal t r e a t m

en t

. T h i s wi l l a l l ow r esp o nd e rs t o a lt e r p ra c t i ces i n 10

re a l

- ti m

e, i de n t i fy t he n eed for s pec i f i c i n t e r v en t i on / an t i d o t e ( i f t he h ea l t h c a r e f a c i l i t y i s f i r st t o 11

i de n t i fy t he po i s o n), o r a l e r t res p ond e rs of ad v e r se e ff e c t s ( e. g ., p a t i e n t s a

re a r r i v i ng h y po t he r m

i c). I n 12

add iti o n, f

i r s t resp o nd e rs s h ou l d co m m un i c a t e t o ho s p i t a l f

i r s t rec e i v ers t he sus p ec t ed o r f i e l d 13

c o nf

i r m ed i de n t i t y (us i ng f

i e l d c he m i cal d e t ec t

i on m e t hods an d

/ or d e v i ce s ) o f t h e a g ent r e l e ased i n 14

o rd e r f

or appro p r i a t e d e f

i n i t i v e c are t o o cc u r. F u r t h er m or e

, i f d eco n t a m

i na t i on i s n ot o r ca n not (due t o 15

en v i ron m

en t a l con d i t i o n s) b e per f

or m ed, t h i s m ust a ls o be co mm

un i ca t ed t o h e a lt

h ca r e f ac i l i t i es and 16

m ay resu l t i n ro u ti ng con t a m i n a t ed p a t i e n t s t o fa c i l i t i e s wi t h d e c o n t a m i na t i o n cap a

b i l i ti e s. 17

18

T he L ab o r a t ory R espo n se N e t w ork

- C li n i c a l ( LR N

- C ) m ay a l so pro v i de co m m u n i c a t i on t o f

i r s t r ec e i v ers 19

on t he l i k

e l y che m i cal i de n t it y

. LR N

- C i s a n a t i on w i d e ne t w o rk of l o c al and s t a t e pub l i c h e a l t h acc r ed i t ed 20

c l i n i c a l l abo r a t o r i es. T he s e l a

bo r a t o r i es r ec e i v e b l ood and u r i n e s p ec i m ens f rom hosp i t a l s i n ord e r t o 21

an a l y z e for t h e b i o l o g i cal i nd i ces i n d i c a t i v e of a pa r t i cu l ar che m

i cal exp o s ure. F

rom t he c li n i c a l 22

l ab o ra t ory re s u l t s, LR N

- C fac i l i t i es c an co mm unica t e t he l i k e l y che m i cal i de n t i t y (or a t l e a st c l a ss o f 23

che m

i cal a g en t s ) i n v o l v ed w it h p a t i e n t ex p osu r e. T h e proc e ss, h o w e v er, m ay t a k e se v er a l ho u rs 24

depen d i ng upon t he nu m b e r of c l i n i cal sa m

p l es re c e i v ed and t he an a l y ti c al m e t h o ds us e d. 25

26

D ef

i n i ng t he endp o i nt of w hen d e con t a m ina t i on and fi e l d e m

e r g ency m

ed i cal t r ea

t m ent ha v e ce a sed a l so 27

req u i r e s co mm un i ca ti o n t o ser v i c i ng hea l t h c a r e f a c i l i t i es. T h i s i nf

o r m a ti on pro v es v a l ua b l e for t r ac k i ng 28

pa t i e n t s a

r r i v i ng t o a h o sp it al a t a l a t er t i m e (but w ho m a y ha v e l eft t he sce n e e a r l i er i n t he re s pons e ). 29

T h e se p a t i e n t s, t hen, w ou l d req u i r e de c on t a m i na ti o n a t t he h o s p it a l ( w h i ch re q u i r e s a s t a t e o f r e ad i ne s s i n 30

an t i c i pa t

i on t h a t p a t i en t s wi l l s how up a f t er t he i n c i d e n t r e spo n se t ra n s i ti o ns t o r e c o v er y ). 31

32v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

71 

### G u ida n ce S tat e me n t 5.7

PP E se l ec t i on, t r a i n i ng and use s h ou l d be b a sed on ap p li c ab l e r e g u l a t i ons ( O S H A 17 ) , s t a n da r ds

( N I O S H 18 ), an d

/ o r g u i dan c e ( N FP A 19 ), su b j e c t m at t e r ex p er t i s e , and m anuf a c t u r e r s ’ s pec i f

i ca t i o n s, i n

co n j u n c t i on w it h sce n e e v a l ua t i on a n d r i sk as s ess m ent and A u t h o r it y H a v i ng J u r i s d i c ti on s t an d a rd

oper a t i ng proce d ur e s or s ta ndard ope r a t i ng g u i de l i ne s

. Considerations:

• PP E se l ec t i on sho u l d i nc o r por a t e t he c on t i n g ency t h a t resp o nd e rs m ay conduct l if e

- sa v i n g m

ed i cal

i n t er v en t i ons, supp o r t i v e c a re, a n d / o r a n t i do t e ad m

i n i st ra t i on for co n t a m

i na t e d p a t i en t s p r i or t o or

dur i ng t h e co n du c t of pa t

i e nt t ech n i c a l d e co n t a m

i na t i o n.

• A l l r es p i r a t o rs u sed by civilian r e s p onde r s and re c e i v e r s sho u ld be N I O S H

- appro v ed.

Level of Confidence: III

1

D i sc u s s i o n : 2

S t ud i es on pe r son a l p ro t e c t i v e equ i p m ent ( PP E ) e f

f i ca c y a g a i nst a v a r i e t y of che m i cal a g en t s a nd a m

ong 3

f

i r st r e spond e r a nd r ec e i v er co m m un iti es a r e w e l l f

ou n ded ( M y ers, 2 0 00; Z i s k i n e t a l , 2 0 03 ). P P E i s t he 4

l a s t i n t h e l i ne o f d e fe n se t o pro t e c t p e rson n e l ; t y p i ca ll y PP E fo ll o w s a f t e r en g i n ee r i ng co n t r o l s, w or k p l ace 5

p r a c t i c e s and a d m i n i s t r a t i v e con t

r o l s ( O S H A , 2006). I

n a che m i c a l e v en t , ho w e v er, t h e u s e of t he s e 6

h i g h e r h i er a rchy f o r m s of p ro t e c ti on i s not i m m ed i a t e l y a v a i l ab l e or p r ac t i ca l , p a r t i c u l a r l y w it h in t he f

i rst 7

few h o urs of a d y na m i c i nc i de n t

. Pe rso n al p r o t e c ti v e e q u i p m ent ( PPE ), t her e fo r e, r e m a i ns t h e m ost v i ab l e 8

a n d r e ad i l y ac c ess i b l e f o rm of pr o t e c ti o n a g a i nst c he m i cal a g ent e x p o sur e s. I

n add i t i on, PP E w il l l i m

i t 9

cr o ss c on t a m i na t i on f r om pa ti e n t t o r e spon d e r. 10

11

The O S HA

, N I O S H and, N F P A ad v i se a r i s k

- based ap p r o ach w hen de t er m i n i ng t he t y pe and use o f PPE

. 12

H or t on e t

. al (200 8 ) f ound t hat t he l e v el o f PP E a n d r es p i r a t o ry pro t ec t i on n ee d ed by H A Z M A T pe r sonn e l 13

v ar i es g re at l y and dep e nds on t h e i r an t i c i p a t ed w o rk a c ti v i t i e s

. T he fa c t o rs t o co n s i de r i n t he s e l e c ti o n of 14

PP E i n c l ude t he an t i c i p a t ed sub s t an c e, t ox i c i t y of t h e s ubs t a nce, po t en t i a l r o u t e s o f exp o su r e, de g r e e of 15

con t a c t

, and t he spe c i f i c t a s k ass i g ned t o HA Z M A T p e rson n e l

. P er s onn e l m ust be pro v i ded w it h 16

appro p r i a t e r e sp i r a t ory and der m al pr o t e c t i on s p e c i f i c t o t he con t a m

i nan t

. C u r r en t l y , no PP E can p r o t e c t 17

t he we ar e r f rom exposu r e t o a l l po s s i b l e h a z ards ( N F P A 472, 2013 E d ). T h er e f o r e, r e spon d ers and 18

rec e i v ers m ust d e t e r m

i ne t h e ap p rop r i a t e c o m

b i na t i on of PP E b a sed o n t h e sp e c i f i c sub s t a n c e a nd a r i sk 19

ass e ss m

en t

. 20

21

A li m

it a ti on of PP E i s t he physical, psychological and communication h i nd r anc e s t o t h e pro v i d er, w h i ch 22

m ay li m

i t t he a m ount of ca r e due t o red u ced dex t e r i t y w h i l e w e a r i ng t he equ i p m

en t

. B er k ens t adt et a l

., 23

(200 3 ) d e sc r i b e s p a st s t ud i es t h at show e m

er g ency m

ed i cal t ech n i c i ans w ea r i ng i n c re a sed PP E l e v e l s h a v e 24

de c re a sed d ex t er i t y

. K o e n i g (20 0 3) a l so de s c r i bed t he p h y s i o l og i cal b u rde n s of P P E t o t he hu m an w earer 25

and c on c l u d ed t h e i m por t ance t o cre a t e app r op r i a t e PP E g u i dance m i n i m i z i ng respon d e rs’ and h ea l t h c are 26

w or k

er s ’ ab i l i ti e s t o p e rf

o rm t h e i r p r i m ary du t i es. F u r t h er m ore, C l a r k e e t

. al (200 8 ) exp l a i n e d t h at 27

li m

it at i ons i nc l u d e t h e l i m

it ed l i fe span o f t h e r es p i r a t i on f i l t er s and t he t i m

e i t t a k es t o re p l a c e t h ese 28

f

i l t e r s; ro t a t i on of s t a f

f m e m bers t o a v o i d f

a ti g ue a n d he a t e xh a

us t i on; and t he cu m

berso m e na t ure of t he 29

17 OSHA’s mission is to assure safe and healthful working conditions for working men and women by setting and enforcing

standards and by providing training, outreach, education, and assistance. OSHA HAZWOPER (29 CFR 1910.120) and PPE

(29 CFR 1910 Subpart I) regulations can be found at the following:

h tt p :/ / ww w

. o s h a

. g o v / p l s/ o s h a w eb / o w a s r c h

. s earc h

_ f o r m ? p

_ doc_ t y pe= S T A N D A R D S & p

_ t oc_ l e v e l =1 & p_ k e yv a l u e= 1910

18 NIOSH is a federal public health agency that develops techni cal performance standards and evaluates respirator

technologies and PPE. For additional information regarding NIOSH

- approved respirators and PPE, please see the following :

h tt p :/ / ww w

. c d c. g o v

/ n i o s h / n pp tl/

19 The mission of the NFPA is to reduce the worldwide burden of fire and other hazards on the quality of life by providing

and advocating consensus codes and standards, research, training, and education. For additional information regarding

NFPA standards for PPE, please see the following: NFPA 1991 and 1992 at h ttp://www.nfpa.org/catalog/v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

72 PP E su i t s t h at c ause de c re a sed dex t e r i t y and i n t er f e r e w i t h co m m

un i ca t i on b e t w een E D s t a ff a nd p a t i en t s. 1

I n add i ti on, o t h er li m it a t i ons f i r st r e spond e rs and f

i rst r e ce i v ers w i l l e n cou n t e r a r e li m it ed v i s i on and 2

h e a r i ng, w h i l e w e a r i ng PPE. 3

4

T h e r e fo r e, PP E r eq u i r e s e x t ens i v e p re

- e v ent t r a i n i ng and re g u l a r p r a c ti c e t o a t t a i n s k

ill s, su s t a i n s k

i l l s, and 5

a c h i e v e f

a m ili a r i t y w i t h t he p h y s i c a l r e s t r i c t i o n s. When p e r for m i ng m ass hu m an decon t a m i na t i on, PP E 6

w ear wi l l s i g n i f i ca n tl y af f ect t o t a l p a t i ent d eco n t a m i na ti on nu m

bers o v er t i me, and t hus, p l ann i ng and 7

l o g i s t i c a l m ana g e m ent (e. g ., deco n t a m

i na t i on pe rs onnel r o t a t i o n s, r ep l ace m ent of a i r p u r i f

y i ng f i l t e r s or 8

s w ap p i ng out s e l f

- c on t a i ned b r e a t h i ng a i r t an k s) m ust a ccou n t f

or t h i s f ac t or. 9

10v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

73 

### G u ida n ce S tat e me n t 5.8

S cene res p onse and h e a lt h care f a c i l i t y e m er g ency p l anners sho u l d w o rk w it h f e d er a l

, s t a t e, a n d l o c a l

g o v ern m ent of f i c i a l s t o e n s ure a ny g u i dance, p ra c t i ces, and p l ans pr o p e r l y addr e ss appr o p r i a t e l a w s,

re g u l a t i o n s and g u i d an c e c once r n i ng en v i ron m en t a l i s s ues such as t he m ana g e m e nt of l i qu i d and so l i d

w as t e s, en v i r on m

en t al m on it o r i ng of deco n t a m

i n a ti on are a ( s ) and o t h er en v i ron m en t a l i m pact i s su e s.

Considerations:

• E n v i ron m

en t al con c erns n e ed t o b e s u bor d i n a t e t o l i f e

- saf e t y conc e rns.

• C oord i na t i on t h r ou g h t he L ocal E m er g ency P l an n i ng C o m m

itt ee ( LEP C ) or s t a

t e and l o c a l a g en c i es

m a y be nece s sar y

.

• C urre n t EP A g u i da n ce s u gg es t s d e con t a m i na t i on p e r f

or m ed for l i f e

- sa v i ng oper a ti o n s t a k

es pr e ce d ent

o v er con t a i n i ng or on

- s i t e tr ea t m ent o f w a t er ru n

- off.

Communication and coordination with wastewater treatment facilities of the contaminant identity (if

known) and approximate quantities discharged can help plan these facili ties’ operations including the

protection of their plant personnel

Level of Confidence: IV

1

D i sc u s s i o n : 2

S c i e n t i f

i c l i t er a t u re a n d r e g u l a t ory g u i dan c e po i n t s t o w ard t he req u i r e m en t s of co n t a i n i ng ha z ard o us w as t e 3

( w h i ch i nc l udes dec o n t a m i na t i on run

- off). T i t l e I II of t he S u pe r fund A m en d m ent and R eau t h o r i za ti o n A ct 4

( S A R A ) of 1 9 86 r equ i r e s hos p i t a l s t o p a r t i c i p a t e i n co mm

u n it y d i s as t er p l a

nn i ng f o r HA Z M A T i nc i de n t s 5

( C ox, 2009). T he E n v i r o n m en t al P ro t e c t i on A g ency ( EP A ) i s ch a r g ed w it h c a

rr y i ng out t he 6

r esp o n s i b i l i t i es o f S A R A

, T i t l e III

, w h i ch s t a t e s l oc a l e m er g ency p l an n i ng co m m

itt ees ( LEPC ) m

ust 7

de v e l op a c o m m un it y ha z ardous sub s t a n ce e m er g ency con t i n g ency p l an t o b e f o ll o we d by fa c i l it y o w ners, 8

po l i ce, hos p i t a l s, l ocal e m er g ency respond e rs, and e m er g ency m

ed i c a l p e rson n e l

. 9

10

T h e US E n v i ron m en t al P ro t e c ti on A g ency (2000) ho w e v er h a s i s sued t he f o ll o w i ng s t a t e m

en t for 11

CERLCA

- related activities and enforcement authorities 12

13

D ur i ng a haz a rdous m a t e r i a l s i n c i de n t ( i n c l u d i ng a c h e m i c a l/ b i o l og i cal age n t t

e r ror i st eve n t )

, f

i r s t 14

respo n de r

s sho u l d u nde r t

a ke any ne c ess a ry e me rge n c y ac t i o n s t o sa v e l i v e s and pro t e ct t he pu b li c and 15

t he m s e l v es. O n c e any i mmi nent t h r ea t s t o hu m an h e a lt

h and l i ve [ s i c ] a r

e add r es s ed, f i r s t r espo n de r s 16

shou l d i mm e d i a t e l y t a ke a l l reas o nab l e e

ff o r t s t o co n t a i n t h e co n t a m i na t i on a nd a vo i d o r mi ti g a t e 17

env i ron m e n t al co n sequ e nc e s. EP A w i l l n o t p u rsue e n

f o rce m e n t a c t i ons a g a i n st s t a t e and l o c al res

p ond e rs 18

f

or t he e nv i ron m e n t

a l co n s equen c es o

f n e ce s sary and approp r i a t e e me rge n cy r e s ponse a c t i ons. 19

20

T h e EP A po l i cy quo t ed a bov e i s ba s ed on CERCL A S e c t i on 107 (d) ( 2 ). H o w e v er, t h i s p r o t e c t i on d o es 21

not a p p l y i n c as e s w h e re t h e l o c al g o v ern m ent i s g r o s s l y ne g li g ent or i n t e n ti o na l l y en g a g es i n m i scond u c t

. 22

N e g li g ence and i n t e n ti o n al m i sconduct a r e f

a c t

- spec i f i c de t er m i na t i o n s ( EP A , 2 01 1). F u r t h e r m ore, t h i s 23

pro c l a m a ti on does not co n f er i mm un it y from s t a t e en v i ron m en t al re g u l a t i ons. R es ponder and h e a lt h ca r e 24

or g an i z a t i ons sho u l d e n su r e t h a t t h ey co m p l y w it h a l l a

pp l i ca b l e l oc a l

, s t a t e, and fe der a l r e g u l a t i o n s. 25

E m

er g ency responde r s sh o u l d n o t i fy t he F e de r al O n

- S cene C o o r d i n a t or ( F O SC ) t hrou g h t he N a t

i on a l 26

R espon s e C e n t er. B y i n v o l v i ng t he F O S C w hen t h e re i s t he p o t e n t i al for or ac t ual en v i ron m en t a l 27

con t a m

i n a ti o n, r espon d e r s w il l re d uce p o t e n t i a l l i a b i l i t

y concerns as F O SC s can d e t e r m i ne w h i ch 28

en v i ron m

en t a l re g u l a t

i ons a re a p p l i ca b l e (or r e l e v ant a nd ap p rop r i a t e) t o t he r e sp o nse a c t i ons b e i ng t a k en. 29

T he F O S C can a l s o pro v i d e add i ti o nal t e ch n i c a l a s s i s t a nce a n d sup p o r

t or assu m

e t he en v i r o n m

en t al 30

resp o nse ac t i on, i f ne e ded. 31

32

T he LEP C i d en t i f i es a l oc a l hea l t h c a r e f

a c i l i t y t h a t h a s a g reed t o a c ce p t and t r e a t patients of e m

er g ency 33

i n c i de n t s. H o w e v er, e v i de n ce i s l a c k i ng t o show t h a

t s e l f

- t ra n spo r t i ng pa t i en t s a

re a w are of t h i s 34

des i g na t i on or t h a t t h ey w i l l g o t o t h e d e s i g na t ed h o sp i t al e v en i f t h ey w ere a wa re ( A uf de H e i d e, 200 6 ). 35v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

74 D ea l i ng w it h c o n t a m

i n a t ed pa t i e n t s r eq u i r e s E D s t a f f t o con s i d e r k

ey aspec t s of r e ad i n e ss, i n c l u d i ng 1

m

iti g a ti on, p re p a r edne s s, re sponse and re c o v ery ( A d i ni et a l ., 2 0 06). T he r e a re n u m erous h i s t o r i c al 2

exa m

p l es o f t h e l ow p e r ce n t a g es of pa t ie n t s a r r i v i ng t o t he h o s p it a l v i a a m bu l a n c e

. T h ey i nc l ud e : 3 3 % of 3

k

no w n casua lt i es i n t he b o m b i ng of t he M u r r ah F e d e r al B u i l d i n g

, O k l aho m a C it y i n 19 9 5; l e s s t h an 1 1 % 4

of t h e patients i n t h e s a r i n at t ac k

, T o k

y o, J ap a n, i n 199 5 ; and 6 .8% of p a t i e n t s i n j u r ed f r om t he t e rr o r i st 5

a t t ack on t h e W o r l d T r a de C en t e r, N ew Y ork C it y

, N Y i n 2001 ( O k u m ura et a l

., 1998a

/ b ; H o g an e t a l

., 6

1999; G u t t enb u rg et a l ., 1 1 2; P an g i , 2 0 02). T he r ef o re, non

- LEP C des i g na t ed h ea l t h c a re f a c i l i t i e s sh o u l d 7

a l so p l a n and pre p a r e t o t re at c h e m i ca l l y con t a m

i n a t ed pa t i e n t s. 8

9

F ur t h er, t he EP A i s s ued a C he m i cal S a fe t y A l e rt t o a d dre s s t h e po s s i b i li t y of en v i ron m en t al de g rad a t i on 10

from con t a m i n a t ed run o ff ( F e l d m an, 2010 )

. P ro v i s i o n s at t he dec o n t a m i n a ti on s it e m

ust be m ade t o 11

co l l e c t w a s t e wa t er and p re v ent i t from run n i ng o v er l aw ns and i n t o se we r d ra i ns ( C ox, 200 9 ). I dea l l y

, 12

t h i s i s ac c o m p li sh e d by t he use o f a p o r t ab l e, o u t s i de d econ t a m i na t i on u n i t or a d e d i c a t ed 13

deco n t a m

i na t i on fa c i l it y wi t h a p p ro p r i a t e v e n t i l a ti on a nd w a t e r c o n t a i n m

ent ( B u r g ess et a l

., 1 999). T h i s 14

assu m

es t h ere i s e i t h e r a se par a t e wa s t e w a t e r c o n t a i n ment s y s t em or se w er s y s t em for t he he a lt h c a re 15

fa c i l it y t h a t h as t he c apa cit y t o t r e at t he l ow c o nce n t ra ti o n s of che m

i c a l co n t a m

i n an t s ( B ur g ess et a l

. , 16

1999). Wa s t e wa t e r c a n be k ept i n s ea l ed c on t a i n ers f o r l a t e r d i spo s al ( B ur g ess et a l ., 1 9 99). P o r t a b l e 17

poo l s can b e u s ed f or c o l l e c ti on, but pro v i s i ons m ust be m ade t o pre v e n t a c ce s s t o t hese p r i or t o r e m

o v al 18

( C ox, 200 9 ). De sp i t e t h e s e eff o r t s, i n a l ar g e

- sca l e i n ci dent, con t a i n m ent of w a s t ew a t er m ay be 19

i m

poss i b l e. T h i s i ss u e sh o u l d be ad d re s sed t hr o u g h co m prehens i v e p l an n i ng t h a t i n c l ud e s l o c a l 20

en v i ron m

en t a l and wa t e r a u t ho r i t i e s ( Ma c i n t y re et a l

., 2 000). B y w or k i ng w it h l o c al en v i ron m

en t al and 21

w a t er a u t ho r i t i e s, p l ans for t he m ana g e m ent of co n t a m

i na t ed m a t er i a l s and eq u i p m ent i s l e s s su b j e c ti v e 22

and f

o r t i f i ed by sc i e n t i f

i c i n put ( K o en i g et a l

. , 200 8 ). S i m il a r l y , so l i ds m

ust be co ll ec t e d and pro p e r l y 23

s t o r ed p r i o r t o ch a r a c t e r i zat i on a n d d i spo s al ( C ox, 2 00 9). C o n t a m i na t e d m a t e r i al m

ust be sa f e l y s t or e d i n 24

appro v ed HA Z M A T c o n t ai ners a w ay from t he h e a l t h c are w o r k ers ( F e l d m an, 20 1 0). P l a s ti c ba g s (3 o r 6 25

m

l ) are l i k e l y t o p ro v i de a d equa t e p ro t ec t i on for t r ans p ort t o s t o ra g e, but a l so s h ou l d be k ept i n a 26

cen t

r a li z ed HA Z M A T s t o ra g e con t a i n e r ( F e l d m an, 20 1 0). 27

28

P re

- p l ann i ng i s h i g h l y re c o m mended a m o n g f i rst r e s p onder and f

i rst r e ce i v er c o m

m un iti es. A lt hou g h l i f

e 29

sa v i ng m

easures a re a p r i o r i ty o v er req u i re m en t s f or p rop e r d e co n t a m

i na ti on c on t a i n m

ent, resp o nd e r and 30

re c e i v er co m m un iti es, k no w i ng t h at t h e y are m anda t ed t o p e r f orm m ass hu m an deco n t a m i na t i on a s p a

rt of 31

t he i r m

i ss i on, sho u l d c ond u ct p re

- p l ann i n g

. 32

33v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

75 

### F u nctio n al Ar e a 6: C

r isis and E m erge n cy Risk Co m m unication 1

G u i dan c e s t a t e m en t s i n F u n c t i on a l A r e a 6 ad d r e ss iss u e s r e l a t ed t o c r i s i s and e m e r g ency r i sk 2

co m m

un i ca t i ons. T h ese gu i dan c e s t a t e m en t s p ro v i de r eco m m

enda ti o ns r e l a t e d t o ef

f ec t i v e m essa g i ng t o 3

m

u lti p l e au d i en c es, i n c l u d i ng approp r i a t e t r a i n i n g , p l a

nn i n g , pub l i c edu c a t i on, a n d i m p l e m en t a t i on. 4



### G u ida n ce S tat e me n t 6.1

C o m m un i ca ti on i s an e s se n ti a l co m pone n t of e f

fe c ti v e d i s a s t e r m ana g e m en t

. C r i si s and e m

er g ency r i sk

C o m m un i ca t i o n 20 sho u l d b e i ncorp o r a t ed i n t o a l l s t a g es of d i sa s t e r m ana g e m en t , so t h a t p l ann i ng

addr e ss e s co mm

un i ca ti o n b efo r e, d u r i ng and a f t er an i n c i de n t

. A l l p er s onn e l e x p e c t ed t o res p ond t o a

m ass casu a lt y che m

i c a l i n c i dent sho u l d r ec e i v e j o b

- approp r i a t e t r a i n i ng i n c r i s i s a n d e m

er g ency r i sk

co m m un i ca t i on. U se t h e se pr i n c i p l es f o r e ff e c t i v e co m

m un i ca ti o n w i t h t h e pu b l ic :

• B u il d i ng t r u st

• A nnounc i ng ear l y

• T r ans p a r ency

• L i s t en i ng

• P l an n i ng

Considerations:

• C r i s i s a nd e m

er g ency r i sk c o m m

un i ca ti on t r a i n i ng can be i n cor p or a t ed i n t o e x i s ti n g curr i cu l a i n ord e r

not t o i n cr e ase t h e t

ra i n i ng burden on e m

er g ency resp o n se p e rso n ne l

. H o w e v er, a d d i t i on a l t r a i n i ng

focu s ed on c r i s i s a n d e m

er g ency r i sk co m m

un i ca t i on m ay be appr o p r i a t e i n so m e cases, such as for

pers o nn e l ex p ec t ed t o s e r v e as a p ub l i c i nf o r m a ti on o ff

i c e r ( P I O ) dur i ng an i n c i d e n t

.

• E ff e c t i v e cr i s i s and e m

er g e ncy r i sk co m m

unica t i on i s a l e arn e d s k

i l l

. P e rs o nn e l a t a l l l e v e l s w ho w i l l

be i n v o l v ed i n t h e r e spo n se t o a m ass c asu a lt y che m i c a l i n c i d ent ( f

rom f i r st res p o n ders and f

i rst

rec e i v ers u p t h rou g h h i g h

- l e v el m ana g ers) sh o u l d b e tr a i ned i n e f fe c ti v e c r i s i s a nd e m

er g ency r i sk

co m m un i ca t i on p r i n c i p l es.

Level of Confidence: II

5

D i sc u s s i o n : 6

E xpe r i m

en t al s t u d i e s on t he su b

j ect of t he ro l e of co mm

un i ca ti o n i n sha p i ng ou t c o m es i n a m ass ca s ua l t y 7

i n c i de n t a

re l ac k i ng and n o t li k

e l y t o b e co n du c t ed i n t h e ne a r f u t u r e. H o w e v er, a g re a t de a l o f e m p i r i c a l 8

e v i dence i s a v a il a b l e

, i n c l u d i ng res u l t s of ca s e s t u d i es of a c t u a l i nc i de n t s, u p on w h i ch an e m

phas i s on t he 9

i m

por t an c e of e f

fe c ti v e c o m m

un i ca ti on t o s uc c es s ful d i s a s t e r m ana g e m ent i s b as ed. C o m m

un it y 10

m

e m bers’ r e spon s e s t o a d i sas t er can i n f l u e nce m orb i d it y and m

or t a l i t y ; i n t u r n, c o m m

un i ca ti on w i t h t h e 11

pub l i c c an i n f luen c e t he i r r espon s es. E f f ec t i v e co mm

un i c at i on e n han c es t he li k e l i hood t h a

t at

- r i sk 12

co m m

un it y m e m bers w i l l t a k

e appro p r i a t e pr o t e ct i v e ac t i ons a nd r ea s su r es t hose a t l o we r r i sk ( R o g ers et 13

a l ., 2 0 07). Many of t he ca s es a n a l y z ed i n t he li t e r a t u re de m ons t r a t e t he d e t r i m en t a l e f fe c t s of p o or 14

co m m

un i ca t i on on p a t i e n t s and / o r co mm un it y m e m bers’ b e ha v i or o r h e a l t h. A n i m p li ca t i on o f s u ch 15

f

i n d i n g s i s t h at i m

pro v ed co m m

un i ca ti on co u l d ha v e l ed t o b e t t e r o u t co m es; t ho ug h i t i s pe r haps m ore 16

d i f

f i c u l t t o de m

ons t r a t e d ir ec t l y t hrou g h c a se s t u d i e s t hat e f f ec t i v e co m m un i ca t i o n pos i ti v e l y i n f

l uen c ed 17

hea l t h o u t co m es. S i nce e m

p i r i c a l e v i d e nce r e l e v ant t o t h i s g u i dan c e s t a t e m ent has been re v i e w ed i n t he 18

l i t e r a t u re by nu m erous e x p er t s i n t he f

i e l ds o f co mm

u n i c a t i on, r i sk m a na g e m

en t , beha v i o r al h e a lt h and 19

o t h e rs a nd i s t o o e x t en s i v e t o co v er co m prehe n s i v e l y i n t h i s d i sc u ss i on, a few e x a m p l e cases a

re 20

h i g h li g h t ed a l o ng w it h s e l e ct a r t i c l es. 21

22

 I n t he T o ky o sar i n a t t ac k

, p assen g e r s on t he a f fe c t ed s u b w ay t ra i ns g ene r a l l y ac t e d ca l m l y and 23

20 C r isi s a n d e m e r g e n c y r i s k c om m

u n i ca ti o n i s d ef

i n ed b y t h e C DC as “ t h e e ff o rt b y e x p er t s t o p r o v i d e

i nf o r m a ti o n t o a ll o w an i n d i v i d u a l

, st a k e ho l d er, o r an e n ti re c o mm u n i t y t o m a k e t h e b e s t po ssi b l e d ec i si o n s a bo u t

t h e i r w e l l

- b e i n g w i t h i n n ear l y i m po ssi b l e t i m

e c on st ra i n t s a n d h e l p p e op l e u lt i m a t el y t o acce p t t h e i m

p e r f ect

n a t u re o f c h o i ces d u r i n g t h e cr i s is ” ( C D C

, 200 2 ).v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

76 w it ho u t p a n i c ( M ura k a m

i , 2000). H o w e v er, so m

e pa s sen g ers rep o r t ed b e co m i ng fe a rf u l w hen 1

t h e i r c a l l s t o e m er g ency se r v i ces w e r e n o t ans w ered i n a ti m e l y m anner ( S h e ppa r d et a l ., 20 0 6; 2

Mura k a m i , 2000). A nu m

ber of f a c t o rs m ay ha v e con t

r i b u t ed t o t he n er v ous n ess a nd une a se 3

i n c l ud i n g : f a l se annou n ce men t s on t

r a i ns, n e w s m

ed i a r epo r t s o f co n fu s i on, cha o s and, p a t i en ts 4

beco m

i ng ill

, and l a t er, li m

i t ed i nf o r m a ti on and a l a ck of op e nne s s f rom off i c i a l s ( P an g i , 2002 ). 5

 T he C en t e r s f o r D i s ea s e C o n t r o l a n d P re v e n ti on ( C D C ) rec e i v ed an g ry fee d back f r om pos t al 6

w or k

ers a f t e r t hey l e a

rned t hey w ou l d r e c e i v e a d i ff

e r e nt a n ti b i o t i c (d o x y c y c li n e ) t han 7

C on g ress i o nal m e m b ers, C on g ress i on a l s t a f

f, a n d t e l e v i s i on n e t w ork e m p l o y ees ( c i p r o f

l ox a c i n ) 8

af

t er t he m a i l i ng of a n t h rax i n l e t t e rs i n t h e U S i n 200 1

. A m essa g e exp l a i n i ng t he d i s t r i bu t i on of 9

dox y c y c li ne t o a t

- r i sk pos t a l w or k

ers w as d i s t

r i bu t ed b y t he C D C

. T h ese co m m u n i c a t i ons fa i l ed 10

t o a d equ a t e l y exp l a i n t he r e ason for t he d i f f e re n t a n t i b i o t i c d i s t

r i b u t i on p ro v i d e d t o pos t al 11

w o r k

ers. A s a r e su l t , p o s t al w o r k ers expr e ss e d t h e p e rce p t i ons t hat t hey w ere b e i ng t re a t ed as 12

s e con d

- c l ass c i t i z ens a nd p e rha

p s b e i ng d i s c r i m

i n a t ed a g a i nst ( V a n der f

ord, 200 3 ; S hep p ard et 13

a l ., 2 0 06). 14

 Im

pro v ed cr i s i s and e m

er g ency r i sk co m m

u n i ca t i on p o t e n ti a ll y co u l d h a v e red u c e d t he i n t en s e fe a r 15

and s t

re s s

- i nduced ph y s i c a l e f

f ec t s s u ch a s v o m

iti n g , d i ar r hea, b l i s t e r s, b u rns and r edde n i ng of t he 16

s k

i n, a s we l l as l on g er t erm ne g a ti v e cons e que n ces i n c l ud i ng d i s c r i m i na t i on e xpe r i en c ed by re s i de n ts 17

o f G o i an i a, B r a z i l at t he ti me of t he ra d i a t i on acc i de n t i n 1987 ( B ec k er, 2 004). 18

 P erha p s one of t he m ost c o m pe lli ng exa m

p l es o f l ess t

han o p ti m al co mm

un i ca ti o n l e a d i ng t o 19

de t r i m

en t a l be h a v i or i s I srae l i c i ti z ens d y i ng due t o i m prop e r u s e of g as m as k s d u r i ng the 1991 20

P e r s i an G u l f W a r ( B a rach e t a l ., 199 8 ). A t l e ast 13 p e o p l e rep o r t ed l y d i e d f rom asph y x i a t i on a f

t er 21

fa i l u r e t o f o l l ow i n s t r

uc t i o n s f o r and d e m

ons t r at i on s o f prop e r u s e of pr o t e ct i v e m as k s and i nf

a nt 22

ca r

r i e rs i n resp o nse t o a m

i ss i l e a t t ack a l a

rm ( H i ss & A rensb u r g , 1992). 23

 I n a s t udy of t he t y pes o f i n for m a ti on de s i r ed by t he p u b l i c du r i ng a h y po t h e t i c a l a tt a ck us i ng p l a g ue, 24

su b

j e c t s pr e d i c t ed t hat t hey w ou l d b e f ea r f u l as t hey l e a

rn e d abo u t t he at t a ck and re s u l ti ng casu a l t i e s. 25

H o w e v er, m any rep o r t ed t h at t h e i r f e ar w o u l d be re d uced by co m m un i ca t i on su gg es ti ng t hat 26

e m

er g ency resp o nd e rs we re r esp o nd i n g t o t he i n c i de n t

. Mo s t su b j e c t s s a i d t h ey w ou l d s eek out 27

i nf

o r m a ti on about t he a t t a ck and use t h at i nf o r m a ti on t o d e c i d e w h at a c t i ons t o t a k e f o r t h e m se l v es 28

and t h e i r fa m ili e s ( W r ay & J up k a, 2004). 29

30

T h e se cas e s h e l p t o i l l us t r at e t he r o l es of c r i s i s and e m er g ency r i sk co m m

un i ca t i on i n b o t h i n s t

ru ct i ng 31

peop l e t o t a k e a p pro p r i a t e p ro t e c t i v e a c ti o n s t o be n e f i t t he i r he a l t h and sa f

e t y and r eass u r i ng peop l e and 32

eas i ng t he i r f e a rs w hen t he r i sk i s l o w

. A f t e r t he 20 0 1 an t h rax a t t ack i n t he U S

, e f fe c ti v e co mm

un i ca ti on 33

w as nee d ed t o su p po r t t he t re a t m ent of t ho s e d e t er m

i n ed t o b e a t

- r i sk w it h a n t i b i o ti c s f o r p o s t

- exposu r e 34

proph y l a x i s. I n I srael du r i n g t he P er s i an G u l f W a r, p r e c i se i n s t

ru c ti o n s f o r t he u se o f r es p i r a t o ry 35

pro t ec t i v e de v i c e s, a co m p l ex a c ti v it y n o t w i t ho u t r i sk it s e l f, w as nec e ss a ry t o p r o m

o t e prop e r use and 36

pre v ent i n

j ur y

. T he c as e s o f t h e T o ky o sar i n a t t ac k

, t h e an t hr a x l e t t e r s, t h e r ad i a ti on ac c i d e nt i n G o i an i a 37

and t h e h y po t h et i c a l p l a g ue a t t ack i l l u s t r a t e t h e n e ed t o pro v i de c o m p l e t e, acc u r a t e and t i m

e l y 38

i nf

o r m a ti on, ex p l an a t i ons f

or o f f i c i al a c t i on s , and re as sura n ce w h e n ap p ro p r i a t e. G aps i n co m m un i ca t i on 39

l ed t o i n t e nse fe a r, s t r ess

- i nduced p h y s i c a l e ff e c t s and l ar g e nu m

bers of peo p l e s e e

k i ng po t en t i a l l y 40

unnec e ss a

ry m ed i cal c ar e

. 41

42

Mo t i v a t ed by t h e e m er g ence of s e v ere a cu t e r es p i r a t o r y s y ndr o m

e ( S A RS ) i n 2 0 0 1, t he W o r l d He a l t h 43

O r g an i z a ti on (W H O ) con v e ned a m ee t i ng i n 2004 t o c o ns i d e r t he ro l e of pub l i c c o m m un i ca ti o n s i n a 44

d i s e ase ou t b rea k

. R i sk co m m un i ca ti on and p u b l i c h e a l t h ex p e r t s f

rom m u lt ip l e c oun t r i e s and i n t ern at i on a l 45

or g a n i z a ti o ns re v i e w ed t he r i sk co m m un i ca t i on l i t e r a t u re and t h e i r o w n expe r i e n ces w i t h ou t b r eak 46

re s pon s e. B a s ed on t he g a t he r ed e v i d e nce, t hese exp e r t s i d en t i f i ed b e s t pra c t i ces for co m m un i ca t i ng w it h 47

t he p u b l i c du r i ng a d i se a se o u t b r e ak i n ord e r t o r ap i d l y con t a i n t he o u t b reak w h i l e m i n i m i z i ng t he 48

d i s ru p t i on t o econo m i es and s oc i e t y ( W HO , 2004). A l t hou g h t h i s e f fo r t w as fo c used on i nf

e c t i ous d i se a se 49

o u t b r ea k s, t h e re are no a p pa r ent r e a s ons w hy t he b e st pr a c t i c e s or p r i n c i p l es w o u l d n ot app l y t o c he m i cal 50v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

77 i n c i d e n t s or o t her pu b li c he a lt h e m er g enc i es. 1

 B u il d i ng t r u s t : t ru s t i n t h e peop l e m ana g i ng and co m m un i ca ti ng abo u t a n e m

er g ency enhan c es 2

t he li k e l i hood t h a

t co mm un it y m e m bers w il l co m

p l y w it h reco mm

ended pro t e c t i v e a c ti o n s. I t 3

a l so redu c es t he li k e l i hood of s u sp i c i on t h a

t i nf o r m a ti on i s be i ng con c e a l ed o r do w n p l a y ed and 4

t h e po t e n t i al for co m m un it y me m

bers t o a ct on s u ch s u sp i c i on. P r e

- i nc i d ent p l a nn i ng pre s en t s 5

oppo r t u n i t i es t o b u i l d t ru s t

. When e m

er g ency m ana g ers and c o m m un it y l ead e rs w ork t o g e t h e r, 6

t h ey can e s t a b l i sh t r u s t e d r e l a t i o ns h i p s t h at w i l l su p po r t e f f ec t i v e d i s as t er re s pon s e. W it h 7

co m m un it y l ea d ers i n v o l v ed i n e m er g ency p l an n i ng and p e rha p s, i n e m er g ency respons e

, 8

i n d i v i dual co mm un it y m e m bers m a y be m

ore li k e l y t o fo l l ow t h e r eco m m

enda t i ons m ade by 9

au t h o r i t i es i n an e m er g ency ( FE M A , 20 1 1). 10

 A nnounc i ng ear l y : co m m u n i c a t i ng w it h t he pu b l i c a bo ut an e m er g ency as soon a s pos s i b l e 11

a l l o w s or p r o t e c ti v e a c t i o n s t o be t a k en du r i ng t he e f

fe c ti v e ti m

e w i ndo w

. I

t a l so supp o r t s 12

c o n f i de n ce a n d t ru s t t h a t a u t h o r i ti e s a re b ei ng honest a

nd f o r t hco m i ng w it h t he i n f

or m a ti on t h a t 13

t h ey ho l d. T he f i r s t m essa g e about an i n c i d e nt i s o f t en t he m ost i m por t a n t and i n f

l uen c es a l l 14

su b sequ e nt co m m un i ca t i ons. 15

 T r ans p a r enc y : co mm un i ca t i on t hat i s can d i d, ea s il y u n der s t ood, co m p l e t e and ac c ura t e p ro v i des 16

t ra n sp a re n c y

, w h i ch i n t u rn he l p s t o bu i l d a nd m a i n t a i n t r u s t

. 17

 L i s t en i n g : t he con c er n s of co m m un it y m e m bers sho u l d be co n s i d e r ed l e g iti m a t e and ad d re s sed i n 18

m

essa g es. T he co m m

un it y w il l co m

pr i se m any d i ffe re nt au d i e n ces, ba s ed on h ow t hey are 19

a f

fe c t ed by or t h e i r ro l es i n m ana g i ng t he i n c i d e n t

. 20

 P l an n i n g : as m uch a d v an ce d p l a n n i ng as p os s i b l e sh ou l d be d one i n o rd e r t o a v o i d rus h ed e ff o r t s 21

t h at can c a use m i s t a k es. 22

23v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

78 

### G u ida n ce S tat e me n t 6.2

D e v e l op a s t r a t e g i c co m m u n i c a t i ons p l an for d e li v e r i n g v ar i ous t y pes o f m essa g es dur i ng an i n c i d e n t

. P rep a re a s m uch m a t er i a l i n ad v ance a s po s s i b l e : i de n t i fy m essa g e t op i c s a n d t h e i r aud i enc e s; w r i t e p re

sc r i p t ed m

essa g es; i de n t i fy appro p r i a t e spo k es p eop l e o r m

essen g ers for each t y pe of m essa g e.

C o m m un i ca ti on nee d s t o b e c o o rd i n a t ed a c ro s s a l l o r g an i z a t i ons so t h a t a s i n g l e m essa g e i s spo k en wi t h

m a n y v o i ces t h r ou g hout t he co m m un it y

. Considerations:

• E nsure m

essa g es are de v e l oped f

or a nd d i sse m

i n a t ed t o a l l s t a k

eho l d er s :

o T h o se w ho we re expo s ed a nd dec o n t a m i n a t ed

o T h o se w ho m ay ha v e been expos e d b u t l e ft t h e s c ene w it ho u t b e i ng deco n t a m i n at ed or

e v a l u a t ed

o T h o se w ho we re at t he sce n e and h a v e a l ow li k e l i hood of ha v i ng been exp o sed

o T h o se wi t h fa m

il y m e m bers or l o v ed ones w ho w e r e a t t he s ce n e

o C o m m un it y m e m bers w ho w ere n o t a

t t he s cene

o E m er g ency response o r g an iz a ti ons

o H ea l t h c a

re p ro v i d e rs

o P ub l i c h e a l t h co mm

un it y

• U ti l i z e an a u t h o r it a ti v e s ou rce, such as an e l e c t ed o f f i c i al (e. g

., m a y or), a pu b li c h ea l t h o f f i c e r, a

m ed i cal a sso c i a ti o n or a we l l

- k no w n l ocal ph y s i c i a

n, t o de l i v er m

essa g es t o t he p u b l i c f

o r g re a t er

cre d i b il i t y

.

• A l l e l e m

en t s o f c r i s i s co mm

un i ca ti o n and i n s t

r uc t i on dur i ng an i n c i de n t s hou l d b e re d unda n t a nd

i n t ero p er a

b l e

, v erb a l and n on

- v erba l , a n d be a v a i l a b l e i n a l l co m m

on l an g ua g es s p o k

en i n t h e

co m m un it y

.

• C o m m un i ca ti on ch a l l en g es m a y i nc l ude he a r i ng i m pa i r m en t

, l an g ua g e bar r i e rs, i l l i t e r ac y

, v i s i on

i m pa i r m ent, and i m

pa i r m ent ca u sed by t h e c h e m

i cal e x posu r e i t s e l f.

• C o m m un i ca ti ng i n for m a ti o n abo u t w hy deco n t a m i na ti on i s nec e ss a

ry and ab o ut t he pr o ce s s, ( e. g

.,

se g re g a ti on of p a t i e n t s by g ende r

, k eep i ng fa m

i l i es and car e t a k

e r s t o g e t he r ) how p osse s s i o ns a nd

fun c ti o n al nee d s wi l l b e h a nd l ed (e. g ., e y e g l ass e s, wal k ers, pr o s t h es e s), m ay i ncr e ase c o m p li an c e w i t h

t he p ro c ess.

• G i v e s i m

p l e, c l e a r i n s t ru c t i ons u s i ng a c a l m but au t ho r it a ti v e v o i ce br o adc a st t h r o u g h a pub l i c a d dr e ss

or v o i ce a m

p li f i c a ti o n de v i ce. I

t i s e sse n t i al t o d i r ect p eop l e

– ex p e c t t h em not t o act q u i c k l y and n o t

t o pa n i c.

• P a t i en t s sh o u l d be i nf

o r m ed of p o t e n t i al h e a lt h r i s k s t o t he m se l v es a n d fa m il y me m bers i f t hey ne g l e c t

deco n t a m i na t i on t r e a t m

en t

.

• E v i dence s u gg es t s t h a t p an i c i s n ot a co mm on response by peop l e i n v o l v ed i n a m ass c a su a lt y

d i s a s t e r

. H o w e v er, ps y choso c i a l i n t e r v en ti on in the first hours to several month s following a disaster

that provides the following elements can mitigate social and behavioral distress and dysfunction that

may develop over time and promote recovery (Hobfoll et al., 2007)

o A sense of s a f

e t y

o C a l m i ng

o A sense of s e l f

- and co mm

un it y e f f i cacy

o C onnec t edn e ss

o H ope

• I n t e g ra t e beha v i o ral he a l t h pro f es s i on a l s ea r l y i n t he r e sponse t o add r ess po t en t i a l acu t e s t r e ss rea ct i on

i n p a t i en t s, as r e sou r ces a ll o w

. Level of Confidence: II

1

D i sc u s s i o n : 2

A s w it h se v er a l o t her g u i d a nce s t a t e m

en t s, t he e f

f e c t s of t h e r eco m m

enda t i ons m ade h e re on p a t i e n t 3v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

79 ou t co m es m ay be d i f

f i c u l t t o t e s t i n ex p e r i m

en t al s t u d i es. H o w e v er, t he c on t ent a bo v e i s 1

su b s t an t

i a t ed by r i g orous sur v ey or i n t e r v i e w

- based r e se a rch and s o m

e by e m p i r i c al e v i den c e f

r o m 2

ac t ual e v en t s

. 3

4

A f

t e r t h e 2001 t e rr o r i st a t t a c k s i n t h e U S

, C D C fun d ed a s e r i e s of s t ud i es t o a i d p l ann i ng f o r e ff e c t i v e 5

co m m

un i ca t i on i n che m

i c al , b i o l o g i c a l

, r ad i o l o g i c a l o r nuc l e ar ( CBR N ) t e r ro r i s t i n c i de n t s. S e v er a l 6

res e a r ch t ea m s u t i li z ed fo c us g roups a nd i nd i v i d u al i n t er v i e w s t o as s ess t he t y pes of i n f o r m a ti on t h a

t 7

m

e m bers of t h e pu b l i c w i s h t o r ec e i v e du r i ng such a n i n c i d e n t

. T h i s w as b a sed o n t he p re m i se t h a t i n 8

ord e r t o be o p ti m a ll y e f f e c t i v e, m essa g es m ust t a k e i n t o acc o unt t he re c i p i e n t s’ n e eds a n d co n cer n s. 9

E xpe r t s i n t

he f i e l ds o f r i sk co m m

un i ca t i on, b e ha v i or a l hea l t h, and pu b l i c h e a l t h h a v e reco mm ended 10

t hat cr i sis and e m er g ency r i sk co m m

un i ca ti o n s i nc l ude w h at m e m bers of t h e pu b l i c w ant t o k now i n 11

a d d i ti o n t o w h a t g o v ern m

ent of f i c i a l s w ant t hem t o k

now ( R o g ers e t a l ., 20 0 7; W HO , 200 4 )

. 12

13

T h i s P

re

- E v ent Messa g e D e v e l op m ent P r o j e c t w or k ed w it h a t o t a l sa m

p l e s i z e o f 1013 i n d i v i du a l s i n 14

se v eral d i ff e re n t r e g i ons o f t he U S

. T h e pr o j e ct g a t h e r ed d a t a t hrou g h p u rpo s i v e s a m p li ng t o pro v i de 15

adequ a t e re p re s en t a t i on o f e t h n i c g rou p s, ur b an a nd r u ral d w e l l e rs, p ro f

i c i ency i n t he E n g l i sh l an g ua g e, 16

a g e, soc i o eco n o m i c s t a t us, educ a ti o n l e v el and g end e r (W r ay et a l ., 20 0 8; B e c k er, 2004; G li k et a l

., 200 4 ; 17

H ende r son e t a l ., 20 0 4; W r ay and J up k a, 200 4 ). P a r t i c i pa n t s i n t he s e s t ud i es e x p r essed t h e i r de s i r es for 18

i nf

o r m a ti on abo u t t h e n a t u r e of t he t h r e a t , how t o pr o t e ct t he m se l v es and t h e i r fa m i l i es, and t he o f

f i c i a l 19

resp o nse t o t he si t u a ti on. S pec i f i ca l l y re g ar d i ng pro t e c ti v e a c ti o ns, t hey w an t e d t o k now how t o a v o i d 20

expos u re, reco g n i z e s y m p t o m s and t r e at ef

f e c t s. I n add i t i on, t hey w an t ed as m uch pr o t e c ti v e i nf

o r m a ti on 21

as po s s i b l e. 22

23

I nfo r m a ti on n eeds d i d not d i f f er a m ong re g i ons of t he U S or a m ong o t her s u b

- g roups. S t udy par t i c i pa n t s 24

rep o r t e d t h at o ne o f t h e i mm ed i a t e a c t i ons t hey w i l l t a k e i s a c ti v e i n f

o r m a ti on s e e k

i n g

, w h i ch supp o r t s t h e 25

best pr a c t i ce of a nnou n c i ng ea r l y

. S t udy res u l t s a l so s ug g est t h at peo p l e wi l l seek and co m pare 26

i nf

o r m a ti on from m

u lti p l e s ourc e s, s u bs t an t i a ti ng t h e re co m m

enda ti on t h a t co mm

u n i c a t i on be coor d i n a t ed 27

ac r oss or g an i za ti o n s so t h a t a s i n g l e m

ess a g e i s de l i v ere d

. I

ncons i s t e n c i es w i l l n o t o n l y cau s e conf u s i on 28

f

o r t h e pu b l i c b u t can un d er m i ne t h e i r t r u st a nd co n f

i d ence i n t he g o v er n m

ent and o t h er au t h o r i t i es ( W ray 29

et a l ., 2 0 08). R e p o r t s on t he r e spo n ses o f N ew Y ork C it y r e s i d en t s and w o r k ers t o co m m

un i ca t i ons from 30

g o v e rn m

ent o f f i c i a l s i n t he f

i r st w ee k s and m

on t hs a f t e r t he S ep t e m

ber 11 a t t a c k s on t he W o r l d T ra d e 31

C e n t er i l l u s t r a t e t he po t en t i a l f

o r p oor co mm

un i ca ti o n p r ac t

i c es t o c r ea t e un c e r t a i n t y a m o n g m e m bers of 32

t he pu b li c and m i s t ru s t of a u t ho r i ti es. M i x e d m essa g es w ere c re a t ed by t h e co m b i na t i on of e a

r l y 33

re a ss u ran c es t h a t t h e l o c a l en v i r o n m

ent w as s a fe wi t h s ubs e q uent g u i d ance t h a t c i t i z ens s hou l d be ca u ti o u s 34

w it h d u st and a sh a n d r e po r t s t hat t h e en v i r o n m

ent w as cau s i ng peop l e to beco m e i l l ( L y m an, 2003). 35

O nce i n con s i s t e n c i e s b e c a m e appare n t , se v e r al o r g an iz a ti ons re q ue s t ed acc e ss t o d a t a on en v i r o n m en t al 36

m

on i t o r i ng for h ea l t h h a z ards i n t he a rea but we re d e n i e d

. T h i s l ed so m e peop l e t o co n c l u de t h a t 37

a u t ho r

i t i e s w ere c o nc e a l i ng i nf

o r m a ti o n abo u t dan g e r s t o hu m an hea l t h ( L y m an, 2003). 38

39

Me m

bers of t h e pu b l i c w a n t t o k now t h at t he i n for m a t i on t hey r e c e i v e about an e m er g ency i s cred i b l e. 40

Many pa r t i c i p an t s i n t he P r e

- E v ent Mes s a g e D e v e l o p m ent P r o j e ct s t u d i e s s t a t ed t h a t t h ey w an t ed t o k now 41

t he s ou r ce o f t h e i n f o r m a ti o n, so t hat t h ey can j ud g e c r ed i b i l it y f o r t h e m se l v es. S o m

e offer e d exa m

p l es of 42

r e sp e c t e d so u rc e s, w h i ch i n c l uded bo t h l o cal and n a t i on a l l e v el a u t h o r i ti e s: l o ca l he a l t h de p a r t m en t s, f i r e 43

d e pa r t m

en t s, p o l i ce d e p ar t m

en t s, t h e C D C

, t he A m

er i can R e d C ro s s, t

he U S P re s i de n t

, t he 44

m

ilit a r y / N a t i on a l G uard, and o t h e r or g a n i z a ti o ns ha v i ng re l e v ant e x pe r t i se (W r ay et a l ., 2 0 08). 45

46

T he i n f

l u en c e of n on

- v erb a l i n s t

ru c ti o n s on t he e f

fe c t i v eness of pa t i e n t d e co n t a m i na t i on h a s b e en ass e ssed 47

i n o ne s t ud y . A p i c t o r i a l a i d w as pro v i d e d t o su b j e c t s i n one g roup i n a d d i t i on t o v erb a l i n s t ru ct i ons o n 48

w hat a c ti on s a su b j e ct sho u l d p e rf

o rm for d e con t a m

i na t i on. The p r opor t i on of con t a m i na n t r e m o v ed from 49

t he s e su b

j e c t s w as co m

par e d t o t he p rop o r t i on re m o v e d from su b

j ec t s w ho rec e i v ed o n l y v erbal 50

i n s t

ru c ti o n s. D e c on t a m

i na ti o n e ff

ec t i v eness wa s n o t s i g n i f

i c a n tl y d i ff

e re n t b e t w e e n t he g roup w ho had 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

80 re c e i v ed v erbal p l us non

- v erbal i n st ruc t i o n s and t he g roup w ho had r ec e i v ed on l y v erbal i n s t r u c t i ons 1

( A m

l ôt et a l ., 20 1 0). T h i s r e su l t se e m s coun t e r i n tu i ti v e a nd c o n t r a d i c t o ry t o t h e g u i dance p ro v i ded he r e. 2

H o w e v er, t he i n v es t i g a t o rs h a v e pro v i ded a dd i ti o nal ex p l an a t ory i n f o r m a ti on i n a sub s eque n t a r t i c l e t h a t 3

s u g g es t s t hat t h e p i c t o r i al i n st ruc t i o n s w e r e m

i s i n t er p r e t e d, at l e a st by t h e ad u l t s t udy su b j e c t s ( W i n f

i e l d, 4

2 011). I

n add i ti o n

, m any c i rcu m s t ances and ch a ll e n g es t h a t co u l d a r i se d u r i ng a m ass pa t i ent 5

deco n t a m

i n a t i on i n c i d e nt w o u l d s eem t o w arr a nt t he i n c l u s i on o f n o n

- v erbal i n s t ru c ti o ns i n a resp o nse 6

p l a n

. T h e se i nc l u de v erb a l i n s t ru c ti o n s n o t b e i ng a v a il a

b l e i n a l l l an g ua g es spo k

en by pa t i en t s and 7

d i f

f i c u lt y he a r i ng and / o r und e r s t an d i ng v erbal i n s t r uc t i ons spo k

en by resp o nd e rs w e a

r i ng r e s p i r a

t ory 8

pro t ec t i on de v i c e s. T he l a t t er w as re c en t l y rep o r t ed i n a s t u dy of pa rt i c i pa n t s i n p a ti e nt d eco n t a m

i na t i on 9

f

i e l d e xe r c i ses ( C a r t e r e t a l

. , 2012). 10

11

T he r e co m m enda ti o n t o e x pect peo p l e n o t t o a c t q u i c k l y and not t o p an i c i s ba s ed on nu m erous c ase 12

s t u d i es ( A uf der H e i d e, 19 8 9; D i Gi o v anni e t a l ., 20 0 3; S hepp a rd e t a l ., 20 0 6; Mu ra

k a m i , 2000; S u l l i v an & 13

B on g ar, 2007). F i r s t

, i t i s i m por t a n t t o be c l ear abo u t t h e d e f i n i t i on o f p an i c and reco g n i z e t hat f e ar, 14

anx i e t y and a sen s e o f ur g e ncy are o f t e n ap p ro p r i a t e a nd ne c ess a ry res p ons e s t o a

n e m er g enc y , as t hey can 15

f

ac il it a t e p r o t e c ti v e a c ti ons, s u ch as e v acu a t i o n and deco n t a m i na t i on, i n a t i m

e l y m anner. I

n t he con t e xt o f 16

an e m

er g ency affe c ti ng a co mm un it y , pan i c i s c h a r ac t e r i z ed by i r r a t i o n al b e ha v i o r s, hope of rec e i v i ng 17

appa r en t l y sc a rce res o ur c es, a fo c us on ac h i e v i ng person a l s a f e t y ra t h er t han a s s i s t i ng o t he rs, and 18

co n t a g i o u sne s s, i n ad d i ti on t o t he h e i g h t e ned anx ie t y and f e ar o f d y i ng ass o c i a t ed wi t h p an i c i n o t h er 19

s i t ua t i o n s ( K e a t i n g , 1982; S hepp a rd e t a l ., 20 0 6). D i G i o v anni a nd c o l l ea g ues ( 2 0 03) a n a l y z ed se v er a l 20

na t u ral d i sa s t e rs a n d co n c l u ded t h at p eo p l e g ene r a l l y ac t ed w it h co m posure and d i d not e xh i b i t i rr a t i on a l 21

beha v i o r s. T he au t ho r s ad d ed a c a v ea t , ho w e v e r

, t h at p eop l e m i g ht beha v e d i f

f e r e n tl y i n t e rr o r i st a t t ac k s 22

w it h CBR N a g en t s t h a n i n na t u ral d i sa s t e rs. H o w e v er, four t e rr o r i st a t t ac k s ( t he T ok y o sar i n a t t a c k

, t he 23

S ep t e m

ber 11, 2001 Wo r l d T r ade C en t er a t t ac k

, t he U S an t h rax l e tt e r m a i l i n g s and t he Ju l y 7, 2005 24

L ondon bo m b i n g s) w e r e a n a l y z ed by S heppard a nd c o l l ea g ues (20 0 6 ) a n d i n a l l c a ses i t wa s co n c l u d ed 25

t h a t t h e a f

f e c t e d co mm

un it y m e m bers g e n er a ll y ac t ed ca l m l y and r a ti o na l l y , r a t h e r t h an wi t h p a n i c. 26

I nd i v i dua l s on t he t r a i n c a r s i n v o l v ed i n t he T o ky o sa ri n a t t ack and t he L o ndon bo m b i n g s repor t ed u n it y 27

and co h e s i on a m ong t hose af

f ec t ed ( S hep p ard et a l

., 2 006). O t he r s ha v e d e sc r i b e d t he co m

posure 28

exh i b i t ed by co m m un it y m e m

bers i n t he T o ky o sa r

i n a tt a ck (M u ra k a m

i , 2000) w h i ch wa s d i sru p t ed by 29

s l ow r espo n ses by e m er g e n cy ser v i ce p ers o nn e l and i m a g es of c h aos and s e v ere l y i l l p a t i en t s i n t he ne w s 30

m

ed i a ( P an g i , 20 0 2). 31

32

D i s t i n c t f

rom t he qu e s t

ion of how p e op l e be h a v e dur i n g and i n t h e i mm ed i a t e a f te r m a t h of an i n c i d ent i s 33

t he i ss u e of r e l a ti v e l y l on g e r

- t erm ps y cho l o g i cal e f f ec t s of a d i sa s t er on t he p eop l e i m pac t e d

. E v i d ence 34

from ac t u al i n c i de n t s, i n c l u d i ng m a n y of t he ca s es m en ti o n ed a b o v e, s u gg es t s t h at t he p s y cho l o g i c a l 35

i m

pact of t e rr o r i st a t t ac k s, CBR N i nc i d e n t s , or o t h er d i sa s t e rs can b e s i g n i f i ca n t

, bo t h i n t er m s of t he 36

nu m

bers of p eop l e a ff

e c t ed and t h e se v e r it y of e f f e c t s ( S u l l i v an & B on g ar, 200 7 ; B l e i ch e t a l ., 200 3 ; 37

Mura k a m

i , 2000). T he t y pes of s y m p t o m s expe r i en ce d can b e de s c r i bed by m ass ps y cho g en i c i l l ne s s, 38

acu t e s t r e ss rea ct i on, p o st

- t r au m a ti c s t r ess d i s o rd e r a n d o t h e r s y ndro m es or d i s o rd e rs ( S u l li v an & B on g ar, 39

2007; B l e i ch e t a l ., 2 0 03). I n ord e r t o s upp o rt t o o l s f or m iti g a ti ng such ps y cho l o g i cal ef f e c t s, a l a r g e body 40

of e m

p i r i c al e v i den c e w as co m p il ed by a pan e l of exp e r t s on t he s t udy and t r ea t m ent o f i n d i v i du a l s 41

expos e d t o d i s a s t er and m a s s v i o l e n ce a n d us e d t o de f i n e by conse n sus a s e t of e v i d ence

- i nfor m ed 42

ps y choso c i al i n t e r v en ti o n p r i n c i p l es ( H ob f o l l e t a l ., 2 0 07). T h e a u t ho r s r eco m m end t h a t t he s e e l e m

en t s be 43

i n cor

p or a t ed i n t o i n t e r v en ti o n e f f o r t s du r i ng t he sh o rt a

nd m i d

- t erm per i od ( i m m

ed i a t e ho u rs t o s e v e ral 44

m

on t hs) f o ll o w i ng a d i sa s t e r or t e rr o r i st at t ac k

. T he p r i nc i p l es a r e: (1) pro m o t e se nse o f s a f

e t y , (2) 45

pro m

o t e c a l m i n g , (3) pro m

o t e s en s e of se l f

- eff i cacy a n d co l l e c ti v e e f

f i c a c y , (4) p r o m

o t e conne c t e d ness 46

and ( 5 ) p ro m o t e hope. E a c h of t he s e m easur e s c an be addr e ss e d at l e a s t p a r t i a l l y t hrou g h c r i s i s a n d 47

e m

er g ency r i sk co m m

un i ca ti on. F or exa m

p l e, s af e t y i nc l u d es s af

e t y from bad n ew s and s o ur c es o f 48

add i ti o nal s t re s s, w h i ch a

re of t e n con v e y ed t h rou g h t he m ed i a i n a d i s a s t er. E duc a

ti on abo u t b e ha v i or a l 49

hea l t h res p ons e s t o d i sa s t e r

, t ec h n i q u es for m ana g i ng anx i e t y , s i g ns of se v ere i l l n e ss and so u rc e s of 50

pro f

es s i on a l e v a l u a t i on and t r e a t m en t

, a l l of w h i ch h e l p t o p ro m o t e c a l m i n g , can be pro v i d ed t h

rou g h 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

81 co m m un it y ou t re a ch. 1

2

S e l f

- ef f i c a cy and co m m

un i t y eff i c ac y

, w h i ch are d i re ct l y re l a t ed t o t he s e l f

- care ti er of p a ti e nt 3

deco n t a m

i na t i on d es c r i b ed i n t h i s g u i d an c e, can be p r o m o t ed pr e

- i nc i d e nt t hr o u g h pub l i c e d uc a t i on 4

ca m

pa i g ns and d u r i ng an i n c i de n t t hr o u g h m essa g es de li v ered by e m

er g ency responder s , r e c e i v ers, pu b l i c 5

hea l t h o f

f i c i a l s a n d o t h er t r

us t ed co m m

un it y l ea d er s

. R es i li e nt c o m m un iti e s en c o ura g e pe r ce p ti o ns o f 6

bo t h s e l f

- eff i c acy and c o l la

bor a ti v e su p po r t of one an o t her du r i ng ti m es of nee d

. H obfo l l e t a l . ( 2 007) 7

no t e t h a

t t he p o s i ti v e r o l e o f so c i a l su p po r t a n d con n e c t edn e ss i n m iti g a t i ng s t

ress and t rau m a i s p rob a

b l y 8

t he b est e m

p i r i ca l l y supp o r t ed of t h e i r f i v e r eco mm

en d ed p r i n c i p l es, y et t h e re i s l it tl e e v i den c e su gg es ti ng 9

how t o a

p p l y i t f o r e ff e c t i v e i n ter v e n ti on i n a d i sa s t e r. T h i s p r i nc i p l e i s i n t e g r a t ed i n t o se v er a l p a r t s o f t he 10

g u i dance p re s en t ed h e re. K eep i ng f a m ili es and l o v ed o nes t o g e t h e r du r i ng deco n t a m i na ti on a nd 11

espe c i a ll y k eep i ng ch i l d ren conn e c t e d ( o r r econ n e c ti ng t he m ) w it h pa r en t s or c a

re t a k ers ( G u i da n ce 12

S t a t e m

en t s 2 .6 and 5. 4 ) wil l sup p o r t t h e co n ne c t ed n ess reco mm ended by H obfo l l et a l

. ( 200 7 ). F ac i l i t a ti ng 13

t h e r e con n ec t i o n of f a m il y m e m bers w ho w ere i n d i f

f er e nt l o c a t i ons at t he ti m

e of t he i nc i de n t ( A uf d e r 14

He i de, 1 989) as w e l l as re a ch i ng o u t t o co mm un it y m e m bers w ho m ay be soc i a l l y i s o l a t ed o r l ack s t rong 15

so c i al sup p o r t m a y a l so a l l ow c onne c t e dn ess t o h e l p s hape an e f f ec ti v e co m m

un it y response t o a d i s a s t er. 16

H o b f

o l l et a l

. (200 7 ) e m

phas i z e d t h a

t a se nse o f hope can be e n han ce d by m any ex t ern a l fa c t o r s and i s n ot 17

so l e l y an i n t ern a l a t t r i bu t e h e l d by an i nd i v i d u a l

. T hey su gg est t hat a co m m un it y can fos t er hope by 18

“h e l p i ng pe o p l e foc u s on m ore a c cu r a t e r i sk a s sess m

en t

, po s i t i v e g o a l s, b u i l d i ng s t

r e n g t hs t h a

t t h ey ha v e 19

as i n d i v i du al s and c o m m un iti e s, and he l p i ng t hem t e l l t he i r s t or y ” (H obf

o l l e t a l ., 20 0 7). 20v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

82 

### G u ida n ce S tat e me n t 6.3

P ub l i c ed u c a ti on can be a c h i e v ed by us i ng na t ur a ll y o c cur r i ng oppo r t u n i t i e s t o c o m m un i ca t e p a t i ent

deco n t a m i na t i on g oa l s, p o t en t i al pr a c t i c e s, r espo n s i b il i t i es o f r esp o nd e rs, rec e i v e r s and p a t i e n t s, a nd

expe c t ed o u t co m

es. A s t r a t e g i c p l a n f

o r p r e

- i nc i de n t c o m m

un i ca ti on t o enha n ce c o m m un it y

prepar e dne s s shou l d be d e v e l oped t o i n cl ude i n f o r m a ti on a b out pa t i e nt d e con t a m i na t i on i n co mm

un it y

ou t re a ch by f

i re ser v i ce and E MS or g a n i z a t i ons, pu b l i c s e r v i ce annou n c e m en t s, public venues and o t h e r

p l an n ed e v en t s.

Considerations:

• P r i o r i ti z e co mm

un iti es t h a t are a

t

- r i sk (e. g

., due t o t he pre s ence of a n i n du s t r i al s it e or a t ra n sp o r t a t i on

r ou t e) for m

essa g i ng t a i l o red t o t he co mm un it y ’s spe c i f

i c h a z ards.

• I n t e g ra t e pre

- i n c i d ent co mm un i ca ti o n abo u t p a t i e n t d e con t a m i n a ti o n i n t o on g o i ng eff

o r t s by t he

che m i cal i nd u s t

ry and o t h er or g a n i z a t i ons (e. g

., LEP C

, T r ans p o r t a t i on C o mm un it y Aw aren e ss a n d

E m er g ency R esponse [ T R

AN SC A ER ]).

• P ub l i c i n t e re s t i n l ea r n i ng a bout a nd p r ep a

r i ng f o r r are ha z ardous m a t e r i a l s i n c i d e n t s m ay be l o w

. S o m e c o m m un iti e s m ay d e c i de t h a

t i t w o u l d b e m

ore e ff i c i ent t o p re p are pub l i c m essa g es for

d i s s e m i na t i on a t t h e t i m e of an i n c i d ent t h a n t o en g a g e i n a p r e

- i nc i d ent pub l i c ed u ca t i on

ca m pa i g n.

Level of Co nfidence: V

1

D i sc u s s i o n : 2

F rom t he pe r sp e c t i v e of an i nd i v i d u al li v i ng i n t he U S

, ha z ardous m a t er i a l s i n c i d e n t s a re r a re; t he 3

li k

e l i hood t h a t an i n d i v i du a l w i l l b e i n v o l v ed i n or a f f e c t ed by such an i n c i d e nt i s r e l a ti v e l y l o w

. 4

A ccor d i ng t o t he P i p e li n e a nd H a z ardous M a t e r i a l s S a f e t y A d m i n i s t r a t i on o f t h e D epa r t m ent of 5

T r ans p o r t a t i on, du r i ng t he t en y ears o f 20 0 3

- 2012, t he r e w ere 159,411 ha z ard o us m a t er i a l s i n c i de n t s i n t he 6

U S by a l l m odes of t r a n spo r

t a t i on, r e su l t i ng i n 129 dea t h s a n d 2,690 i n j u r i e s

, a m o n g a popu l a ti o n of >280 7

m

il l i on p eop l e ( U S D O T P i pe l i ne and H a z a r dous Ma t e r i a l s S a f e t y A d m i n i s t r a t i on [ P H M S A ], 2013). 8

T he r ef

o re, i t i s n ot s urp r i s i ng t h a t m e m bers of t he pu b li c a r e g ener a ll y n o t w e l l i n f or m ed abo u t ha z ardous 9

m at e r i a l s

. C D C ’ s P re

- E v ent Mes s a g e D e v e l op m ent P r o j ect fou n d t h at s t udy pa r ti c i p a n t s had li m it ed 10

und e rs t an d i ng of C BR N a g en t s or t he d i f f e re n ces b e t w e e n c a t e g or i es o f a g en t s (e. g

., i nf e c t i ous v s. non

11

i nfec t i ou s ) ( W r ay et a l

. , 2008). P r e

- i nc i d e n t ed u c a ti on co u l d i m pro v e t he pu b l i c ’ s un d er s t an d i ng of 12

ha z ardous m a t e r i a l s

, w hat t o exp e ct from resp o nd e rs, r ece i v e r s and o f f i c i a l s d u r i n g a respo n se a n d w hat 13

t hey can do t o p r o t e c t t he m se l v es a nd t h e i r f

a m ili e s

. I n t u r n, t h e i nc r ea s ed k no wl ed g e and en h anc e d 14

unde r s t a nd i ng a m ong t he p ub l i c c a n i m

pro v e t he p o t e n ti a l f

or a n e ff e c t i v e res p on s e i n a n a c t u a l i nc i de n t 15

by pro m

o ti ng approp r i a t e p ro t e c t i v e a c ti o n s. 16

17

A s t udy of t he i m pact of p u b l i c ed u ca t i on pro g ra m s on t he p u b l i c ’ s p r ep a red n ess t o re s pond t o a che m i cal 18

t e r

ro r i s t i nc i de n t i n t he U n it ed K i n g dom ( U K ) a n d i n I sra e l su gg es t s t h a t t h e r a t e s of u p t a k e and 19

ass i m

i l a t i on o f t h e i nf

o r m a ti on we re r e l a t i v e l y l ow ( Hil debr a nd & B l e e t m an, 200 7 )

. T h i r t y

- t hree pe r ce n t 20

of r e spon d en t s i n t h e U K a nd 22% i n I sra e l r epo r

t ed r ead i ng t h e ed u c a ti o n al bo ok l et pro v i d ed t o a l l 21

c i t i z ens. L ar g e p e rce n t a g es of r espo n de n t s i n b o t h co u n t r i es (4 1 % i n t h e U K and 33% i n I srae l ) s t a t ed t h a t 22

t h ey w ou l d n o t w a i t f or e mer g ency ser v i ces t o a r r i v e at t h e i r l o ca t i o n ; r a t h er, t hey w ou l d t ra v el t o or ca l l a 23

h o sp i t a l f

or h e l p. T h ese a c t i ons w o u l d be c o n t r a ry t o w hat wa s r eco mm

en d ed i n t he edu c a t i on a l boo k l et 24

a nd co u l d u nd e r m i ne t h e l o cal e m

er g ency res p onse. H o w e v er, as n o t ed i n o t h e r p a r t s of t h i s g u i dance 25

d ocu m

en t

, i f r es p onse o r g an i z a t i ons are pr e p ared for so m e af f e c t ed c o m m

un it y m e m

bers t o s e lf

- e v acua t e 26

and se l f

- prese n t a t a he a lt h c a

re fa c i l it y

, t h en t he co m m un it y ’s o v er a l l r es ponse w i l l n o t nece s s a r i l y be 27

und e r m

i ned. F ur t h er m

ore, p e rh a ps i m pro v ed educ a ti o n and a w a r e n ess a m ong e v en a s m a l l per c en t a g e of 28

a p opu l a t i on can be con s i d e red a p a r t i a l succ e ss. 29

30v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

83 T he i n f l u en c e of a p r e

- e v e n t pu b li c ed u ca t i on ca m pa i g n on t h e e ff

e c t i v eness of a r espon s e t o a c h e m i cal 1

or ha z ar d ous m a t e r i a l s i n ci dent (e

. g ., u s i ng hea l t h o u t c o m es or pr o t e c ti v e a ct i ons by t he pu b li c or s o m e 2

o t h e r m

easure of e f

f e c ti v e n es s) has not b een s t u d i e d. T h i s w o u l d r eq u i re m easur i ng d i sa s t er r e spon s e 3

ef

f ec t i v ene s s b e fo r e and a ft er a p ub l i c educ at i on c a m p a i g n i n t he s a m

e co m m un it y or co m

par i ng d i s a s t er 4

resp o nse e f

fe c ti v en e ss i n tw o s i m

il ar co m m

un it i es, o ne of w h i ch h ad c ondu c t ed a p ub l i c edu c a t i on 5

ca m

pa i g n and one o f w h i ch had n o t

. P u b l i c he al t h p ra c t i t i on e rs u s e pu b l i c ed u c at i on c a m pa i g ns re g u l a r l y 6

t o p r o m

o t e he a lt hy be h a v i ors, wi t h d e m ons t r a t ed suc ce ss i n a r eas o f h i g h

- pre v a l ence, h i g h

- r i sk beha v i ors 7

such a s s m

o k i ng cessa t i on and t h e p r e v en t i on of H I V t rans m i s s i on. H o w e v er, t he ex t e n s i o n of such 8

pu b li c hea l t h s uc c ess e s t o p r ep a r e dness for l ow p rob a

b i l i t y e v en t s su c h as a ha z ar d ous ch e m i cal r e l ease i s 9

ques t i o n ab l e. 10

11

C o m m

un it y res i l i e n ce d e p e nds on i nf o r m ed, e m po w ered and p re p ar e d co m m un it y m e m bers. T h i s 12

req u i r e s ed u c a ti o n

, t w o

- w ay c o m m un i ca t i on, a nd c o l la

bor a ti v e p l an n i n g

. HH S and FE MA bo t h 13

reco mm

end t hat s i g n i f

i ca n t pr e

- i nc i d ent w o rk be con d uc t ed on an on g o i ng bas i s t o en g a g e t he w ho l e 14

co m m

un it y i n e m

er g ency p l an n i n g

. C o m m un iti es sh o u l d l e v era g e e x i s t i ng pro g r a m s and e v en t s w h ile 15

a l so i n i t i a ti ng ad d i t i on a l a c t i v it i es f ocu s ed on e m

er g ency prepa r edn e ss ( FE M A

, 2 011; HH S , 20 1 2). 16

17

T h i s g u i d a nce s t a t e m ent ac k no w l ed g es t h a t t h e a v a i l a b l e e v i d e nce su gg es t s t h at t h e ti m e and a t t e n ti on of 18

t he p u b l i c a re li m it e d , es p e c i a ll y f

o r t o p i c s t h at t hey p erc e i v e as l ow r i sk t o t he m se l v es, and t i m e and o t h e r 19

r eso u rc e s of e m er g ency respon s e a n d pu b li c he al t h or g a n i z a ti o ns a re li m i t e d

. S o m

e su b j e c t m a tt e r expe r t s 20

are s k

ep t i c a l t h at t h e co s t/

b en e f i t r a t i o f or p re

- i nc i d e nt p ub l i c educ at i on a b out c h e m i cal i n c i de n t s i s 21

f

a v ora b l e. T h e s t udy de s cr i b ed a bo v e ( Hi l de b rand & B l ee t m an, 200 7 ) a l so ca s t s so m e dou b t on t he 22

po t e n t i al for edu c a t i on a l m a t e r i a l t o s i g n i f i ca n tl y i n cr e ase p rep a

re d ne s s. T h e se fa c t o r s a

re re f l e c t e d i n t he 23

l ow L e v el o f C on f i d e nce a s s i g ned t o t h i s g u i d a nce s t a t e m ent ( L O C = V ). F u r t he r

, t he g u i d a nce s t a t e m ent 24

e m

phas i z es e f

f i c i e ncy

- ed u ca t i on a

bout ha z ard o us m a t er i a l s , p a ti e nt d eco n t a m i na t i on, a n d p r o t e c t i v e 25

ac t i ons as s oc i a t ed wi t h s e lf

- and c o m m

un it y ef f i cacy s hou l d b e i nco r

po r a t e d i n t o co m m

un it y ou t re a ch 26

eff

o r t s and p l anned e v en t s as ap p ro p r i a t e. 27v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

84 

### G u ida n ce S tat e me n t 6.4

T o fa c i l i t a t e e f

f e c t i v e t w o

- w ay co mm

un i ca t i on d u r i ng and a f

t e r an i n c i d en t :

• P ro v i de p a t i en t s wi t h p re

- scr i p t ed and p r i n t e d f o l l o w

- up i n for m a ti o n b e fo r e t h ey l ea v e t h e s c ene o r

pr i o r t o d i sch a

r g e f r om t he hea l t h c are f

a c i l i t y

.

• O b t a i n p a

ti e nt con t a c t i n fo r m a ti on p r i or t o re l ea s e f r o m t he hea l t h c are f

a c i l i t y t o a l l ow f

o r f o l l o w

up by t he pu b l i c h e a l t h co mm un it y

.

• E s t a b l i sh an ea si l y acce s s i b l e m echan i sm for p a t i en t s t o ob t a i n a dd i t i on a l i n for m a ti on or a d v i ce a nd

for a u t h o r i t i es t o res p ond d i re c tl y t o p a t i e n t s ’ qu e s t i ons or co mm en t s.

• P ro v i de f

o l l o w

- up i nfor m a t i on f

or o t h e r co mm

un it y me m

bers w ho w ere e i t h e r a t t he s c ene a nd n o t

deco n t a m i na t e d or not at t h e sc e ne.

Considerations:

• D e v e l op f

o ll o w

- up i nf

o r m a ti on i n cons u l t a t

i on w it h a p prop r

i a t e m ed i c a l

, t e c hn i ca l

, beha v i o r al he a lth

and c r i s i s and e m

er g ency r i sk co m m

un i ca ti on exp e r t s.

• I nc l ude i n s t r u c t i on s he e t s i n t he m ost c o m m on l an g ua g es used i n t h e co mm un it y ; con f

i rm t h a t

t ra n s l a t i ons use p ro p er s y n t ax.

• T h i s i nf

o r m a ti on sho u l d be acc e ss i b l e e l ec t ro n i c al l y and t h r ou g h m

u lti p l e m echan i s m s or l oc at

i ons.

• E n g a g e t he pub l i c h e a lt h c o m m un it y

, P o i son C on t

rol C en t e rs, and o t h e r co mm un it y resour c es t o

he l p coo r d i n a t e de l i v ery of pa t i e n t f o ll o w

- up i nf

o r m a t i on and d e v e l op p at i e n t re g i s t ry f o r f u r t her

co m m un i ca t i on.

• T he A g ency for T o x i c S u b s t an c es a nd D i s ea s e R e g i s tr y ( A T S D R ) M ed i cal Ma n a g e m ent G u i d e li n es,

a v a il a b l e o n t h e i n t e rn e t ( at h tt p : // www .a t sdr

. cdc. g o v / mm g / I ndex.asp )

, i nc l ude a pr i n t a b l e P a t i e n t

I nfo r m a ti on S h e e t and F o ll ow

- U p I ns t ruc t i o n s f o r do z ens o f sp e c i f

i c che m i c a l s as w e l l as g u i d a nce for

res p ond e rs a nd r ec e i v e r s t r e a ti ng p a ti e n t s exp o sed t o an un k no w n che m

i c a l

.

• A l l m ed i c a l i nf o r m a ti on d i s se m

i na t ed t o p a t i e n t s a nd c o m m un it y m e m bers m ust ha v e a con s i s t e n t

m essa g e and be co o r d i n a t e d ac r oss t he en t i r e r e spo n s e

. Level of Confidence: III

1

D i sc u s s i o n : 2

P ro v i d i ng w r i t t en, i n ad d i ti on t o v er b a l

, fo l l o w

- up or d i sc h ar g e i n s t ru c ti o ns t o p a t i en t s i s co m m on m ed i cal 3

p ra c t i ce a n d has b e en sho w n t o i nc r ea s e p a t i e n t co m p li a n ce w it h m

ed i c al r eco m m

enda ti o ns co m

pared t o 4

v e r

bal i n s t r uc t i ons a l o n e. P r ep a

r a ti on of pa t i e n t f

o ll o w

- up i nf

o r m a t i on i n a d v ance o f an i n c i de n t a ll o w s 5

f

o r t h o rou g h re v i ew a n d i n p ut by m ed i cal exp e r t s and enha n ces p r epa r edn e ss. T h e pr i n t a b l e P a t i e n t 6

I nfor m a ti o n S he e t s a n d F o l l o w

- U p I n s t r u c t i o n s a v a i l ab l e on A T S D R ’s w e b s it e ( at 7

h tt p : /

/ www .a t sdr

. cdc. g o v

/ mm g / I ndex.asp) ha v e b e en de v e l oped by expe r t s i n m ed i c i ne a nd t ox i co l o g y 8

and a

re r e g u l a r l y re v i e w ed and up d a t e d. 9

10

T he C D C ’s P r e

- E v ent M es sa g e D e v e l op m ent P r o j e c t w h i ch c ondu c t ed o v er 1000 foc u s g roup and 11

i nd i v i d u al i n t er v i e w s , fo un d t h a t s t udy pa r t i c i p an t s w o u l d a c t i v e l y seek i nf o r m a t i on abo u t how t o p r o t e ct 12

t h e i r h ea l t h a nd t hat of t h e i r fa m

ili e s i n a CBR N t e rr o r i sm i nc i de n t ( W r ay et a l ., 2 0 08). I n t he s t udy of a 13

h y po t he t i c a l p l a g ue a tt a c k , par t i c i pa n t s re p o r t ed t ha t a f t er i n i t i a ll y see k

i ng i n for m a ti on f

r om l ocal and 14

na t i on a l a u t h o r i ti e s, o v er t i m e, t hey w ou l d use t he i n t e rnet and n e w sp a pe r s t o f i nd m ore i n

- dep t h 15

i nf

o r m a ti on ( W ray & Jup k a, 2004). T he r ef o re, t he i n t e rnet and n e w sp a pe r s co u l d be us e d t o d i s se m i na t e 16

fo l l o w

- up and pro v i de add i ti o n al i n f or m a ti on t o pa t i e n t s a n d o t her co m m un it y m e m bers as t h e i nc i de n t

, 17

resp o nse and reco v ery pr o c eed. T h e sa m e m echan i s m s co u l d p r o v i de m eans f o r c o l l ec t i ng and resp o nd i ng 18

t o pa t

i e n t s ’ a n d co m m

un it y m e m bers’ q u e st i ons and co m

m en t s. 19

20

O b t a i n i ng pa t i e n t c on t act i n for m a ti on a l l o w s for ad d i ti onal m ed i c al o r o t h e r i n fo r

m a ti on r e l a t ed t o t he 21

i n c i de n t t o be c o m m un i ca t e d t o p at i e n t s l a t er, i f nec e s s ar y

. Mo s t i m por t an t l y , su c h co m m

un i ca t i on 22v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

85 shou l d ad d

re s s p a t i en t s’ p hy s i ca l

, b eha v i o ral and m en t al h e a l t h n e eds. A dd i ti o na l l y , da t a o n t h e i m pac t s 1

of t h e i n c i d e n t and t he e f f e c ti v en e ss o f co u n t e r m

easu r es c a n be c o l l e c t ed t h rou g h pos t

- e v ent 2

co m m

un i ca t i on. A s s ess m

ent of pa t i e n t s exp o sed t o sa r i n v ap o rs i n t h e 1994 M a t s u m o t o and t h e 1995 3

T o ky o, J a

pan at t ac k s h a s l e d t o d o cu m en t a t i on o f a cu t e and l o ng

- t erm hea lt h e f fe ct s as we l l as d a t a on t he 4

ef

f i c a cy of m

ed i c a l i n t e r v en ti o ns ( Y ana g i sa w a et a l

., 2 006). T h i s t y pe of an a l y s i s pro v i des i n for m a ti o n on 5

t he e f

fe c t s o f ha za

rdous m a t er i a l s on hu m an hea l t h t hat i s d i f f i c u l t t o ob t a i n , h el ps t o f

i l l i n s i g n i f

i c ant 6

k

no w l ed g e g aps, and can b e used t o i m pro v e e m er g e n cy prepa r edn e ss a nd r espo n se. 7

8v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

86 

## Bibli og r a phy 1

2

A d i n i

, B

., G o l d b er g

, A

., L a or, D

., C ohe n

, R

., Z ado k

, R ., & B ar

- D a y an, Y . (200 6 ). A sses s i ng l e v e l s of 3

hosp i t a l e m er g ency prep a

r e dness. P reh o sp i t a l and D i s as t e r M ed i c i n e, 21 ( 6

)

, 451

- 457. 4

5

A m

er i c a n P s y ch i a t r i c A ss o c i a ti o n. (2 0 13 ). D i agn o s t i c and s t a t i s ti c al m an u al o

f m en t a l d i sor

d ers ( 5 t h ed, 6

Tex t R e v i s i o n ). 7

8

A m

l ôt, R

., L a

rn e r, J

., M a t ar

, H

., J one s

, D

. R

., C a r t e r, H

., T u rn e r, E

. A

., P r i ce, S

. C

. , et a l

. (201 0 ). 9

C o m

para ti v e an a l y s i s o f s h o w er i ng pr o t o c o l s f o r m ass

- casua lt y deco n t a m i na t i on. P rehos

p i t al a nd 10

D i sa s t er Me d i c i ne, 25 ( 5 )

, 435

- 439. 11

12

A uf der H e i d e, E

. ( 200 4 ). C o m m on m i sconcep t i o n s i n d i s a s t e r s : p a n i c, t h e " d i s as t er s y ndro m e," a nd 13

l oo t i n g . In M. O’Leary. T he F i r s t 72 H o u r s : A C o m m un it y A pproach t o D i s a s t e r P r ep a red n ess (pp. 14

340

- 380). L i nc o l n, NE: i U n i v er s e P u b l i s h i n g

. R e t r i e v ed from 15

http://www.atsdr.cdc.gov/emergency_response/common_misconceptions.pdf

. 16

17

A uf der H e i d e, E

. ( 198 9 ). I n t er

- a g ency co mm un i ca t i o ns. I n Mosby, C.V., Di sa s t e r R esp o nse: P r i nc i p l e s 18

o f P rep a r a ti on and C o o r d i n a t i on ( p p. 79

- 102). St. Louis: C enter of Excellence in Disaster 19

Management and Humanitarian A ssistance. R e t r i e v ed f r om h tt p : / / www .co e 20

d m

ha.or g / Med i a

/ Di sa s t e r

_

R espon s e_ P r i n c i p a l s. p df. 21

22

A uf der H e i d e, E

. ( 200 6 ). T he i m por t a nce o f e v i d e nce

- based d i s a s t er p l a nn i n g

. A n n a l s o f E m e r gen c y 23



### Me d i c i ne, 47 ( 1 )

, 34

- 49. doi:10.1016/j.annemergmed.2005.05.009 24

25

A u f der H e i d e, E . a n d J

. S c an l on (20 0 7). T h e r o l e o f t h e he a lt h se c t o r i n p l a nn i ng and r espo n se. 26

In Waugh, W. L

. J. and Tierney, K

. E m er g ency Mana g e m

en t : P r i n c i p l es and P ra c t i ce f or L ocal 27

G o v ern m en t (pp. 183

- 204). Was h i n g t on, D C : I n t e r na t i o n al C it y

/ C ou n t y Mana g e m

ent A ssoc i a t i o n

. 28

R e t r i e v ed from 29

http://www.atsdr.cdc.gov/Auf_der_Heide_2007_Role_of_the_Health_Sector_in_Planning_&_Respo 30

nse.pdf. 31

32

B arach P

, R i vk i nd A

, I srae l i A

, B er d

u g o M, R i c h t e r E. D.(1998). Emer g ency prepare d ne s s and res p onse 33

i n I sra e l dur i ng t h e G u l f W ar. A n n E m erg M e d , 32

, 224

- 233. 34

35

B ec k

er, S . M. (20 0 4). E m

e r g ency c o m m

un i ca t i on a n d i nfor m a ti o n i ssu e s in t e r r o ri st e v en t s i n v o l v i ng 36

rad i oa c ti v e m a t e r i a l s. B i os e cur i t y & B i o t err o r i s m

, 2 ( 3 )

, 195

- 207. 37

38

B e ll o, D ., W o s k i e, S

. R

., S t

re i ch e r, R

. P

., S t o w e, M

. H

. , S par e r, J

. , R ed l i c h, C

. A

., C u ll e n, M. R

., et a l

. 39

(200 5 ). A l a bo r a t o ry i n v es ti g a ti on o f t h e e ff e c t i v eness of v ar i o us s k

i n a nd s u r f

ace deco n t a m

i nan t s f o r 40

a l i ph a ti c po l y i s o c y ana t es. J ourn a l of E

nv i ron m e n t a l M

on i t or i ng: J

E M, 7 ( 7 )

, 716

- 721. 41

42

B enn e t t

, R

. L

. (200 6 ). C h e m i cal or b i o l o g i c a l t e r r o r i st a t t ac k s: a n a n a l y s i s of t he prep a re d ness of 43

hosp i t a l s for m ana g i ng v i c ti m s aff e c t e d by che m

i cal o r b i o l o g i cal w eapo n s o f m ass de s t r u c t i on. 44

In t e rn a ti o nal Jour n al o f E n v i ron m en t

a l R e se a rch a n d P ub l i c H e a lt h

, 3 ( 1 )

, 67

- 75. 45

46

B erdo w s k

i

, J

., B erg R

. A

., T i

j s sen, J. G ., & K os t er R

. W. ( 201 0 Nov ). G l o b al i n c i d e nc e s of o u t

- o f

- hosp it a l 47

car d i ac a r re s t a n d s u r v i v al r a t e s : S y s t e m a t i c r e v i ew of 67 pr o spe c ti v e s t u d i es. R e s usc i t a ti on 48

81 ( 11 ) , 14 7 9

- 1487. 49

50v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

87 B er k ens t a d t

, H

., Z i v

, A

., B arsu k

, D

., L e v i ne, I

., C ohe n

, A ., & V a rd i

, A

. (200 3 ). T he use of a d v anced 1

s i m

u l a t i on i n t h e t

r a i n i ng of an e s t h e s i o l o g i s t s t o t r e at c he m i cal wa rf a re c as u a l ti e s. A nes t

he s i a and 2

A na l g e s i a, 96 ( 6 )

, 1739

- 1742. 3

4

B j ar n ason S

. , M i k l er, J., Hi ll

, I

., T e n n, C

., G a r r e tt

, M., C add y

, N ., & S a w y er, T

. W . (200 8 ). C o m par i s on 5

of s e l e c t e d s k i n d e con t a m

i na t i on p r odu c t s a nd r e g i m ens a g a i n s t V X i n d o m

es ti c sw i ne. H

u m an & 6

E

xpe r i m en t

al T o x i co l o gy, 2 7, 253

- 2 61. 7

8

B ond, W. F

., S ubb a rao, I

., Ki mm

e l

, S

. R

., K u k

li n s k i

, J

, Johns o n, C

., E b e rh a

rd t

, M

. , V o z en i l e k

, J

. (200 8 ). 9

T e s t i ng t he u se o f s y m p t o m

- based t e r

ro r i sm t r i a g e a l g or i t h m s w it h h o sp i t a l

- based pro v i de r s. 10

P rehos p i t al D i sa s t Me d

, 23 (3), 2 34

– 243. 11

12

B ou t s i ou k

i

, P

., T ho m

pson, J

. P ., & C l ou g h, G

. F . ( 2 0 0 1). E f fe c t s o f l oc a l b l ood f

l o w on t he pe r cu t ane o us 13

abso r

p t i on o f t h e o r g anop h ospho r us co m pound m a l a t h i on: A m

i c r od i a l y s i s s t u dy i n m an. A rch i v es o f 14

T

ox i c o l o g y, 75 ( 6 )

, 321

- 328. 15

16

B raue, E

. H

., Jr. (19 9 9). De v e l op m ent of a re a c t i v e t o p i c a l s k i n p ro t e c t a n t

. Jo u rn a l of A pp l i ed 17

T

ox i c o l o g y: J AT , 19 S u pp lem en t al 1, S 4 7

- S 53. 18

19

B raue, E

. H

., Jr., S m it h, K

. H

., D ox z on, B

. F

., L u m p k i n H

. L ., & C l ar k son, E

. D

. ( 2011). E f f i c a cy s t u d i es 20

of r e a c ti v e s k i n d e co n t a m

i na t i on l o t i on, M291 s k

i n de c on t a m

i na t i on k i t , 0. 5 % b l e a ch, 1% soapy 21

w a t e r , and s k i n exp o s u r e r e duc t i on p as t e a g a i n st che m i cal wa r f are a g en t s, P a r

t 1 : G u i nea p i g s 22

cha l l en g ed wi t h V X

. C u t a n eous a n d O cu l ar T

o x i c o l o g y, 30

, 15

- 28. 23

24

B raue, E

. H

., Jr., S m it h, K

. H

., D ox z on, B

. F

., L u m p k i n, H

. L ., & C l ar k son, E

. D

. (201 1 ). E f f i cacy s t u d i e s 25

of r e a c ti v e s k i n d e co n t a m

i na t i on l o t i on, M291 s k

i n de c on t a m

i na t i on k i t , 0. 5 % b l e a ch, 1% soapy 26

w a t e r , and s k i n exp o su r e r e duc t i on p as t e a g a i n st che m i cal wa r f are a g en t s, P a r

t 2 : G u i nea p i g s 27

cha l l en g ed wi t h s o m an. C u t aneous and O c u l ar T

o x i co l ogy, 30

, 2 9

- 37. 28

29

B renna n

, R

. J

., Wa e c k er l e, J

. F

., S h a

rp, T

. W., & L i l l i b r i d g e, S

. R

. ( 199 9 ). C he m i c al wa rf a re a g e n t s: 30

E m

er g ency m

edical and e mer g ency pub l i c h e a l t h i ss u e s. A nn a l s o f E m er g ency M ed i c i ne, 34( 2 ), 1 9 1

- 31

204. 32

33

B r i n k

er, A

., P r i o r, K ., & S c hu m acher, J

. (200 9 ). P e rs o nal p ro t e c ti on du r i ng re s us c it a t i on of c a su a l t i es 34

con t a m i n a t ed w it h che m

i c a l or b i o l o g i c a l w a r f

a re a g e n t s

- A sur v ey of m ed i c a l f i r st r ec e i v ers. 35

P rehos p i t al a nd Di sa s t er M

ed i c i ne, 24( 6 ), 5 2 5

- 528. 36

37

Bryant, Richard A., Friedman, Matthew J., Spiegel, David, Ursano, Robert, and Strain, James. (2011) A 38

Review of Acute Stress Disorder in DSM

- V. Depression and Anxiety Vol 28: 802

- 817 39

40

B uc k

l y

, T

. J

., S a

p t o k a, A

., C ard e ll o, N

., D e l l a r co, M. J., & K l i n g er, T

. D

. (n.d

. ). A ra t i on a l a p pr o ach t o 41

s k

i n deco n t a m

i na t i on. R e tr

i e v e d f rom http://

www

. s k c i nc.c o m / C L I / A %2 0 R a ti o n a l %2 0 A pproa c h.pdf 42

43

B uc k s, D

. A ., Ma i b ach, H

. I ., Menc z e l

, E ., & We s t e r, R

. C . (198 3 ). P e rc u t an e ous pene t r a ti o n of 44

h y droco r ti s one i n hu m ans f o ll o w i ng s k

i n de l i p i d i z a t i o n by 1 : 1 : 1 t r i c h l o r oe t hane. A rch i ves of 45

D er

m a t o l og i cal R e s earc h

, 275( 4 ), 242

- 245. 46

47

B ur g ess, J

. L

., K i r k , M., B o rron, S . W., & C i se k

, J

. ( 1 9 99). E m er g ency depa

r t m ent ha z ar d ous m a t e r i a l s 48

pro t o col f o r co n t a m i na t ed p a t i en t s. A nn a l s of E me rge n cy M

ed i c i n e, 3 4 (2), 205

- 212. 49

50

B ur g ess, J

. L

., B l a ck m on, G . M., B rod k

i n, C

. A ., & R obe r t son, W. O

. (199 7 ). H osp i t a l p r ep a redn e ss for 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

88 ha z ardous m a t e r i a l s i n c i d e n t s a n d t re a t m ent of con t a m

i na t ed p a ti e n t s

. W

es t ern J o urnal of Me d i c i ne, 1

167( 6 ), 387

- 391. 2

3

B ur g ess, J

. L

. (19 9 9). H o s p i t al e v ac u a t i ons due t o ha z ardo u s m a t e r i a l s i n c i d en t s. T he A m e r ican Jour

n al 4

of E

m er g ency M e d i c i n e, 1 7 (1), 5 0

- 52. 5

6

B y ers, M., R u s s e ll

, M., & L oc k e y

, D

. J . (2 0 08). C li n i c al care i n t he “ H ot Z one”. E m ergen c y M ed i cal 7

Journ a l

, 20 0 8(2 5 ), 1 0 8

- 112. 8

9

C aba l

, J., K a s sa, J., & S e v era, J

. (20 0 3). A c o m par i son of t h e d e co n t a m

i na t i on e f fi cacy of f

oa m

- m a k i ng 10

b l en d s b a sed on c a ti o n i c a n d non i o n i c t e ns i des a g a i n s t or g anophos p hor u s co m pounds d e t e r m

i ned i n 11

v it ro a n d i n v i v o. H u m an & E

xpe r i m e n t al T

o x i co l o gy, 22(9 ) , 507

- 514. 12

13

C a l i for n i a. G o v er n o r ’s Of f i ce of E m er g ency S er v i c e s

. (200 6 ). Mu l t i

- casu a l t y m ass deco n t a m i na t i on 14

g u i dance d ocu m ent f o r f i r st res p ond e rs. R e t r i e v ed f rom 15

http:// www .ca l e m a.ca. g o v / ha z ardous m a t er i a l s / d ocu m en t s / m c m d

- 1

- 2

- 06.pd f

. 16

17

C ar t e r, H

., Dr ur y

, J

., R u b i n

, G

. J

. , W i l l i a m s, R . & A m l ô t

, R

. ( 2012 )

. P u b li c exp e r i ences of m ass c asu a lt y 18

deco n t a m i na t i on. B i o s ecu ri t

y and B i o t e r ro r i s m : B i o d e f ense S t r a t e g y, P r a c t i ce, a n d Sc i ence

, 10 ( 3), 1

- 19

10. 20

21

C ase, G

. G

., W e s t

, B . M., & Mc H u g h, C

. J

. (20 0 1). H osp i t a l p r ep a redn e ss for b i o l o g i c a l and che m i cal 22

t e r

ro r i sm i n c e n t

ral N ew J e rse y

. N

ew Je r sey M e d i c i n e

, 98(1 1 ), 23

- 33. 23

24

C handr a

, A

., J

. A c o s t a, e t a l . (2 0 11). B u i l d i ng co m m un it y r e s i li e nce t o d i s a s t er s : A w ay for w ard t o 25

enhan c e n a t i on a l he a l t h s ec ur i t y

. S an t a Mo n i ca, C A: R AND

. 26

27

C han g

, S

. K

., B r o w n i e, C

. , & R i v i ere, J. E . ( 1 994). P e r cu t a n eous abs o r p ti o n of t o p i c a l p a r a t h i o n t h rou g h 28

por c i ne s k i n: I n v it ro s t ud ie s on t he e ff

e ct of e n v i ron m en t a l p e r t ur b a t i ons. Jou r nal of V e t e r i n a ry 29

P har

m ac o l ogy a nd T

h e ra p eu t i cs, 1 7( 6 ), 434

- 439. 30

31

C han g

, S

. K ., & R i v i e re, J. E . (199 3 ). E f fe c t o f hu m

i d it y and occ l u s i o n on t he p er c u t an e ous abs o rp t i on o f 32

par a t h i on i n v it r o. P har m a c eu t i c a l R e s ear c h, 10 ( 1), 15 2

- 155. 33

34

C hen, H

., Z hen g

, J

., Z

han g

, X

., L u o , M., Wan g

, Z ., & Q i ao, X

. ( 200 7 ). S u r fa c e d e sor p ti o n a t m osph e r i c 35

pre s su r e che m i c a l i on i z a t i o n m ass spe c t ro m e t ry f o r d ir ect a m

b i ent s a m p l e an a l y s i s w it h out t o x i c 36

che m

i cal con t a m

i na t i on. J o urnal of Ma s s Sp e c t ro m e t r y

, 42( 8 ), 1045

- 10 56. 37

38

C h il c o t t

, R

. P

., Da lt o n, C

. H

., A sh l e y

, Z

., A l l en, C

. E

. , B rad l e y

, S

. T

., M a i d m en t

, M. P

., Jenn e r, J

., et a l

. 39

(200 7 ). E v a l u a ti o n of ba r r ie r c r ea m s a g a i nst su l phur m us t a rd: ( I I ) I n v i v o and i n v i t ro s t u d i e s u s i ng 40

t he do m es t i c w h i t e p i g

. C u t

aneous and O c u l ar T

o x i co l ogy, 2 6 (3), 235

- 247. 41

42

C h il c o t

t, R

. P

., Da lt o n, C

. H

., H il l

, I

., D a v i son, C . M., B l oh m

, K

. L

., C l ar k son, E

. D ., & H a m ilt on, M. G

. 43

(200 5 ). E v a l u a ti o n of a b a r r i er cr e am a g a i nst t he c he m i cal wa r f are a g ent V X u s i ng t he do m es t i c 44

w h it e p i g

. B as i c & C li n i cal P har m ac o l ogy & T

ox i co l o gy, 97 ( 1), 3 5

- 38. 45

46

C h il c o t t

, R

. P

., Jenn e r, J

., H o t ch k i ss, S

. A ., & R i c e

, P . (200 1 ). I n v it ro s k i n a b so r p ti o n and 47

deco n t a m i na t i on o f s u l ph u r m

us t ard: C o m

pa r i son o f h u m an and p i g

- ear s k i n. J ou rnal o f A p p l i ed 48

T

ox i c o l o g y: J AT

, 2 1 (4), 27 9

- 283. 49

50

C h il c o t t

, R

. P

., Jenn e r, J

., H o t c h k i ss, S

. A . M., & R ic e, P . (2 0 02). E v a l ua t i on of bar r i e r c rea m s a g a i n s t 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

89 su l p h ur m us t a rd. I

. I n v it ro s t u d i es us i ng hu m an s k i n. Sk i n P h a r

m ac o l ogy and A

p p li e d S k i n 1

P hys i o l o g y, 1 5 (4), 225

- 235. 2

3

C i e s l a k

, T

. J., R o w e, J. R

., K o r t e p e t er, M. G

., M ad s en, J

. M., N e w m ar k

, J

., C h r i s t opher, G

. W., 4

C u l pep p er, R

. C

., et a l

. (2 0 00). A f i e l d

- exped i e nt a l g or i t h m

i c app r oach t o t he c l i n i c a l m ana g e m ent of 5

che m

i cal and b i o l o g i cal ca s ua l ti e s. M i l i t ary M ed i c i n e, 165( 9 ), 659

- 662. 6

7

C l ar k

, C

. R

., S m it h, J

. R

., & S h i h, M. L . (1 9 99 ). D e v e l op m ent of an i n v it r o s c re e n i ng m e t hod for 8

e v a l ua t i ng deco n t a m i na t i on of s u l f

u r m us t a r d by re a c ti v e der m al for m u l a t i o n s. J

o urnal of A

p p l i ed 9

T

ox i c o l o g y 19( S upp l 1), S 7 7

- S 81. 10

11

C l ar k

e, S

. F

. J., C h i l c o tt

, R

. P ., W i l s o n, J

. C

., K a m an y i re, R

., B a k er, D

. J., & H a l l e tt

, A

. (200 8 ). 12

D econ t a m i na t i on of m

u l t i p l e ca s ua l t i es w ho are che m i c a ll y co n t a m

i na t ed: A ch a ll e n g e for a cu t e 13

hosp i t a l s. P reh o sp i t al and D i sa s t er Me d i c i ne, 23 ( 2 )

, 175

- 181. 14

15

C od y

, R

. B

., L ara m ée, J

. A

. , N il e s, J

. M., & D u r s t

, H

. D . (200 5 ). Di re c t a n a l y s i s i n re a l t i m e ( DA RT t m

) 16

m ass spec t ro m e t r y

. J E O L N e w s, 40 ( 1 )

, 8

- 12. 17

18

C one, D

. C ., & K o en i g

, K

. L . (200 5 ). M ass ca s ua l t y t r i a g e i n t he che m

i ca l

, b i o l o g i c a l

, r ad i o l o g i c a l

, o r 19

nuc l e ar en v i ron m en t

. E u r o pean J o urn a l of E

m erg e ncy Me d i c i ne, 1 2 ( 6 )

, 287

- 302. 20

21

C one, D

. C

., M ac M i l l an, D

. S

., P ar w a n i

, V ., & V an G e l d e r, C

. ( 200 8 ). P i l o t t e st of a p rop o sed 22

che m

i ca l / b i o l o g i c a l / r a d i a t i on/ n u c l e a r

- capab l e m ass c asu a lt y t r i a g e s y s t e m

. P re h osp i t al E m erg e ncy 23

C

are, 12 ( 2 )

, 236

- 240. 24

25

C one, D

. C ., & D a v i dson, S

. J . ( 1 9 97). H a z ardo u s m a t e r i a l s p re p are d ne s s i n t he e m er g ency depar t m

en t

. 26

P rehos p i t al E me rge n cy C

a re, 1 ( 2), 8 5

- 90. 27

28

C ons i d i ne, J., & M i t ch e ll

, B . (200 9 ). C he m i c a l , b i o l og i cal a n d r a d i o l o g i c a l i nc i d en t s : P r ep a red n ess and 29

per c ep t i ons of e m er g ency n urs e s. Di sa s t e r s, 3 3 (3), 48 2

- 497. 30

31

C i ra u l o, D

. L

., F r yk ber g

, E

. R

., F e l i c i ano, D

. V

., K n u t h

, T

. E

., R i c h a r t

, C . M

. , W es t m ore l and, C

. D ., & 32

W i l l i a m s, K

. A

. ( 200 4 ). A sur v ey asse s s m ent of t he l e v el of p r ep a

red n ess for d o m

es ti c t e r ro r i sm and 33

m ass casu a lt y i n c i d e n t s a m ong E as t e rn A ss o c i a t i on f or t he S u r g ery of T r au m a m e m bers. T he Jo u rn a l 34

of T

rau m a, 56 ( 5 )

, 1033

- 1039. 35

36

C ox, R

. D . (199 4 ). De con t a m i na ti on and m ana g e m

ent of ha z a r dous m a t e r i a l s ex p osure v i c t i m s i n t he 37

e m

er g ency depar t m

en t

. A n na l s o

f E m e r gen c y M ed i c i n e, 23 ( 4 )

, 761

- 770. 38

39

C ox, R

. D . (2013 Sept 30). HA Z M A T

. Medscape

. R e t ri e v ed from 40

h tt p : /

/ e m ed i c i ne. m edsc a pe

. co m

/ ar t i c l e / 7 64812

- o v er v i ew

. 41

42

C ra i g

, F

. N

., C u m m i n g s, E

. G ., & S i m

, V . M. ( 197 7 ). E n v i r on m en t al t e m per a t u r e and t h e p e rc u t a n eous 43

abso r

p t i on o f a c ho l i n e s t er a se i n h i b it o r, V X

. T he Jou r n al of In v e s ti g a t i ve De r

m a t o l ogy, 6

8 ( 6 )

, 357

- 44

361. 45

46

C s i s z ár, E

., B or s a, J

., R ác z

, I

., & O bendorf, S

. K

. (1 99 8). R ed u c t i on i n hu m an ex p osure t o p e s ti c i de u s i ng 47

t ra d i ti o n al w o rk c l o t h i ng f a br i c s wi t h c h e m

i cal f i n i s h i ng : C arbox y m

e t h y l a ti on and s t a

rch. A rc h i v e s of 48

E

nv i r o n m en t al C o n t a mi na t i on and T

o x i c o l ogy, 3 5 ( 1 )

, 129

- 134. 49

50

D arc h i ni

- Mara g heh E

, Ne m a t i

- K ar i m ooy H

, H asanabadi H

, B a l a l i

- Mood M

. (2 0 12 Dec). De l a y ed 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

90 neur o l o g i c a l co m

p l i ca t i o n s of s u l ph u r m

us t ard and t a b un po i son i ng i n 43 I ran i an v e t era n s. B a s i c C

lin 1

P har

m ac o l T o x i c o l

. 111(6), 426

- 432. 2

3

D i G i o v ann i

, C

., Jr., R e y no l ds, B

., H ar we l l

, R

., S t o ne ci pher, E

. B ., & B u r k l e, E

. M

., Jr. (200 3 ). 4

C o m m

un it y reac t i on t o b i o t e rr o r i s m : pros p ec t i v e s t udy of s i m u l a t ed ou t b r e a k

. E

m erg i n g I n f e c t i ous 5

D i sea s es 9(6 )

, 708

- 712. 6

7

D i G i o v ann i

, C

., Jr. (199 9 ). D o m es ti c t e r ro r i sm w it h c he m

i cal o r b i o l o g i c al a g e n t s: p s y ch i a t r i c a spe c t s. 8

A m er i c a n Jo u rnal of P syc h i a t ry, 1 5 6, 1 5 00

- 1505. 9

10

D i G i o v ann i

, C

., Jr. (200 3 ). T h e sp e c t rum of hu m an r e ac t i ons t o t e rr o r i s t a t t ac k s w it h we apons of m ass 11

des t

ru c ti o n: E a r l y m an a g e m

ent cons i d e r a t i ons. P re h osp i t al and Di sa s t er M e d i ci ne 18(3), 253

- 257. 12

13

D uncan, E

. J. S

., B ro w n

, A

., L und y

, P

., S a w y er, T . W., H a m i lt on, M

., Hi ll

, I ., & C on l e y

, J

. D

. ( 200 2 ). 14

S it e

- spec i f i c p e rc u t a n eous abso r

p t i on o f m e t h y l sa l i c y l a t e and V X i n do m es t i c s w i ne. J

ourn a l of 15

A

pp l i ed T o x i c o l o g y, 22(3)

, 14 1

- 148. 16

17

D uncan M A

, D ro c i uk D

, B e l f l o we r

- T ho m as A

, V an S i c k l e D

, G i bson J J

, Y o un g b l ood C &D a l ey W R

. 18

(201 1, Mar ). F o l l o w

- up asse s s m ent o f h e a l t h c o nseq u en c es af t er a c h l o r i ne r e l e a se f

r o m a t ra i n 19

d e r a i l m ent

- G ran i t e v il l e, SC

. J Med To x i c o l

. 7 ( 1 ), 85

- 91. 20

21

E d w ards, J. G

. ( 197 6 ). P s y ch i a t r i c as p ec t s of c i v i li a n d i s a s t ers. B r it i sh Me d i c a l Journ a l

, 1 ( 6015 )

, 944

- 22

947. 23

24

el S a n ad i

, N

., G ro v e, C

., T a k acs, M., Da l y

, S ., & E ll e n ber g er, D

. ( 199 3 ). A ho s p it al

- based, ha z ar d ous 25

m a t er i a l s d eco n t a m i na t i on and t

re a t m ent u n i t : U t i l i z a t i on pa t t e rns o v er a n i n e

- m o n t h p e r i od. 26

P rehos p i t al a nd Di sa s t er M

ed i c i ne, 8 ( 4 )

, 337

- 340. 27

28

E n g e l

, C

. C

., L oc k e, S

., R ei s m ann, D

. B

., D eMa r ti n o, R

., K u t z

, I ., Mc D ona l d, M

. , & B ars ky

, A

. J

. 29

(200 7 ). T e rr o r i s m

, t rau m a, and m ass ca s ua l t y t r i a g e: H ow m i g ht w e so l v e t he l a t e s t m i n d

- bo d y 30

prob l e m ? B i os e cu r it y and B i o t err o r i s m : B i od e f en s e S t r a t egy, P ra c t i ce, a n d S c i e n ce, 5 ( 2 )

, 155

- 163. 31

32

F e l d m an, R

. J . ( 2 010 )

. C h e m i cal a g ent s i m

u l ant r e l e as e from c l o t h i ng fo l l o w i ng v apor expos u re. 33

A cade mi c E m er g ency M e d i c i ne, 17 ( 2 )

, 221

- 224. 34

35

F e t t er J C

. (2 0 05). P s y cho l og i cal r esp o nse t o m ass c a s u a lt y t e r r o r is m : G u i d e li n es f or p h y s i c i a n s. P r i m 36

C

are C o m pa n i on J C

li n P s ych i a t r y, 7(2), 49

- 52. 37

38

F osse, C

., M a t h i eu, L

., Ha l l

, A

. H

., B occh i e t t o, E

., B u r g her, F

., F i s chb a ch, M ., & Ma i b ach, H

. I . (201 0 ). 39

D econ t a m i na t i on of t e t r a me t h y l a m m on i um h y drox i de ( T M AH ) s p l a sh e s: P ro m i s i ng resu l t s wi t h 40

D i pho t e r i ne i n v i t ro. C u t a n eous a n d O cu l ar T o x i c o l o g y, 29 ( 2 )

, 110

- 115. 41

42

F re y ber g

, C . W., A r q u i l l a

, B

., F er t e l

, B

. S

., T u n i k , M. G

., C ooper, A

., He on, D

., K o h l ho f f, S

. A

., et a l

. 43

(200 8 ). D i s a s t er pr e pa r ed n ess: H os p it a l d e co n t a m i na ti on a nd t he p ed i a t

r i c p a ti e n t

-- gu i de li n es for 44

hosp i t a l s a nd e m er g ency p l anne r s. P r

ehos p i t al a nd Di sas t er Me d i c i ne

, 2 3 ( 2 )

, 166

- 173. 45

46

F r i t sch, W. C ., & S t ou g h t o n, R

. B . (196 3 ). T h e e f f e ct of t e m pera t u re a nd hu m

i d it y on t he pe n e t

r a ti on of 47

C 14 ac e t y l s a li c y l i c a c i d i n exc i sed h u m an s k i n. T he J o urnal of Inv e s t i g a t i ve D er m a t o l ogy, 4 1: 307

- 48

311. 49

50

F u l l e r t on, C

. S

., U rsa n o, R

. J

. , K ao, T ., & B h a r t i y a, V

. R . (199 2 ). T he che m i cal a n d b i o l o g i c a l w a r f

a re 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

91 en v i ron m en t : P s y cho l o g i c a l r e spo n ses and s o c i al sup p or t s i n a h i g h

- s t re s s en v i r on m en t

. Journ a l o

f 1

A

pp l i ed S o c i a l P s

ych o l ogy

, 22 ( 20 )

, 1608

- 1624. 2

3

G a ll a ch e r, J

., B ron s t e r i n g

, K

., P a l m er, S

., F on e

, D ., & L y ons, R . (200 7 ). S y m p t o m a t o l o g y a tt r i b u t a

b l e to 4

ps y cho l o g i c a l e x pos u re t o a che m i cal i n c i de n t : a n a t u r a l ex p e r i m en t

. Jou r nal of E p i de mi ol 5

C o mm un it y He a l t h ( 61 )

, 5 0 6

- 512 6

7

G a tt u, S ., & M a i b a ch, H

. I . (2010 a ). E n h anc e d a b sor p t i on t h rou g h da m a g ed s k i n: A n o v er v i ew of t h e i n 8

v it ro hu m an m ode l

. S k i n P har

m ac o l ogy a nd P h

y s i o l o gy , 23 ( 4 )

, 171

- 176. 9

10

G a tt u, S ., & M a i b a ch, H

. I . (2010 b )

. M ode s t b u t i nc r e a sed p e ne t r a ti o n t h rou g h d a m a g ed s k i n: A n 11

o v er v i ew of t h e i n v i v o hu m an m ode l

. Sk i n P har

m a c o logy a nd P h

y s i o l og y , 24 ( 1 )

, 2

- 9. 12

13

G e ll e r, R

. J., S i n g l e t on, K

. L

., T ar a n t i no, M. L

., Dr en z e k

, C

. L ., & T oo m e y

, K

. E . (200 1 ). N os o co m i al 14

po i s o n i ng as s oc i a t ed wi t h e m er g ency depar t m

ent t r e at m ent of or g anoph o sph a t e t ox i c it y

- G eor g i a, 15

2000. C l i n i c a l T o x i c o l o g y, 39 ( 1 )

, 109

– 111. 16

17

G eor g opou l o s, P

. G

., F e d e l e, P

., S ha d e, P

., L i o y

, P

. J

., H od g son, M., L on g m i re, A

., S ands, M., e t a l

. 18

(200 4 ). H os p i t al re s pon s e t o che m i cal t e rr o r i s m : pers o nal p ro t e c ti v e eq u i p m en t

, tr a i n i n g , and 19

oper a t i ons p l a n n i n g

. A m e ri can Jo u rn a l of Ind u s t r i a l M ed i c i ne, 46 ( 5 ), 432

- 445. 20

21

G hanei M, N a d e r i M, K o s a r A M, Ha ran d i AA

, H op k

i n son N S

, P o u rs a l eh Z . (20 10 ). L on g

- t erm 22

pu l m

onary co m

p li ca t i o n s o f che m

i c a l w a r f a re a g ent e x posu r e i n I

raqi K u r d i sh c i v i li a ns. I

nh a l 23

T

ox i c o l

. 2 010 A ug, 22 ( 9 )

, 719

- 7 24 24

25

G h il a

rdu c c i

, D

. P

. , P i rr al l o, R

. G ., & H eg m ann, K

. T

. ( 2000). H a za rdous m a t e r i a l s re a d i n ess of U n it e d 26

S t a t es l e v el 1 t r au m a cen t er s. Jo u rnal of Oc c up a ti o nal and E n v i ron me n t

a l , 42 ( 7 ) : 683

- 692. 27

28

G l ass, T

. A . (2 0 01). U n de r s t an d i ng pub l i c re s pon s e t o d i s a s t ers. P ub l i c H ea l t h R epor t

s 116 ( Sup p l 29

2), 69

- 73. 30

31

G li k

, D

., H ar r i so n

, K

. , D a v oud i

, M. & R i o p e l l e, D

. (2 0 04). P u b l i c p e rce p t i ons and r i sk co mm un i ca t i o n s 32

for b o t u l i s m

. B i osec u r i t y a nd B i o t e r ro r i s m : B i od e f e n s e S t r a t e gy, P r ac t i c e, and S c i en c e , 2 ( 3 )

, 216

- 223 33

34

G ong J r., E

. J., D au b er, W., & Cruz, E

. ( 1996 )

. P o l i cew o m en w i n se t t l e m

ent

– m en a l l e g ed l y g a w k

ed as 35

fe m a l e o f f i ce r s s t r i pp e d. T

h e Se a t t l e T

i m es . (La te Ed.) R e t r i e v ed f ro m : 36

h tt p : /

/ co mm un it y .sea t t l e ti mes.n w so u rc e .co m / arc h i v e / ? da t e =1996 0 711 & s l u g =23 3 8653 37

38

G reen b er g , M. I

., J u r g ens, S . M., & G r a ce l y

, E

. J

. (2 0 02). E m er g ency depa r t m

ent p r ep a redn e ss for t he 39

e v a l ua t i on and t r e a t m ent o f v i c ti m s of b i o l o g i ca l or c h e m i cal t e r ro r i s t a t t a c k

. T

he Journ a l o

f 40

E

m ergen c y M ed i c i n e, 22 ( 3 )

, 273

- 278. 41

42

G u tt e n ber g , M. G

., As ae d a, G ., & C herson, A

., et a l

. ( 2 002). Uti li z a t i on o f a m bu l a nce r eso u rc e s a t t h e 43

Wo r l d T r ade C e n t e r: Im p li ca t i ons f

o r d i sa s t e r p l an n i ng

. A nna l s of E m e rg e ncy M

e d i c i n e , 40 ( S92) 44

[ a b s t ra c t ]

. 45

46

H a ll

, A

. H

., B l o m e t

, J ., & Ma t h i e u

, L . ( 2 002 )

. D i ph o t er i n e f or e m er g ent e y e / s k

i n che m i cal sp l ash 47

deco n t a m i na t i o n : A re v i e w

. V

e t e r i n a ry a n d H

u m an T o x i c o l og y

, 44 ( 4 )

, 228

- 231. 48

49

H a ll

, A . & Ma i bach, H . (2 0 06). W a t er d eco n t a m i na t i o n of c h e m

i cal s k i n e y e sp la she s : A c r i t i c al re v i e w

. 50

C u t ane o us a nd O c u l ar T ox i co l o gy , 25(2), 6 7

- 83. 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

92 H a ll

, S

. K

. (19 9 5). Mana g e m ent of che m

i c a l d i sa s t e r v i c t i m s. C li n i c a l T o x i c o l o gy

, 33 ( 6 )

, 609

- 616 1

2

H a ll o we l l

, S

. F

. ( 200 1 ). S cr een i ng pe o p l e f o r i l l i c i t su b s t a n ce s : A s u r v ey of cu r re n t po r t a l t ech n o l o gy

. 3

T

a l a n t a

, 54, 447

- 458. 4

5

H a m

ilt on, M. G

., H i l l

, I

., C on l e y

, J

., S a w y er, T

. W., C a ne v a, D

. C ., & L und y

, P .M. (200 4 ). C l i n i c a l as p e c t s 6

of p e rc u t an e ous p o i s on i ng by t he che m i c a l w a r f a re a g ent V X : E f

f ec t s o f ap p l i ca t

i on s i t e and 7

deco n t a m i na t i on. M i l i t a r

y Me d i c i ne, 1 6

9, 856

- 862. 8

9

H ende r son, J

. N

., H end e rs o n, L

. C

., R as k ob, G

. E . & B oa t r i g h t

, D

. T

. ( 200 4 ). C he m i cal ( V X ) T e rr o r i st 10

T h re a t : P ub l i c K no w l ed g e, A tt i t u d es, a nd R es p ons e s. B i os e cu r it y and B i o t

err o r ism : B i o d

e f e nse 11

S t r

a t eg y

, P ra ct i ce, a nd S c i e nc e

, 2 ( 3 )

, 224

- 228. 12

13

H i c k

, J

. L

., H an f l i n g

, D

., B urs t e i n

, J

. L

., M a r k ha m

, J

., Ma c i n t y re, A

. G ., & B a rb er a, J

. A

. ( 2003 a ). 14

P ro t e c t i v e eq u i p m ent f o r h e a l t h c a

re fa c i l it y de c on t a m

i na t i on p e rs o nn e l : R e g u l at i o ns, r i s k s, and 15

r eco mm enda ti ons. A nn a l s of E

m er g ency M e d i c i n e, 4 2 ( 3 )

, 37 0

- 380. 16

17

H i c k

, J

. L

., P enn, P

., H a n f li n g

, D

., L appe, M. A

., O ' L au g h li n, D ., & B u r s t e i n, J. L . (2003 b ). E s t a b l i s h i ng 18

and t

r a i n i ng he al t h c a

re fa ci l i t y decon t a m

i na t i on t ea m s. A nna l s of E m erg e ncy M

e d i c i n e, 42 ( 3), 381

- 19

390. 20

21

H il de b ra n d S

, B l ee t m an A

. (200 7 ). C o m para t i v e s t u dy i l l u s t r a t i ng d i f

f i c u l ti e s ed u c a t i ng 22

t he pu b li c t o res p ond t o che m i c a l t e rr o r i s m

. P reho s

p D i sa s t Med, 2 2 ( 1 )

, 35

- 41. 23

24

H i ss, J. and B

. A ren s burg ( 1992). S u f

f oc a ti o n f rom m i suse o f g as m as k s dur i ng t h e G u l f w ar. B r i ti s h 25

Me d i c a l Jo u rn a l

, 304(6819), 92. 26

27

H obfo l l

, S

. E

., W a t son, P

., B e ll

, C

. C

., B r y an t

, R

. A

., B ry m er, M. J

., F

r i ed m an, M. J

., F r i ed m an, M., e t a l

. 28

(200 7 ). F i v e e s se n t i al e l e men t s of i m m ed i a t e and m

i d

- t erm m ass t rau m a i n t e r v en t i o n: E m p i r i c a l 29

e v i dence. P sy c h i a t ry 70 ( 4 )

, 283

- 315. 30

31

H o g an, D

. E ., Waec k e r l e, J

. F . & D i re, D

. J. et a l

. (19 9 9 )

. E m er g ency depar t m

ent i m pact of t he O k

l aho m a 32

C it y t e r r o r i s t bo m

b i n g

. A n n a l s o

f E m er g en c y M ed i c i n e

, 34(2), 160

- 167. 33

34

H ood J

, F e rnan d es

- F l ack J

, L ar r ana g a M D

. (201 1 ). E ff

ec t i v eness of h o sp i t a l

- based deco n t a m i na t i on 35

dur i ng a s i m u l a t ed m ass c a sua l t y expos u re. Jour n al o f O ccupa t i on a l a n d E

n v i ro n m en t al H

yg i ene, 36

8(12), D 131

- D 138 37

38

H or t on, D

. K

., O rr, M., T s o n g as, T

., L e i k er, R ., & K a p il

, V

. (200 8 ). S e cond a ry c o n t a m i na t i on o f m

ed i c a l 39

pers o nn e l , eq u i p m en t , a n d f ac i l i t i es r es u l t

i ng from ha z ardous m a t e r i a l s e v en t s, 20 0 3

- 2006. D i sas t er 40

Me d i c i ne a n d P ub l i c He a lt h P rep a redn e ss, 2 ( 2 )

, 104

- 113. 41

42

H or t on, D

. K

., B er k o w it z

, Z ., & K a y e, W. E . (2 0 03). S econd a ry con t a m i na t i on o f E D pe r son n el from 43

ha z ardous m a t e r i a l s e v en t s, 1995

- 2001. T he A m e r i can Journ a l o

f E m er g ency M e d i c i ne, 21 ( 3 )

, 199

- 44

204. 45

46

H ous t on, M., & H en d r i c k son, R

. G . (20 0 5). De co n t a m i na ti on. C

r i ti c al C a re C l i n i cs, 21 ( 4 )

, 653

- 672. 47

48

H uff, S

. (199 1 ). L e sso n s le arned f r om ha z ardous m a t e r i a l s i n c i de n t s. E m erg e ncy C

are Q ua r t e r l

y, 7 ( 3 )

, 49

17

– 22. 50

51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

93 I ns tit u t e of Me d i c i ne, C o m m itt ee o n R & D N ee d s f

o r I m pro v i ng C i v ili an M ed i c al R e spo n se t o 1

C he m

i cal and B i o lo g i c a l T err o r i sm I nc i den t s .(1 9 99). C he m

i cal and B i o l o g i c a l T err o r i s m : R ese a rch 2

and D e v e l op m ent t o I m pro v e C i v ili an Me d i c a l R e s p o nse. W as h i n g t on, D C : T he N a ti o n al A cade m i es 3

P res s

. 4

5

Jag m

i nas, L

. (200 8 a). CB R

N E

- E v a l ua ti o n of a c h e m i cal wa r f are v i ct i m

. Medscape

. R e t r i e v ed f rom 6

h tt p : /

/ e m ed i c i ne. m edsca p e. c o m

/ ar t i c l e / 83 1 040

- o v er v i e w 7

8

Jag m

i nas, L

. (2008 b ). C B R N E

- Che m i cal dec o n t a m

i na t i on. Medscape

. R e t r

i e v ed 9

from h tt p : / / e m ed i c i ne. m ed s cape. c o m

/ ar t i c l e / 831175

- o v er v i ew 10

11

K a d ar, T

., F i s h b i n e, E

., M e shu l a m

, J

., S a h ar, R

., A m i r, A ., & B arne s s, I . (2003). A t op i c a l s k i n p ro t ec t ant 12

a g a i nst che m i c a l w a r fa r e a g en t s. T

he Is r ael M e di c al A sso c i a t i on Jour

n a l , 5 ( 10)

, 7 1 7

- 719. 13

14

K e e b l e

, V

. B

., C o r re l l

, L

., & E hr i ch, M. (199 3 ). E v a l u a t i on of k n i t g l o v e fa b r i cs a s ba r

r i ers t o d er m al 15

abso r

p t i on o f or g ano p hos p horus i n s e c ti c i d e s u s i ng an i n v it r o t est s y s t e m

. T ox i c o l ogy, 81 ( 3), 195

- 16

203. 17

18

K e i m M E

, P es i k N

, T w u m

- D anso NAY : L ack of hos p i t al pr e pa r edn e ss f or che m i c al t e r ro r i sm i n a m a

j or 19

U S c it y : 1 9 9 6

– 20 0 0. P re ho sp D i s a st Me d , 2003, 18( 3 ), 193

– 199. 20

21

K e n ar, L ., & K a ra y i l ano g l u

, T

. (200 4 ). P reh o sp i t a l m ana g e m ent and m ed i cal i n t e r

v en ti on a f t er a 22

che m

i cal a t t ac k

. E

m er g en c y M e d i c i ne Jou r

na l

, 21 ( 1), 84

- 88. 23

24

K e n ar, L

., K ara y i l ano g l u, T ., & G u l ec, M. ( 200 4 ). H o w w ou l d m il i t ary hos p i t a l s cope wi t h a nu c l e a r, 25

b i o l o g i ca l

, or che m i cal d i s a s t e r? M i l i t

a r y M ed i c i n e, 1 6

9 ( 1), 757

- 760. 26

27

Ki m

, K

. (200 1 ). N o E D e n t ry w it h o ut d eco n t a m i na t i o n for HA Z M A T pa t i e n t s. E m ergen c y M ed i c i n e 28

N

e w s, 23 ( 9)

, 38

- 41. 29

30

K i r k , M. A

., C i se k , J., & R ose, S

. R

. (19 9 4 ). E m er g ency depa r t m

ent re s pon s e t o ha z ardous m a t e r i a l s 31

i n c i de n t s. E me rge n cy Me d i c i ne C

li n i c s of N

or t h A m e ri ca, 12 ( 2 )

, 461. 32

33

K i r k , M. A ., & D e a t on, M. L . (200 7 ). B r i n g i ng ord e r out o f ch a os: E f f e c ti v e s t r at e g i es f o r m ed i c a l 34

resp o nse t o m ass c h e m i cal exp os u re. E

me rge n cy Me d i c i ne C

li n i c s of N

or t h A m e ri ca, 25(2), 5 2 7

- 548. 35

36

K oe n i g

, K

. L

., B oa t r i g h t

, C . J., H anc o c k , J. A

., D enn y

, F

. J

., T e e t e r, D

. S

., K a h n, C

. A ., & S chu l t z

, C

. H

. 37

(200 8 ). H e a lt h c a re fa c i l it y

- based decon t a m i na t i on o f v i c ti m s expo s ed t o che m i c a l , b i o l o g i c a l

, and 38

rad i o l o g i c al m a t e r i a l s. A m er i c an J o urn a l of E

m erg e n cy M

ed i c i n e, 26 ( 1 )

, 71

- 80. 39

40

K oe n i n g

, K

. L

. (2 0 03). S t ri p and s h o w e r : T he duck a n d co v er f o r t he 2 1 st ce n t ur y

. A nna l s of E m erg e ncy 41

Med., 42 ( 3 )

, 391

- 394. 42

43

K op e r, O

., L u cas, E

. , & Kl abunde, K

. J. ( 1999 )

. D e v e l op m ent of r ea c ti v e t op i cal s k

i n pro t ec t an t s a g a i n st 44

su l f

ur m us t a rd a n d n e r v e a g en t s. Jou r nal of A p p l i ed T o x i c o l og y 19(S u

pp l 1), S 5 9

- S 70. 45

46

K o r i n t h, G

., G eh, S

., S c h a ll er, K

. H ., & D re x l e r, H

. ( 2 0 03). I n v it ro e v a l u a t i on o f t

he e f f i cacy of s k

i n 47

bar r i e r c rea m s and p ro t e c t i v e g l o v es on perc u t an e ous abso r p t i on o f i n du s t r i al s o l v en t s. I n t e r na t i on a l 48

A rch i ves of Oc cup a ti o n al a nd E nv i ron m e n t a l H

ea l t h, 76 ( 5 ), 382

- 386. 49

50

K o v a l c h i c k

, D

. F

., B ur g es s

, J

. L

., K y es, K

. B

., L y m p, J. F

., R usso, J. E

., R o y

- B y r n e, P

. P ., & B rod k i n, C

. 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

94 A . (200 2 ). P s y cho l o g i cal e ff e c t s of h a z ardo u s m a t e r i a l s exp o sur e s. P s ych o so m a ti c M

e d i c i ne, 64 ( 5), 1

841

- 846. 2

3

L aure n t

, J. F

., R i ch t er, F

., & M i c h e l

, A

. (199 9 ). M an a g e m ent of v i c ti m s of u r

ban che m i cal a t t ac k : T he 4

F rench a p p roa c h. R e s us c it

a ti on, 42 ( 2 )

, 141

- 149. 5

6

L a v o i e, F . W., C oo m es, T

., C i se k

, J

. E ., & F u l k erson, L . (199 2 ). E m

er g ency depar t m

ent e x t e rn a l 7

deco n t a m i na t i on for h a z ar d ous c h e m i cal e x pos u re. V

e t e r i na r y and H u m an T ox i c o l ogy, 3 4 ( 1 )

, 61

- 64. 8

9

L e i ba, A

., G o l d b er g

, A

., H our v it z

, A ., W e i s s

, G

., P e r e s, M., K a rs k ass, A

., S ch war t z

, D ., et a l

. ( 200 6 ). 10

Who s h ou l d w o rry f o r t h e "w orr i ed we l l " ? A n a l y s i s of m il d casu a l t i e s c e n t e r d r i ll s i n non

11

con v en ti o n a l s c ena r i o s

. P r e hosp i t a l and D i sa s t e r M

ed i c i ne, 21 ( 6

), 441

- 444. 12

13

L eona

r d, L

., S c h eu l en, J., & Muns t er, A

. (198 2 ). C h e m i cal bur n s: E f

f ect of p ro m

pt f i r st a i d. T he J o urn a l 14

O

f T rau m a, 2 2 ( 5 )

, 420

- 42 3

. 15

16

L ep l e r, L ., & L u c c i

, E . (2 0 04). R e spon d i ng t o a n d m ana g i ng casu a l t i e s : D e t e c ti o n, pe r son a l p r o t e c t i on, 17

and d e con t a m i na t i on. R e sp i ra t o ry C

a r e C l i n i cs o

f N o rt h A m er i ca, 10 ( 1 )

, 9

- 21. 18

19

L e v iti n, H

. W., & S i e g e l s o n, H

. J . ( 1 996). H a z ardo u s m a t er i a l s. D i s a s t e r m ed i c a l p l an n i ng and res p onse. 20

E

m ergen c y M ed i c i n e C l i n ic s of N

o r t h A me r i ca, 14 ( 2 )

, 327

- 348. 21

22

L e v iti n, H

. W., S i e g e l s o n, H

. J

., D i c k i n s on, S

., Ha l p er

n, P

., H ara g uc h i

, Y

., N o c e r a, A ., & T u r i nec k

, D

. 23

(200 3 ). D ec o n t a m i n a ti on of m ass casu a l t i e s

— r e

- e v a l ua ti ng ex i s t

i ng dog m a. P reh o sp i t al a nd Di sa s t er 24

Me d i c i ne, 18 ( 3 ), 200

- 207. 25

26

L i o y

, P

. J . (1 9 95). M e as u r e m ent m e t hods f o r hu m an e xposu r e a n a l y s i s

. E n v i ron m en t a l H

e a lt h 27

P ersp e c t i v e s, 103 ( 3 )

, 35

- 44. 28

29

L i u, D

. K

., W anne m ach e r, R . W., S n i der, T

. H ., & Ha y es, T

. L

. (199 9 ). E f f i cacy of t h e t o p i c al s k

i n 30

pro t ec t ant i n ad v anced d e v e l op m en t

. J ourn a l o f A p p l i ed T o x i c o l ogy 19( Su

p p l 1), S 4 0

- S 45. 31

32

L y m an, J

. ( 200 3, Sep ). M essa g e s i n t he d us t : W hat a r e t h e le ssons of t he e n v i ron m en t a l hea l t h res p onse t o 33

t he t e r

ro r i s t a t t ac k s of S e p t e m

ber 1 1 ? Denver, CO: N

a ti o nal E n v i r o n m en t a l H

e a lt h A sso c i a ti o n

. 34

R e t r i e v ed f ro m : h t t p : // ww w .neha. o r g / pd f

/ m essa g es_ i n_

t he_d u s t

. pd f

. 35

36

Ma c i n t y re, A

. G

., C h r i s t op her, G

. W., E i t z en Jr, E

., G u m

, R ., We i r, S

., D e A t l e y

, C

., T o n a t

, K

., et a l

. 37

(200 0 ). W eapo n s of m ass des t ru c ti o n e v en t s w i t h co n t a m i na t e d c a su a l t i e s : E f

fe ct i v e p l an n i ng for 38

hea l t h c are f a c i l i t i es. J our n al of t h e A m e r i can Me d i c a l A sso c i a t i on, 283 ( 2 )

, 242. 39

40

Mar k

e l

, G

., K r i v o y

, A

., R o t m an, E

., S che i n, O

., S h r o t

, S

., B rosh

- N i ss i m

o v

, T

., D u shn i t s ky

, T

., e t a l

. 41

(200 8 ). M ed i cal m ana g e m e nt of t o x i c o l o g i c a l m ass c as ua l t y e v en t s. T he I s ra e l Me d i c a l A s s oc i a t i on 42

Journ a l

, 10 ( 11 )

, 761

- 766

. 43

44

Me r

r i t

, N ., & A nd e rson, M. (198 9 ). C a s e r e v i ew m a l a t h i on o v er d os e : W h en o n e p a t i ent c r ea t es a 45

depa r t m en t al ha z ard. Jo u r

nal o f E m er g ency N ur s i ng, 15 ( 6 )

, 463

- 465. 46

47

M i ll e r i oux, J

. , C ru z

, C

., B az i re, A

., L a l l e m en t

, G

., L e f

eu v re, L ., & J o s se, D

. (20 0 9). I n v it ro s e l e c ti o n and 48

ef

f i c a cy of t o p i c al s k

i n pr o t ec t a n t s a g a i n s t t he n er v e a g ent V X

. T o x i c o l o g y i n V i tr o, 23 ( 3 )

, 539

- 545. 49

50

M i ll e r i oux, J

. , C ru z

, C

., B az i re, A

., P o ll y

, V

., L a l l e m en t

, G

., L e feu v re, L

., & J os s e, D . (20 0 9). E v a l u a t i on 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

95 of i n v i t ro t e s t s t o a s s ess t h e e f f i c acy of for m

u l a t i o n s a s t o p i c a l s k

i n p r o t e c t a n t s a g a i n s t 1

or g anophos p hor u s co m pounds. T o x i c o l ogy i n V

i t ro, 2 3 ( 1 )

, 12 7

- 133. 2

3

Mo f

fe t t

, P

. M., B a k

er, B

. L

., K a n g

, C

. S ., & J o hnson, M. S . ( 2 010 )

. E v a l u a ti on of ti m e req u i r ed f

or wa t e r

4

on l y deco n t a m ina t i on o f an o i l

- based a g e n t

. M i li t ary Me d i c i ne, 1 7

5 ( 3 )

, 185

- 187. 5

6

Mon t e i r o

- R i v i ere, N

. A

., I n m an, A

. O

., J ac k son, H

., D unn, B ., & D i m ond, S . (20 0 1). E f

f i cacy of t o p i c a l 7

phenol de c on t a m i na ti o n s t r a t e g i es on s e v er i t y of ac u t e phenol che m i c a l b u rns a nd de r m al ab s or p ti o n: 8

I n v it ro and i n v i v o s t u d i e s i n p i g s k i n. T o x i c o l o g y and Indu s t r i al H

ea l t h, 1 7 ( 4 )

, 95

- 104. 9

10

Mood y

, R

. P

., A k ra m , M., D i c k son, E ., & C hu, I . (20 0 7). I n v it ro der m al a b so r

p ti on of m

e t h y l s a l i c y l a t e

, 11

e t h y l p a r a t h i o n, and m a l a t h i on: F i r st r e spo nd e r s af e t y

. Journ a l o

f T o x i c o l ogy and E

nv i r o n m en t

al 12

H

ea lt h

. P a r t A , 70 ( 12 )

, 98 5

- 999. 13

14

Mood y

, R

. P ., & M a i ba c h, H

. I . (2006). S k i n d eco n t a m

i na ti o n : I m

por t ance of t h e w ash

- i n ef f e c t

. F ood 15

and C

he mi cal T o x i co l o gy, 44 ( 11 )

, 1783

- 1788. 16

17

Mor a n, K

., O ' R e ill y

, T ., & Mun s t e r

, A . (1 9 87). C h e m i cal b ur n s. A t e n

- y ear exp e r i ence. T h e A m e r i can 18

Surgeo n , 53 ( 11 )

, 652

- 653. 19

20

Mura k a m

i

, H . (200 0 ). U n d er g roun d : T he T o ky o g as a t t ack and t he Japa n ese ps y che. New York, NY: 21

V i n t a g e I n t erna t i on a l

. 22

23

M y ers, W. R . (2 0 00). R e s p i ra t o r y pr o t e c ti v e eq u i p m en t

. I n H arr i s, R., ( E d.), P a t t 'ys Indu s t r i al H yg i ene, 24

(5 th Ed) (p p . 1489

- 1550). New York, NY: Wiley

. 25

26

N a ti o n al F i r e P r o t e c t i on As soc i a t i on. ( 2 013 )

. N FP A 472: S t and a rd f or c o m petence o f r e spon d ers 27

t o ha z a r dous m a t e r i a l s / w e a pons o f m ass d e s t r u c t i on i n c i de n t s. 28

29

N a ti o n al F i r e P r o t e c t i on As soc i a t i on ( 2 013 )

. N FP A 473: S t and a rd f or c o m pe t enc i e s f

o r E MS 30

pers o nn e l r e spon d i ng t o h az ardous m a t e r i a l s / w eapo n s of m ass de s t r u c t i on in c i de n t s. 31

32

N ańa g as, K

. A ., & K i r k , M. A . (200 5 ). P e rc e i v ed po is ons. Me d i c a l C l i n i cs o f N o r t h A me r i c a, 89, 1 359

- 33

1378. 34

N ea l

, D

. J

. , B ar b e r a, J

. A

., & H arr a l d, J

. R

. (20 1 0). P L U S preho s p i t a l m ass

- casua lt y t r i a g e: A s t

r a t e g y for 35

addr e s s i ng unusu a l i n j u ry m echan i s m s. P r eho s

p i t al a nd D i s a s t e r M

ed i c i n e, 25 ( 3 )

, 227

- 236. 36

37

N i e l s en, G

. D

., Ni e l sen, J. B

., A nder s en, K

. E ., & Gra n d j e a n, P

. ( 200 0 ). E f

fe c t s o f i n d us t r i al de t er g en t s on 38

t he b a

r r i e r f un c ti on of h u m an s k

i n. I n t e rn a ti o n al J

ou r nal o f O ccu p a t i on a l and En v i ron m en t a l H e a l t h, 39

6 ( 2 )

, 13 8

- 142. 40

41

N i e l s en, J. B . (2 0 00). E f f e c t s o f fo u r d e t e r g en t s on t h e i n

- v it ro b a r r i e r f un c ti on of hu m an s k

i n. 42

In t e rn a ti o nal Jour n al o f Oc cupa t i on a l and E

n v i ron me n t al H

ea l t h, 6 ( 2 )

, 143

- 147. 43

44

N i e l s en, J. B . (2 0 10). E f f i c acy of s k

i n w ash on d e r m al abs o rp t i o n : A n i n v i t ro s t u dy on four m odel 45

co m

pounds of v ar y i ng so l u b i l it y

. I n t e r na t i on a l A r

ch iv es of O ccup a t i onal and E n v i ron m e n t

a l H e a lt h, 46

83 ( 6

)

, 683

- 690. 47

48

N i e l s en, J. B

., N i e l s en, F

., & S øren s en, J

. A

. (200 7 ). D efen s e a g a i n st d er m al ex p osur e s i s o n l y s k i n dee p : 49

S i g n i f

i ca n tl y i n c r e ased pe n e t r a t i on t hr o u g h s li g h t l y da m a g ed s k i n. A rch i ves of De r

m a t o l og i cal 50

R esea r ch, 2 9 9 ( 9 )

, 423

- 431. 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

96 1

N i s k a, R . W., & B u r t

, C

. W . (200 6 ). T r a i n i ng f o r t e r r o r i s m

- re l a t ed con d i t i ons i n h osp i t a l s: U n i t ed S t a t es, 2

2003

- 04. A dvanc e D a t a, ( 3 80 )

, 1

- 8. 3

4

N o ti n g her, I ., & I m hof, R

. E . (200 4 ). M i d

- i nf r ar e d i n v i v o dep t h

- prof

i l i ng of t op i cal che m

i ca l s on s k

i n. 5

Sk i n R ese a rch a nd T e c hno l ogy, 10, 1 1 3

- 121. 6

7

N o z a k

i

, H

., H or i

, S

., S h i n o z a w a, Y

., F u j i s h i m a, S

., T a

k u m a, K

., S a g oh, M., K

i m u ra, H

., e t a l

. ( 199 5 ). 8

S econd a ry expos u re o f m

ed i c a l s t a f

f t o s a r i n v apor i n t

he e m er g ency roo m

. In t en s i ve C a re Me d i c i ne, 9

21 ( 12 )

, 1032

- 1035. 10

11

O k

udera, H

., H . M o r i t a, et a l

. ( 199 7 ). " U n exp e c t e d n er v e g as exposu r e i n t he c i t y of M a t s u m o t o: R ep o rt 12

of r e sc u e a c ti v i t y i n t h e f i r s t s a r i n g as t e rr o r i s m ." A m e r i can Jour n al o f E m e r gen c y Me d i c i ne 15 ( 5 )

, 13

527

- 528. 14

15

O k

u m ura, T

., Hi sao k a, T

., Y a m ada, A

., N a it o, T

., I sonu m a, H

., O k u m ura, S

., M i u ra, K

., e t a l

. ( 200 5 ). T he 16

T o ky o sub w ay sar i n a t t a c k

— l e s sons l e ar n ed. T

o x i c o l ogy and A

p p l i ed P h ar

m ac o l ogy 2 07 (Supp l 2), 17

471

- 476. 18

O k

u m ura, T

., Ni no m

i y a, N ., & O h t a, M. (2 0 03). T he c he m i cal d i s a s t e r r esp o nse s y s t em i n Japan. 19

P rehos p i t al a nd Di sa s t er M

ed i c i ne, 18 ( 3 )

, 189

- 192. 20

21

O k

u m ura, T

., K on d o, H

., N a g a y a m a, H ., Ma k i no, T

., Y osh i o k a, T

., & Y a m a m o t o, Y . (200 7 ). S i m

p l e 22

t r i a g e and ra p i d d e con t a m

i na t i on o f m ass ca s ua l t i es w it h co l o red c l o t h es pe g s ( S T A R DO M

- CCP ) 23

s y s t em a g a i nst c h e m i cal re l eas e s. P r

e hos p it a l a n d D i s as t e r M

ed i c i n e, 22 ( 3 )

, 233

- 236. 24

25

O k

u m ura, S

., O k

u m ura, T

., I sh i m a t su, S

., M i u ra

, K

., Mae k a w a, H ., & N a i t o, T

. ( 2005). C li n i c al re v i e w : 26

T o ky o

- pro t e c t i ng t h e h e a lt h ca r e w or k

er d u r i ng a ch e m

i cal m ass cas u a l t y e v en t : A n i m por t a n t i ssue 27

of co n t i nu i ng r e l e v an c e. C r i t i c a l C a r e, 9 ( 4 )

, 397

- 400. 28

29

O k

u m ura, T

., S u z u k

i

, K

., F u k uda, A

., K o h a m a, A

., T a

k asu, N

., I sh i m a t su, S ., & H i noh a ra, S

. (199 8 a). 30

T he T o ky o sub w ay sar i n att ac k : D i s a s t er m ana g e m en t

, P art 1: C o mm

un it y e m er g e ncy respo n se. 31

A cade mi c E m er g ency M e d i c i ne, 5 ( 6

)

, 613

- 617. 32

33

O k

u m ura, T

., S u z u k

i

, K

., F u k uda, A

., K o h a m a, A

., T a

k asu, N

., I sh i m a t su, S ., & H i noh a ra, S

. (199 8 b). 34

T he T o ky o sub w ay sar i n att ac k : D i s a s t er m ana g e m en t

, P art 2: H o s p i t a l r e spo n se. A cade mi c 35

E

m ergen c y M ed i c i n e, 5 ( 6

)

, 618

- 624. 36

37

O k

u m ura, T

., T a k as u

, N

., I sh i m a t su, S

., M i y ano k i

, S

., M i t su h as h i

, A

., K u m ada, K

., T ana k a, K

., e t a l

. 38

(199 6 ). R ep o rt on 640 v i ct i m s of t he T o ky o sub w ay s ar i n a t t a c k

. A nna l s of E mer gency Me d i c i ne, 39

28 ( 2 )

, 129

- 135. 40

41

O l son, C

. T

., F ed e r, P

. I

., H obson, D

. W., Ki s er, R

. C

., & J o i n e r, R

. L

. (199 1 ). E v a l u a ti on of c o m pounds 42

as b a

r r i e r s t o d e r m al pen e t r a t i on of or g anoph o sph a t e s us i ng ac e t y l ch o li n e s t e r ase i nh i b i t i on. 43

T

ox i c o l o g y L e tt e rs, 5 5 ( 3 )

, 325

- 334. 44

45

P ando l f, K

., F ran c esc o n i

, R

., S a w k a, M., C y m er m an, A

., H o y t

, R

., Y oun g

, A

., Z a m bras k i

, E . (2011 May 46

26). U n i t ed S t a t es A r m y R ese a rch I ns t i t u t e of E n v i r on m

en t al M ed i c i n e: W a

r f i g h t er r e se a

rch 47

focu s i ng on t h e p a st 2 5 y ears. A d v anc e s i n P hy s i o l ogy E

duca t i on, 35, 35 3

- 360. 48

49

P an g i

, R . (200 2 ). C o n seq u e nce Manage m ent i n t he 1 9 9 5 Sar i n A t t

a c ks on t he Jap a nese S ub w ay S ys t e m

. 50

B os t on, M A : Harvard University, John F

. K e n n e dy S chool o f G o v ern m en t

. BC S I A d i scus s i on 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

97 paper 2002

- 4. 36 1

2

P arso n s, K en n e t h. (2002 D e c 26 )

. H u m an t her m al en v i ron m en t s: t h e e f

fe c t s of h o t

, m

odera t e, a n d 3

co l d en v i ron m en t s o n hu m an he a lt h, co m fort and p e r f

o r m ance. CR C P re s s. 4

5

P i l li n, H i l ar y

. (2008 Jan 3 ). T a k en t o t he h ea

r t

. I r i sh E m erge n cy S er v i c e s M

agaz i ne, 4 7

- 51. 6

7

P ons, P ., & D a r t

, R

. C

. (1 9 99). C he m i c a l i nc i de n t s i n t he e m

er g ency depa r t m

en t : I f and w hen. A nna l s o f 8

E

m ergen c y M ed i c i n e, 34 ( 2 )

, 223

- 225. 9

10

P re s t on, R

. J

. , M a rco zz i

, D

., L i m a, R

., P i e t

robon

, R

., B r a g a, L . & Jacob s

, D . (2 0 08 )

. T h e e ff e ct o f 11

e v acua t i on on t he nu m ber o f v i c t i m s fo l l o w i ng ha z ard o us che m i c a l r e l e ase. P re h o s

p it a l E m e r gen c y 12

C

are 12(1), 12

- 23. do i : 10. 1 08 0 / 10903 1 20701710 4 96 13

14

R aber, E

., J i n, A

., N oon a n, K

., Mc G u i re, R ., & K i r v e l

, R

. D . (200 1 ). D eco n t a m i n at i on i ss u es f

or c he m i cal 15

and b i o l o g i c al wa r f are a g en t s: H ow c l e an i s c l e a n eno ug h? In t e rna t i on a l J o urn a l o f E n v i ron me n t a l 16

H

ea lt h R e s earc h , 11 ( 2 )

, 1 2 8

– 148. 17

R aber, E

., C a r l se n

, T

., F o l k s, K

., K i r v e l

, R

. , D an i e l s, J

. , & B o g en, K . ( 2 004). H ow c l e an i s c l ean enou g h? 18

R ecent de v e l op m en t s i n re s ponse t o t hr e a t s po s ed by c he m i cal a n d b i o l o g i c al war fa r e a g en t s

. 19

In t e rn a ti o nal Jour n al o f E n v i ron m en t

a l H e a l t h R e s ea r ch, 14 ( 1 )

, 31

- 41. 20

21

R a m

esh, A ., & K u m ar, S

. ( 2010). T r i a g e, m on it o r i n g , and t

re a t m ent of m ass c as u a lt y e v en t s i n v o l v i ng 22

che m

i ca l

, b i o l o g i c a l

, r ad i o l o g i ca l

, o r n u c l e ar a g en t s. J ourn a l of P har

m a c y and B i oa l l i ed Sc i en c es, 23

2 ( 3 )

, 239. 24

25

R e i f

e nr a t h, W. ( 198 0 ). S h o w er de c on t a m i na t i on e f f i c a cy i n v it ro d e t er m

i na t i on s

. L e t t

er m an A r m y 26

Ins ti t u t e of R es e arch. In st i t u t e R e po r t N o. 86. 27

28

R e i f

e nr a t h, W. G

., M e r sh o n, M. M

., B r i n k l e y

, F

. B ., M i u ra, G

. A

., B r oo m f i e l d

, C

. A ., & C ranf

o rd, H

. B

. 29

(198 4 ). E v a l u a ti o n of d i e t hy l m a l ona t e a s a s i m u l ant f or 1,2,2

- t r i m

e t h y l p r op y l 30

m

e t h y l phosphono f

l u o r i da t e (so m an) i n sho we r d e con ta m i na ti on o f t

he s k i n. Jour n al of 31

P har

m ace u t i cal S c i en c es, 7

3 ( 10 )

, 1388

- 1392. 32

33

R e i n e r, R

., R o s s m ann, K

., v an H oo i don k

, C

., C eu l e n, B

. I ., & B oc k

, J . (1 9 82). O i n t m en t s f o r t he 34

pro t ec t i on a g a i n s t or g ano ph osph a t e p o i s o n i n g

. A rz n e i m i t t e l

- F o r sch u ng, 32 ( 6

)

, 63 0

- 633. 35

36

R o g ers, M. B

., R

. A m l ô t

, G

. J

. R

ub i n, S . W e ss e l y , and K

. K r i e g er (200 7 ). M ed i a ti ng t he so c i a l and 37

ps y cho l o g i c a l i m pac t s of t e rr o r i s t a t t ac k s: t he ro l e of r i sk per c ep t i on and r i sk co mm un i ca ti o n. 38

In t e rn a ti o nal R ev i ew of P s y ch i a t ry, 19 ( 3 )

, 279

- 288. 39

40

S ac k

e t t D L

, R o s enb e rg W M

, G ray J A

, H a y nes RB

, R i c hard s on WS (19 9 6). " E v i d e nce b a sed m ed i c i n e : 41

w hat i t i s a n d w hat i t i sn ' t"

. B MJ 3 1 2 , 7023, 71

– 2. 42

43

S aund e rs, P

. (200 0 ). D e c o n t a m i na t i on o f c h e m

i ca ll y c on t a m

i na t ed c asu a l t i e s: Im

p l i ca t i o n s f

o r t he h e a l t h 44

ser v i ce and a re g i o n al s t r a t e g y

. P re

- H

os p it a l I mm e d i a t e C are, 4 ( 3 )

, 122

- 125. 45

46

S a w y er, T

. (19 9 1). E f f i c a cy of an ox i m a t e

- based s k i n d econ t a m

i nant a g a i n s t or g a n ophosp h a t e ner v e 47

a g en t s d e t e r m i ned i n v i v o a nd i n v i t

ro. T o x i co l o gy, 67 ( 3 )

, 267

- 77. 48

49

S can l o n, J

. (201 0 ). C he m i c a ll y co n t a m

i na t ed c a su a l t i e s: Di f

f ere n t p ro b l e m s and p oss i b l e so l u t i ons. 50

A m er i c a n Jo u rnal of D i sa st er M ed i c i n e, 5 ( 2 )

, 95

- 105. 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

98 1

S chu l t z , M., C i se k

, J ., & W abe k e, R . (19 9 5). S i m

u l a t e d expo s ure of h o sp i t a l e m e r g ency personn e l t o 2

so l v ent v ap o rs a n d r e sp i ra b l e d u st d u r i ng deco n t a m

i na t i on o f che m

i c a ll y exp o sed pa t i e n t s. A n n a l s of 3

E

m ergen c y M ed i c i n e, 26 ( 3 )

, 324

- 329. 4

5

S ch w a r t z M D

, H ur s t C G

, K i rk M A

, R eedy S D

, B ra u e E H J r. (201 2 Aug ). R e a c t i v e S k i n D econ t a m

i na ti o n 6

L o ti o n ( R s d l ) f o r t h e d e co n t a m

i na t i on o f c h e m

i cal war fa r e a g ent ( C WA ) d er m al e x posu r e

. C urr 7

P har

m B i o t echn o l

. 13(10), 1971

- 1979. 8

9

S c i s l o w s k

i S

, ( 199 7 ). N ot A l l o f U s W ere B ra v e. Toronto, Canada: D u n drun P res s

. 10

11

S choch

- S pana, M. (201 2 ). T he peo p l e ’s ro l e i n U

. S

. n a t i on a l he a l t h s e cu r it y : p as t , pre s en t , f u t u r e. 12

B i ose c u r it y and B i o t er r

o r i s m : B i odefe n se S t r

a t e gy

, P rac t i ce, a nd S c i e n ce , 1 0 (1 )

, 7 7

- 88. 13

14

S e t t l e s, G

. S ., & M c G ann, W. J

. (200 1 ). P o t e n t i al for por t al d e t ec t i on of hu m an c he m i cal a n d b i o l o g i c al 15

con t a m i n a ti o n. S

P IE A er o s ense, 4 378 ( 1 )

. 16

17

S hepp a rd, B

., R u b i n, G

. J

. , Ward m an, J

. K ., & Wes s e l y

, S . (2006). T e r ro r i sm and d i sp el li ng t he m y t h of a 18

pan i c pr o ne pu b l i c. J o urn a l of P u b l i c H

ea l t h P o l i cy, 27

( 3 )

, 21 9

- 249. 19

20

S i r i an n i

, G ., & B ora k

, J

. ( 2 010). H ow c l e a n i s " c l e an " ? R e g u l a t i ons and s t a nd a r d s f o r w or k p l a ce c l o t h i ng 21

and p e rso n al p r o t e c ti v e eq u i p m en t

. Jo u rnal of Oc cup a t i on a l and E n v i ron m e n t al M

ed i c i ne, 52 ( 2 )

, 22

190

- 196. 23

24

S t op f

ord B M, J e v i t t L

, L e dg er w ood M, S i n g l e t o n C

, S t o l m ack M. (2 0 05). D e v e l op m ent of 25

Mod e l s for E m er g ency P r e pare d ne s s. R oc k v ill e, M D : A g ency for H ea l t hc a re R e se a rch a n d 26

Q ua l it y

. 27

28

S ubba

r ao, I

., J oh n son, C

., B ond, W. F

., S ch w i d, H

. A ., Wa s ser, T

. E

., D e y e, G

. A ., & B ur k har t

, K

. K

. 29

(200 5 ). S y m p t o m

- based, a l g or it h m

i c ap p ro a ch f

o r h a n d li ng t h e i n i t i a l e n cou n t e r w it h v i c ti m s of a 30

p o t e n t i al t e rr o r i st a t t ac k

. P rehos p i t al a nd Di sa s t er M

e d i c i ne, 20 ( 5 )

, 301

- 308. 31

32

S u l l i v an, G

. R . & B on g ar, B . (200 7 ). P s y ch o l o g i c a l co n seque n ces of a c t u al or t h r e a t ened c b rne t e r

ro r i s m

. 33

I n B o n g ar, B

., B ro w n, L

. M

., B eu t l er, L

. E

., B r ec k enr i dg e, J

. N . & Z i m

bardo

, P

. G

. ( E ds.), P s y cho l o g y 34

of T e rr o r i sm (pp. 153

- 164). New York, NY: O x ford U n i v er s it y P r e ss. 35

36

T a y ss e

, L

., D a u l on, S

., D e l a m anche, S

., B e l l i er, B ., & B re t o n

, P . ( 2 007 )

. S k i n de c on t a m

i na t i on o f 37

m

us t ards a nd or g ano p hos p ha t e s: C o m par a ti v e e f

f i c i e n cy of RS D L an d F u l l e r ’ s e a r t h i n do m

es t i c 38

s w i ne. H u m an & E xper i me n t al T

ox i co l ogy, 2 6, 135

- 1 41. 39

40

T h a

nab a l a s i n g ha m

, T

., B e c k e tt , M. W., & M u r r a y

, V

. ( 1991). H o sp i t a l r espo n se t o a che m i c a l i nc i de n t : 41

R eport on c asu a l t i e s of an e t h y l d i c h l o ro s i l ane s p i ll

. B r i t i sh Me d i c a l J o urn a l , 302 ( 6768 )

, 101

- 102. 42

43

T o k

uda, Y

., Ki k

uc h i

, M

., T a k ahash i

, O ., & S t e i n, G

. H . (200 6 ). P r eho s p i t a l m ana g e m ent of s a r i n n e r v e 44

g as t e r ro r i sm i n u r

ban s e t t i n g s: 10 y ears o f p ro g ress a f t er t he T o ky o sub w ay sar i n a t t ac k

. 45

R esus c i t a t i on, 6 8 ( 2 )

, 193

- 2 02. 46

47

T ö rn g ren, S

., P er s son, S

. A

., L j un g qu i s t

, A

., B e r g l und, T

., N o rd s t r and, M., H ä gg l und, L

., R i t t f e l d t

, L

., e t 48

a l

. ( 199 8 ). P e rso n al d eco n t a m i na ti on a f t e r exp o su r e t o s i m

u l a t e d l i q u i d p h ase co n t a m i nan t s: 49

F unc t

i on a l a ss e ss m

ent of a new un i t

. J

o urn a l of T

o x i c o l ogy

. C

li n i c a l T o x i c o l o g y, 3 6 ( 6 )

, 56 7

- 573. 50

51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

99 T r e a t

, K

. N

., W i l l i a m s, J

. M., F u r bee, P

. M., Ma n l e y , W. G

., R us s e l l

, F

. K ., & S t a m per, C

. D . (200 1 ). 1

H osp i t al pr e pa r edn e ss f or w eapons o f m ass d e s t

ru c ti o n i n c i de n t s : A n i n i t i al a ss es s m en t

. A nna l s of 2

E

m ergen c y M ed i c i n e, 38 ( 5 )

, 562

- 565. 3

4

T r e f

f e l

, P

., P a n i s s e t

, F

., H u m

ber t

, P

., R e m

oussen a rd, O

., B ech t e l

, Y ., & A g ache, P . (199 3 ). E f f e ct o f 5

pre s su r e on i n v it r o p e rc u t a neous abs o rp t i on o f c a f

fe i n e. A c t a D er

m a t o

- V e ne r eo l o g i ca, 7

3 ( 3 )

, 200

- 6

202. 7

8

T u r

- K aspa, I

., L e v

, E

. I

., H end l e r, I

., S i ebn e r, R

., S h a p i ra, Y

., & S he m er, J

. ( 199 9 )

. P re p a r

i ng hosp i t a l s 9

for t o x i c o l o g i c a l m ass ca s u a l t i e s e v en t s

. C r i t i cal C are Me d i c i ne, 2 7 ( 5 )

, 1004

- 10 0 8. 10

11

United States. C he m i cal S a f e t y and H a z ard I

n v es ti g a t i on B o a

rd ( 2008). F i r e and co m m un it y e v acua t i on 12

i n A pex, N or t h C a r o li n a E n v i ron m

en t a l Q ua l it y C o m

pan y

, A pex, N or t h Ca

r o l i na, Oc t ob e r 5, 2006. 13

Was h i n g t on, D

. C .: U. S. C h e m i cal S a f e t y and H a z ard I

n v es ti g a t i on B o a

rd. 14

15

United States. Department of Defense. (2006) CBR N decon t a m i n a ti o n : m

u l t i

- ser v i ce t ac t i c s, 16

t ech n i q u es, a nd p r oce d u r e s for c he m

i ca l

, b i o l o g i c a l

, r a d i o l o g i ca l

, and n uc l e a r de c on t a m

i na t i on. DO D 17

F

M 3

- 11.5 18

19

United States. Department of Defense, Department of the A r m y. E d g e w ood C he m

i c a l B i o l o g i c a l C e n t e r 20

and CBR N S cho o l

. ( 2 009). G u i d e li n es f or m ass casu a lt y dec o n t a m i n at i on d u r i ng a 21

HA Z M A T/ w e apon o f m ass de s t r u c t i on i n c i de n t. 22

23

United States. Department of Defense, Department of the A r m y . Headquarters. (2005, Apr ). P re v e n ti on 24

a nd m ana g e m ent of c o l d w ea t h e r i n

j u r i es. T e c hn ic al B u l l e t i n TB MED 5 0 8

, R e t r i e v ed fro m : 25

h t t p : /

/ ar m y pubs. a r m

y. m il/ m ed / D R _pubs / D R

_ a

/ p df / t b m ed508.pdf 26

27

United States. Department of Defense, Department of the A r m y. S o l d i er and B i o l o g i cal C he m i c a l 28

C o m m and. (200 2 ). G u i de l i n e s f o r c o l d w ea t h er m ass deco n t a m i na t i on d u r i ng a t err o r i st che m i c a l 29

a g ent i n ci den t

. R e t r i e v ed fro m : 30

h tt p s : // www .e c bc. a r m y

. m i l / do w n l oad s / c wi r

p / ECBC

_ cw i rp_ c o l d_ w ea t he r

_ m ass_decon. p df 31

32

Uni ted States. Department of Defense, Department of the A r m y. S o l d i er and B i o l o g i cal C he m i c a l 33

C o m m and. (200 2 ). G u i de l i n e s f o r c o l d w ea t h er m ass deco n t a m i na t i on d u r i ng a t err o r i st che m i c a l 34

a g ent i n ci den t

. R e t r i e v ed fro m : 35

h tt p s : // www .e c bc. a r m y

. m i l / do w n l oad s / c wi r

p / ECBC

_ cw i rp_ c o l d_ w ea t he r

_ m ass_decon. p df 36

37

United States. Department of Defense. T ech n i c al S u ppo r t W or k i ng G roup. (20 0 4). B e st pr a c t i c e s and 38

g u i d e li n es f or CBR m ass person n el dec o n t a m i n a t i on (2 nd Ed). 39

40

United States. D epar t m ent o f H e a l t h a nd H u m an S er v i ces. A g en c y for H ea l t h c are R es e ar c h a nd Q ua l it y. 41

(201 2, Jun ). E v i den c e R ep o r t

s / T echn o l o g y A ssess m en t s 207 : A ll o c a ti on of sc a rce res o ur c es d u r i ng 42

m ass casu a lt y e v en t s. Rockville, MD: Agency for Healthcare Research and Quality. R e t r i e v ed fro m : 43

h t t p : // www .n c b i .n l m .n i h. g o v / boo k s / N B K 9 8 854/ 44

45

United States. Department of Health and Human Services, C en t e rs f o r Di se a se C o n t r o l and P r e v en ti o n. 46

( 2 002). C r i s i s and e m er g ency r i sk co mm

un i ca ti o n. R e t

r i e v ed from 47

h tt p : /

/ www .b t

. c dc. g o v

/ cer c / pd f / CER C

- SEP T 02.pdf. 48

49

United States. D epar t m ent o f H e a l t h a nd H u m an S er v i ces, Centers for Disease Control and Prevention, 50

A g en c y for T ox i c S ub s t a n ces and D i se a se R e g i s t ry,( 2 000). Vol. 1 Mana g i ng ha z ardo u s m a t e ri a l s 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

100 incidents. 1

2

United States. D epar t m ent o f H e a l t h a nd H u m an S er v i ces, (201 2 )

. Im p l e m ent a t i on p l an for t he n a ti o n al 3

he a lt h sec u r i t y s t r a t e g y of t he U n it ed S t a t e s of A m er i c a. R e t ri e v ed fro m : 4

h tt p : /

/ www .phe. g o v

/ P rep ar edne s s / p l an n i n g / a u t h o r i t y / n hss / i p / D ocu m

en t s / nh s s

- i p.pdf 5

6

United States. Department of Health and Human Services. N a ti o n al I ns t i t u t e for Oc c u pa t i on a l S a fe t y and 7

He a l t h. T he e m er g ency respon s e s a f

e t y and hea l t h d a t a

ba s e. R e t r i e v ed f ro m : 8

h tt p : /

/ www .cdc. g o v

/ NIO S H / ershd b / A g en t L i s t Al p h a.h t m l

. 9

10

United States. Department of Health and Human Services, N a ti o n al I ns t i t u t e for Oc c u pa t i on a l S a fe t y and 11

He a l t h, O ccup a ti o n al S af e t y and H ea l t h A d m

i n i s t r a t i on, United States C oa s t G u a rd, and United 12

States. E n v i ron m en t a l P ro t ec t i on A g ency

, (198 5 ). O cc u pa t i o n al S a f et y and H ea l t h G u i d ance M a nual 13

for H a z ardous W a s t e S it e A c t i v it i es. 14

15

United States. D epar t m ent o f H e a l t h a nd H u m an S er v i ces, (20 0 9, Dec). N a ti o n al he a lt h se c u r it y 16

s tr a t e g y of t he U n i t ed S t a t es o f A m er i ca. Washington, DC: U.S. Department of Health and Huma n 17

Services. R e t r i e v ed f ro m : 18

h t t

p : // ww w .phe. g o v

/ P rep a red n es s / p l a n n i n g / a u t ho r

it y / n h s s / s t r a t e gy / D ocu m en t s / nh s s

- f

i n a l .p d f 19

20

United States. Departmen t of Health and Human Services. N a ti o n al L i b r ary of M e d i c i ne. S p e c i a l i z ed 21

I nfor m a ti on S er v i c es. ( n.d

. ). W i r e l e ss i nfor m a ti on s y s t em for e m er g ency r espond e rs. R e t

r i e v ed 22

f

ro m : h t t p : // w i s e r.n l m .n i h. g o v

/

. 23

24

Uni ted States

. D epar t m ent o f H e a l t h a nd H u m an S er v i ces. Of f i ce of t h e A s s i s t a n t S e c r e t ary f or 25

P r epa r edn e ss a nd R espon s e. & United States. Department of Health and Human Services. Na t i o nal 26

L i b r ary of M ed i c i n e ( Last Updated 2011 Aug 6). C he m i c a l h a z ards e m

er g ency med i c al 27

mana g e m ent i n t e l l i g ent s y ndro m

es t ool. R e t

r i e v ed fro m : h tt p : /

/ c h e m m .n l m .n i h. g o v

/ che m m i s t .h t m

. 28

29

United States. Department of Homeland Security, F ede r al E m er g ency Mana g e m

ent A g en cy, (201 1, Dec ). 30

A w h o l e o f co mm uni t y approach t o e m

er g ency m ana g e m

en t : P r i n c i p l es, t he m

es, and p a t h w a y s for 31

a c t i on. 32

33

United States. Department of Homeland Security, Federal Emergency Management Agency. F i re 34

A d m

i n i s t ra t i on (1 9 97, Apr). F i re dep a r t m ent res p o n se t o b i o l o g i c a l t hr e at at B ’ nai B ’ r i t h 35

h eadq u a r t e rs, Was h i n g t on, D

. C: Federal Emergency Management Agency

. U.S. Fire 36

Administration Technical Report Series, USFA

- TR

- 114. R e t r i e v e d from 37

h t t

p : // www .u s fa. fe m a

. g o v

/ do w n l oads /

pd f / pu b li c a t i on s / t

r

- 114.pdf. 38

39

United States. Department of Homeland Security, F ede r al E m er g ency Mana g e m

ent A g ency, (2 0 07). M ass 40

dec o n t a m i n a ti o n p l an n i n g : D e v e l o p i ng p l ans and t he cap a b i l i t y t o dep l oy r e spon d ers of b o t h 41

g ende r s. R e t r i e v ed f rom h tt p s : // www

. l l i s.dhs. g o v / d o cde t a i l s / d e t a i l s. d o?c o n t e n t I D =4930 9

. 42

43

United States. E n v i ron m en t al P ro t e c t i on A g ency (2000). F i r s t re s ponde r s' en v i ron m en t al l i a b i l it y due t o 44

m ass deco n t a m i na t i on run o ff. W ash i n g t o n, D C: Environmental Protection Agency

. R e t r i e v ed f r om 45

www

. epa. g o v / os w eroe 1 / d o cs / c he m

/ onepa g e.p d f

. 46

47

United States. Department of Labor. O ccup a ti o n al S af e t y and H ea l t h A d m

i n i s t r a t i on. (2005). B e s t 48

p r ac t

i c es f o r h o sp i t a l

- based f

i r st r e ce i v e r s of v i c ti m s f

r o m m ass casua l t y i n c i de n t s i n v o l v i ng t he 49

r e l ea s e of ha z ardo u s su b s t a nc e s. Accessed from 50

https://www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdf 51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

101 United States. Department of Labor. O ccup a ti o n al S af e t y and H ea l t h A d m

i n i s t r a t i on (20 0 9). B e st 1

p r a c t i ces f o r p r o t e c t i ng E MS resp o nd e rs d u r i ng t re a t m ent and t r ansp o rt of v i c t i m s of ha z ardous 2

su b s t a

nce r e l ea s es. Accessed from https://www.osha.gov/Publications/OSHA3370

- protecting

- EMS

3

respondersSM.pdf 4

5

United States. Department of Labor. O ccup a ti o n al S af e t y and H ea l t h A d m

i n i s t r a t i on ( 20 0 6 )

. O S H A 6

F ac t S h e e t : P e rso n al p ro t ec t i v e equ i p m en t

. R e t r i e v ed f

ro m : 7

h tt p : // www .osh a

. g o v / O sh D c / d a t a_ Ge ne r a l

_ F a c t s / p p e

- fac t sh e e t .p d f

. 8

9

United States. D epar t m ent o f T r ans po r t a t i on. (20 1 2). E m er g ency r esponse g u i de b o o k: A g u i de b ook 10

for f

i r st r e spon d ers d u r i n g t he i n iti al p ha s e of a d a ng erous g ood s / h a z ard o us ma t e r i a l s 11

t r ans p o r t a t i on i nc i de n t

. 12

13

United States. D epar t m ent o f T r ans po r t a t i on. P i p e l i ne a nd H a z ardous Ma t e r i a l s S a f e t y A d m i n i s t r a t i on. 14

(201 3 ). Da t a & s t a t i s t i cs. 15

16

V an der B i

jl

, P

., Ga r e i s, A

., L ee, H

., v an E yk

, A

. D

., S t ande r

, I

. A ., & C illi e rs, J. ( 2002). E f f ec t s of t w o 17

bar r i e r c rea m s on t h e d i f f u s i on o f ben z o [ a]p y re n e a c r o ss hu m an s k i n. S A D J: Jou r

nal o f t h e So u t h 18

A

f r i can D e n t

a l A ss o c i a t i on, 57 ( 2 )

, 4 9

- 52. 19

20

V an d e r for d , M. (200 3 ). C o m m unic at io n l ess o ns l e a

rn e d i n t he e m

er g ency ope r a t i o ns ce n t e r d u r i ng C D C ’s 21

an t h rax res p ons e : a co m m en t ar y

. Jo u rn a l of H

ea l t h C o mm un i ca t i o n : I

n t e rna t i on a l P ersp e c t i v e s, 22

8( S : 1 ), 11

- 12. 23

24

V a

rd i

, A

., L e v i n, I

., B er k

ens t a d t

, H

., H o u r v it z

, A

., E i se n k raf t

, A

., C o h en, A

., & Z i v

, A . (2002). 25

S i m

u l a ti o n

- based t r a i n i ng o f m ed i cal t e a m s t o m ana g e che m i cal wa r f are ca s ua l t i e s

. T

he I sra e l 26

Me d i c a l A s s oc i a t i on J o ur n a l : IM A J, 4 ( 7 )

, 540

- 544. 27

28

V i a l a

, B

., B l o m e t

, J

., M a t h i eu, L ., & H a l l

, A

. H

. ( 200 5 )

. P re v en t i on o f C S " t e a r g a s " e y e and s k

i n e f fe c t s 29

and a c ti v e d e co n t a m i na t i on w it h D i ph o t e r

i n e : P r e l i m

i nary s t u d i es i n 5 F re n ch G e n dar m es. T he 30

Journ a l o f E m er g ency M e d i c i ne, 29 ( 1 )

, 5

- 8. 31

32

V o l k

l a nd, W

. J

. (200 0 ). H o w c l e a n i s s a fe? Ma s t e r's T hes i s (U S AF / H arv a rd )

. 33

34

V o g t

, B ., & S o r ens e n, J

. ( 2 00 2). H ow c l e a n i s s a fe? Im pro v i ng t he eff

e c t i v eness of d e con t a m

i na t i on of 35

s t r u c t u r e s and peo p l e fo l l o w i ng che m i cal a n d b i o l o g i c al i nc i de n t s. O ak R i d g e N a ti o n al L a b., T

N. 36

37

Waec k

e r l e, J. F

. ( 200 0 ). D o m

es ti c p r ep a

red n ess for e v en t s i n v o l v i ng w eapons o f m ass d es t ru c t i on. 38

Journ a l o f t h e A m e r i can M

ed i c a l A s so c i a t i on, 283 ( 2 )

, 252

- 254. 39

40

Wax P M, B ec k er CE

, C u r r

y SC

. U nexpec t ed “ g as” ca sua l t i es i n M osco w : a m ed i cal t o x i c o l o g y 41

pers p e c ti v e. A nn E me rg Me d. 2003; 41 ,70 0

– 705. 42

43

Wenc k , M. A

., V a n S i c k l e

, D

., D roc i u k

, D

., B e l f

l o w er, A

., Y oun g b l ood, C

., W h is nan t

, M. D

., T a y l o r, R

., 44

et a l

. ( 200 7 ) R a p i d a sse ss m ent of exp o su r e t o ch l o r

i n e r e l e a sed from t r a i n d er a i l m en t

. P ub l i c H

e a lt h 45

R epor t s, 12 2

, 784

- 792. 46

47

We s t e r

, R

. C ., M a i b a ch, H

. I

., B uc k s, A .W., M cM a s t er, J . & Moba y en. (1 99 0 ). P e r c u t an e ous abs o rp t i on 48

and s k i n d e co n t a m

i na t i on o f PCB s: i n v i t

ro s t u d i es w i t h hu m an s k

i n and i n v i v o s t

ud i es i n t he rh e sus 49

m

o n k e y

. Journal of T

o x i c o l ogy and E

n v i ron m e n t al He a lt h, 31,23 5

- 246. 50

51v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

102 We s t e r

, R

. C ., M e l e n dr e s, J

. , and M a i b ach, H

. I . (1992 )

. I n v i v o percu t a n eous abs o r p ti o n and s k

i n 1

deco n t a m i na t i on o f a l ac h l o r i n rh e sus m on k e y

. Journal of T

ox i co l ogy a n d E

n v i r o n m en t a l H

e a lt h, 36, 2

1

- 12. 3

4

We s t e r

, R

. C

., Q uan, D ., & Ma i b ach, H

. I . (199 6 ). I n v i t ro p e r cu t aneo u s a b sor p t i on of m

odel co m pounds 5

g l y phosa t e a n d m a l a t h i on f rom co tt on fa b r i c i n t o a

nd t hrou g h hu m an s k

i n. F ood a nd C

he m i c al 6

T

ox i c o l o g y, 34 ( 8 )

, 731

- 735. 7

8

We s t e r

, R . M., T an o j o, H

., Ma i b ach, H

. I ., & We s t er, R

. C . (200 0 ). P r ed i c t e d ch e m i cal w a r fa r e a g ent V X 9

t ox i c i t y t o u n i f o r m ed so l d i e r u s i ng par a

th i on i n v it

ro h u m an s k

i n exposu r e and a

b sor p ti o n. 10

T

ox i c o l o g y and A p p l i ed P h ar

m aco l ogy, 1 68 ( 2 )

, 149

- 1 52. 11

12

We t t e r, D

., D a n i e l l

, W., & T r es e r, C

. (200 1 ). H os p i t al pre p are d ne s s f o r v i c t i m s of che m

i cal o r b i o l o g i cal 13

t e r

ro r i s m

. A m er i c an J

o ur n al of P ub l i c He a l t

h, 91 ( 5 )

, 710

- 716. 14

15

W i n f

i e l d, G

. (201 1 ). S m a l l i s l and, b i g capa b i li ti e s. H A Z M A T R e s pond e r W o r l d, A

u t u m n 2011 ( 2 ), 8

- 12. 16

17

World Health Organization.(2010) International Statistical Classification of Diseases and Related Health 18

Problems 10 th Revision. Volum e 2. Geneva, Switzerland. Accessed from: 19

http://www.who.int/classifications/icd/ICD10Volume2_en_2010.pdf 20

21

Wor m ser, U

., B

. B r ods ky , et a l

. ( 200 2 ). " S k i n t o x i co k i ne t i cs o f m

us t a r d g as i n t he g u i nea p i g e f fe c t of 22

h y poch l o r i t e and s a fe t y as p ec t s ." A rc h i ves of T ox i co l o gy 76 ( 9 )

, 517

- 522. 23

24

Wra y

, R

., B ec k er, S

., H en d erso n

, N

., G li k

, D

. , J up k a, K

. , M i d d l e t on, S

. , H end e rso n, C

., D rur y

, A . & 25

M i t ch e ll

, E . ( 2 008). C o m m un i c at i ng w it h the p u b l i c a b out e m er g ing hea l t h t

hr e a ts : L e s sons from t he 26

pre

- e v ent m essa g e de v e l op m

ent p r o j e c t

. A m er i can J

o u rnal o f P u b l i c H

e a lt h, 98 ( 12 ) , 2214

– 2222. 27

28

Wra y

, R . & J up k a, K

. (2 0 0 4 ). W h at d oes t he p ub l i c wa nt t o k now i n t h e e v ent o f a t e r

r o r i s t a t t ack us i ng 29

p l a g ue? B i os e cu r i t y and B i o t e r ro r i s m : B i o d e f e nse S t r a t eg y

, P ra ct i ce, a nd S c i e n ce , 2( 3 ), 208

- 215. 30

31

Y an g i sa w a, N

., M o r it a, H

., N a k a ji m a, T

. ( 200 6 ). S a

r i n expe r i e n ces i n Japa n : a cu t e t ox i c i t y and l o ng

- t erm 32

ef

f ec t s. J o urn a l of t

h e N eu r o l o g i c a l S c i en c e s

, 2 49 ( 1 )

, 76

- 85. 33

34

Z a i d i

, S

. H . ( 1 986). B hop a l and a f t e r. A m J Ind Med., 9 (3), 2 15

- 21 6. 35

36

Z e it z

, P.

, Z

. B er k o w it z , et a l . (2 0 00). F re q uency and t y pe of i n j u r i es i n res p ond e rs of ha z ar d ous 37

sub s t an c es e m er g ency e v en t s, 1 9 96 t o 1998. Jour n al o f O ccup a ti o n al a n d E

n v i ro n m en t al M

ed i c i n e 38

42 ( 11 )

, 1115

- 1120. 39

40

Z

ha i

, H

., B arba d i ll o, S

. , H u i

, X ., & M a i b a ch, H

. I . (20 0 7). I

n v it ro m odel f o r de c o n t a m

i na t i on o f hu m an 41

s k

i n: F or m a l d e h y de. F

ood and C

he mi cal T o x i co l o gy, 45 ( 4 )

, 618

- 621. 42

43

Z i s k

i n, M. H

., B eh a

r, J . & Mans d o r f, S

. J

. (200 3 ). F u l l body pro t e c t i on a nd s t an d a r ds. I n A nna, D. H. ( E d.), 44

C

he m i c a l P r

o t e c t i ve C l o t h i ng, (2 nd Ed.) ( pp .41 5

- 474). F a i r f ax, V A : A m

er i c an I ndus t r i al H yg i ene 45

A ssoc i a t i on. 46

47

Z oras t e r, R . M., C h i d es t er, C ., & K oe n i g , W. ( 2 007). F i e l d t r i a g e a nd p a

t i e nt m a l d i s t r i bu t i on i n a m as s

48

casu a lt y i n c i d en t

. P re h os p i t al a nd Di sa s t er Me d i c i ne, 22 ( 3 )

, 224

- 229. 49v. 1 7



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, 2 01 3

103 

## Appendix A : W o r k ing G r o up Ch a r t er a nd M e m ber s hip 1

2

Mass H u man C h e m i cal D eco n t a m i n a t i on W or k i n g G ro u p 3

Sub co m m i t t ee on S ta nd a r d s

- C B RNE 4

C om m i t tee on H om e l a n d a n d N at i o n al S ec u r i ty 5

N at i o n a l S c i e n c e a n d T ec hn o l ogy C o u n c i l 6

7

B ackgro un d 8

C he m

i cal a tt a c k s per p e t

r a t e d by t er r o r i s t s and a c c i d en t al r e l eas e s o f t o x i c i nd u s t r i al c h e m i ca l s a r e 9

reco g n i z ed a s c u rr e nt t h r e at s t o p ub l i c h ea l t h i n t he U n i t e d S t a t es. B o t h t y pes of e v en t s can 10

po t en t i a ll y expose s i g n i f i ca n t nu m bers of pe o p l e t o d an g ero u s ch e m i ca l s t h at w o u l d o v er w h e l m 11

l ocal r e spo n se capa b i l i t i e s. P a ti e nt d eco n t a m i na ti on, w hen p er f

or m ed us i ng ap p rop r i a t e t ec h n i qu es 12

and du r i ng t he appro p r i a t e t i m e fra m e, li m it s pa t i e n t e xpos u re and t he t ox i c i t y t h a t f o l l o w s as w e l l 13

as p r o t e c t s res p ond e rs i n t h e f i e l d a n d i n t he hos p i t al s e t t i ng from secon d ary c on t a m i na t i on. 14

T he r ef

o re, p a t i ent dec o n t a m

i n a ti on i s an i n t e g r a l co m ponent o f t he m

ed i c a l res p onse t o a c he m i cal 15

e v en t

. P a ti e nt d e c on t a m i na t i on a l s o i m

pac t s t he f

l ow o f c a su a l ti es a t m any l e v e l s of a m ass 16

casu a lt y c h e m i cal e v en t

, m

ean i ng t h at de c i s i ons about dec o n t a m i n a ti on w i l l i m

pact t h e e n t i re 17

e m

er g en c y respons e

. T hus v a r i o u s a spe c t s o f p a t i ent deco n t a m i na t i on a re o f i n te re s t t o m

u l t i p l e 18

r esp o nd e r a g enc i es, such as f i re / HA Z M A T

, e m

er g ency m

ed i cal s er v i c e s, ho s p i t a l s, pub l i c h e a l t h 19

o f

f i c i a l s and e m

er g ency prepare d ness p l anne r s. 20

21

P a t i ent dec o n t a m i n a ti o n p la ns and p ro c ed u res h a v e e v o l v ed o v er ti m e w i t h o n l y l i m

it ed g u i dance ba s ed on 22

s c i e n t i f

i c e v i den c e; m a n y bas i c q u es t i o n s ab o ut d e c on t a m i na t i on h a v e not y et b een a d dr e ssed by res e a r ch. 23

E v i de n ce

- based p l an n i ng and b e st p ra ct i ces a re t hus li m

it ed. F or exa m

p l e, a t t e m p ti ng t o fu l l y 24

deco n t a m

i na t e e v ery per s o n i n t he v i c i n i t y of a che m i cal r e l ea s e wi l l s l ow t he t ra nspo r t o f s e r i o us l y i ll 25

pa t i e n t s f

rom t he s cene t o h osp i t a l s. I n t h i s ca s e, i nap p rop r i a t e d eco n t a m i na t i on p r o t oc o l s m

i g ht ha m per, 26

ra t h er t h a

n co n t r i b u t e t o, m

ed i c al m i t i g a ti on of m

orb i d it y and m

or t a l i t y

. I n add it i on, pa s t c h e m

i cal 27

i n c i de n t s d e m ons t r a t e t h a

t s cene p e r i m

e t ers w i l l n o t be es t a

b l i sh e d q u i c k

l y eno u g h af

t er t he r e l e a se t o 28

pre v ent a l a r g e nu m ber of p eop l e f

rom l ea v i ng t he s c e n e. T he s e p o t e n ti al l y expos e d peo p l e wi l l show up 29

at h o sp i t a l s o r o t her f a c i l i t i es wi t ho u t b e i ng deco n t a m i na t e d

. H e a lt h c a

re f a c i l it y che m

i cal i n c i de n t 30

resp o nse p l a n s s h ou l d ad d r ess s uch s ce n a r i os. T h e r e c ent c l o s ure of t w o S t

. L ou i s hosp i t a l e m er g ency 31

depa r t m

en t s d u e t o su s pe ct ed s e cond a ry con t a m i n a ti o n of t he fa c i l i t y f

r om expo s ed p a ti e n t s i ll u s t ra t es t he 32

need for scr u t i n i z i ng t he p a ti e nt d eco n t a m i na t i on p ro ce ss. 33

34

H o m

e l and S ecu ri t y P res i d e n t i al Di r e c t i v e

- 22, D o m

es ti c C he m

i cal De fe n se, c a l l s f

or t h e F e d er a l 35

g o v ern m

ent t o s u ppo r

t t he de v e l op m

ent of S t a t e a nd l ocal p l a ns a n d pr o t o c o l s f o r t he d eco n t a m

i na t i on o f 36

pers o ns. I

n order t o b e s t a c co m

p li sh t h i s t a s k

, t he F e d e ral g o v ern m en t

, t h rou g h t h e Ma s s H u m an 37

C he m

i cal D ec o n t a m

i n a ti on Wor k

i ng G roup (W G ), w i l l a t t e m pt t o ens u re t h a

t t ho s e S t a t e a nd l oc a l p l ans 38

and p r ot o co l s r e f l e c t c u rr e n t be s t p ra c t i ces. T he w o r k i ng g roup w il l a l so i d e n t i fy deco n t a m i na t i on i ss u es 39

i n n e ed of r e se a rch and d ra f

t a s t r a t e g i c p l an f

o r a d dr es s i ng such re s e a

rch g aps. 40

41

Pu rpose 42

T he WG wi l l as s ess t he cu r rent s t a t e of cap a

b i l i t i es a n d t he cu r

re n t k no w l ed g e b a se re g a r d i ng p a ti e nt 43

deco n t a m

i na t i on p ra c t i ces a nd t e chn o l o g i es. R e co m m enda t i ons w i l l t

hen b e m ade as t o ho w t h e F e d er a l 44

g o v ern m

ent cou l d f

a c i l i t a t e i m pro v e m en t s i n t h e se a

r e as. 45

46

S cope 47

T he WG wi l l add r ess a v ar i e t y of i ssu e s i nc l ud i ng op er a t i on a l an a l y s i s and res e a rc h, t e c hno l o g y resea r ch 48v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

104 and de v e l o p m

en t , e m er g ency prepa r edn e ss p l an n i n g

, e duca t i on, t r a i n i n g , e x e r c i s e s and a ss e ss m en t s. 1

2

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j e c ti v es 3

• P rep a

re a s t r a t e g y t hat a dd r ess e s t h e f o l l o w i ng (e st i m a t ed t i m

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ee ti n g ): 4

• R e v i ew na t i on a l s t an d ar d s of c a re for m ass c as u a l t y hu m an decon t a m i n a ti o n

, c o m

pare and co n t r a s t 5

d i f

fe r i ng s t and a

rds and a ss e m

b l e a g ap ana l y s i s 6

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r a i n i n g

, e x e rc i ses, and 7

ass e ss m

en t s f or f i re, E M S

, and ho s p i t al s y s t e m s 8

• P erf

o rm a l i t e r a t u re re v i ew of p a t i ent d eco n t a m i n a ti on res e a r ch, i de n t i fy cur r ent r e sea r ch a c t i v it i es, and 9

des c r i b e r e se a rch que s t i ons t h a t ne e d t o be a ddr e ss e d. 10

• A ssess dec o n t a m i n a ti o n s o l u ti o ns 11

o E v a l ua t e cu r re n t d e co n t a m

i na t i on s o l u ti o ns ( e. g ., soap & w a t er, d i l u t e b l eac h

, RS D L © ) for 12

ef

f ec t i v ene s s /

fea s i b i l it y / c o s t/ b ar r i e rs and s af

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i n, e y es, open w o u n ds, pr o l on g ed 13

con t a c t

, en v i ron m en t a l run

- of

f) 14

o D ef

i n e r o l e o f e ach s o l u t i on i n C on c ept of O p e r a ti o ns ( C ONO PS ) 15

• D e v e l op op t i m i z i ng s t r a t e g i es f

o r d e co n t a m

i na t i on t h a t m a y be e m

p l o y ed reco g n i z i ng cons t r a i n t s i n 16

equ i p m

en t

, t r a i n i n g

, ti m

e, a nd ca p ab i l i t y at l oc a l r esp o nse l e v e l s a nd p r o v i de p ro p osa l s f o r e v a l u a ti on 17

and v a li d a t i on. P rop o sed s t ra t e g i es wi l l con s i d e r c u r re nt c a pa b i l i t i es and ti m

e co n s t r a i n t s for m ass 18

casu a lt y d e con t a m i na t i on. 19

• E s t a b l i sh C ONO P S for m ass dec o n t a m i n a ti on a f t e r ch e m i cal exp o su r e 20

• D ef

i n e m e t r i cs f or m ass p at i e n t de c on t a m i na ti o n a f t e r a che m

i c a l exp o su r e ( e. g

., t

he % p a t i e n t s o r 21

nu m

ber t h a t m

ust be d e co n t a m

i na t ed p er h o ur by “s y s t e m ”) 22

• P ro v i de W or k i ng G roup re co m m

enda ti o n s t o T ar g et C apab il i t i es Wor k i ng G roup 23

• Im

p l e m ent p l ans t o add r e s s h i g hest p r i o r it y a r eas (e s t i m a t ed ti m e li n e: y e a r 2 a n d be y ond) 24

25

Mass H

u m an Ch e m i

cal D eco n t

a m i n a t i on Wor k i n g G ro u p M e m b ers h i p 26

27

C o

- C h a i r s 28

29

S usan C i bu l s k y 30

D epa r t m

e n t of H e al t h and H u m an S er v i ces 31

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess and R espon s e 32

33

Mark K

i rk 34

D epa r t m

ent of H o m

e l and S ecu r it y 35

O ff

i ce o f H e a lt h A ff

a i r s 36

37

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39

B il l A nde r son 40

D epa r t m

ent of H o m

e l and S ecu r it y 41

P l um I s l and F i re D e p a r t m ent 42

43

44

Ja m

es A rea 45

U S Ma r i ne C o rps 46

C he m

i cal B i o l o g i c a l I

nc i d e nt R es p onse F or c e 47

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4

E r i k A uf d e r H e i de 5

Department of Health and Human Services 6

C en t e rs for D i s e ase C o n t r ol and P r e v en ti o n 7

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9

C hr i s t i na B a x t e r 10

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ent of De fen s e 11

C o m

ba ti ng T e r

r o r i sm T e c h n i c a l S up p o r t O f f i c e 12

T e chn i c a l S upp o rt W o r k i ng G roup 13

14

G rant B i s s ey 15

D epa r t m

ent of H o m

e l and S ecu r it y 16

F ede r al E m er g ency Mana g e m

ent A g ency 17

18

E rne s t H

. B r a ue Jr. 19

D epa r t m

ent of De fen se 20

U S A r m

y Med i c a l R e s ea

r c h I ns tit u t e o f C he m

i cal Def ense 21

22

M i c h a e l C a r r i n g er 23

C on t r a ct S upp o rt 24

D epa r t m

ent of H o m

e l and S ecu r it y 25

O ff

i ce o f H e a lt h A ff

a i r s 26

27

Jenn i f

e r H or n sb y

- M y ers 28

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C en t e rs for D i s e ase C o n t r ol and P r e v en ti o n 30

N a ti o n al I

ns t i t u t e for Oc c u pa t i o n a l S a fe t y and He a l t h 31

32

C har l es G

. H u r st 33

D epa r t m

ent of De fen s e 34

U S A r m

y Med i c a l R e s ea

rc h I ns tit u t e o f C he m

i cal Def ense 35

36

J o s e l i t o I g nac i o 37

D epa r t m

ent of H o m

e l and S ecu r it y 38

O ff

i ce o f H e a lt h A ff

a i r s 39

40

J o hn K o e rn er 41

U S D epar t m ent o f H e a l t h & H u m an S er v i ces 42

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess and R espon s e 43

J o hn K u l i f ay 44

D epa r t m

ent of De fen s e 45

O ff

i ce o f t h e S e c r e t a

ry of D efen s e 46

47

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4

A dam D

. L eary 5

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O ff

i c e o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess and R espon s e 7

8

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es Mad s en 9

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ent of De fen se 10

U S A r m

y Med i c a l R e s ea

rc h I ns tit u t e o f C he m

i cal Def ense 11

12

J o e M or

r i s 13

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ent of H o m

e l and S ecu r it y 14

O ff

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a i r s 15

16

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ent of H o m

e l a nd S ecu r it y 18

O ff

i ce o f H e a lt h A ff

a i r s 19

20

H il l ary S ad o ff 21

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ent of H o m

e l and S ecu r it y 23

O ff

i ce o f H e a lt h A ff

a i r s 24

25

P e t e r G

. S ch u l ze 26

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ent of De fen s e 27

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y T ra i n i ng and D o c t r i ne C o m m and 28

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34

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O ff

i ce o f A s s i s t a n t S e c r e t a r

y for P re p ar e dne s s and R e s ponse 38

39

Je r

ry T ho m as 40

C en t e rs f

or D i s e ase C o n t r ol and P r e v en ti o n 41

N a ti o n al C en t er for E n v i r o n m en t al H e a lt h 42

43

A dd i t i on a l s ub j e ct m a t t er e xpe r t s a

re i n v it e d as ne c es s ar y

. T h e w or k i ng g roup m ay i n t e ra c t wi t h a n d 44

rec e i v e ad h o c ad v i c e f rom v ar i ous n o n

- F ederal pe r so n s and e n t i t i es, pro v i d e d s u c h i n t e r ac t i o n s oc c ur i n a 45

m anner t h a t m a i n t a i ns t he w or k i ng g roup’s s t a t u s as c o m p li ant wi t h t he F ed e ral A d v i so r y C o m m itt ee A c t. 46

47

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A r li n g t o n, V A 5

6

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e l and S ecu r it y 8

S c i e n ce & T e c hno l o g y 9

10

T om B l ac k w e l l 11

Mec k

l en b urg E MS A g ency 12

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25

R obert C h i l c o t t 26

H ea l t h P r o t e c t i on A g ency 27

U n it ed K

i n g dom 28

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S usan C i bu l s k y 30

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ent of H e al t h and H u m an S er v i ces 31

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess and R espon s e 32

33

T od C o m

pan i o n 34

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ent of H o m

e l and S ecu r it y 35

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37

J o hn De l aney 38

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41

M i c h a e l B

. D e Z earn 42

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ent of De fen s e 43

E d g e w ood C he m i cal B i o l og i cal C e n t e r 44

45

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5

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ent of H o m

e l and S ecu r it y 7

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i ce o f H e a lt h A ff

a i r s 8

9

Jenn i f

e r H or n sb y

- M y ers 10

C en t e rs for D i s e ase C o n t r ol and P r e v en ti o n 11

N a ti o n al I

ns t i t u t e for Oc c u pa t i on a l S a fe t y and He a l th 12

13

J o s e l i t o I g nac i o 14

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ent of H o m

e l and S ecu r it y 15

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i ce o f H e a lt h A ff

a i r s 16

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F ran c a R

. J o n es 18

Wh i t e H o u se, Of f i ce o f S ci ence a nd T e chn o l o g y P o li c y 19

C he m

i cal and B i o l o g i c a l C oun t e r m easur e s 20

21

Je f

fery K e y ser 22

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ent of H o m

e l and S ecu r it y 23

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25

Mark K

i rk 26

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ent of H o m

e l and S ecu r it y 27

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i ce o f H e a lt h A ff

a i r s 28

29

J o hn K o e rn e r 30

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i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

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33

J o hn K u l i f ay 34

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ent of De fen s e 35

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i ce o f t h e S e c r e t a

ry of D efen s e 36

37

W i l l i am A

. L a k e 38

D epa r t m

ent of De fen s e 39

U S A r m

y Ma t e r i a l C o m m a nd 40

41

A dam D

. L eary 42

C on t r a ct S upp o rt 43

D epa r t m

ent of H e al t h and H u m an S er v i ces 44

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess and R espon s e 45

46

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e rce 4

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ns t i t u t e o f S t and a

rds a nd T e c hno l o g y 5

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P h i l M a t t son 7

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e l and S ecu r it y 8

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10

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e l and S ecu r it y 12

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ent A g ency 13

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C har l es M c K ay 15

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i cal a nd B i o l o g i cal De fen s e 20

21

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rd P a t r i ck 22

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ent of H o m

e l and S ecu r it y 23

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i ce o f H e a lt h A ff

a i r s 24

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P aul P e nn 26

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E nMa g i ne 28

29

G i na P i a zza 30

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i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

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fery R ace 34

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, C i t y of N ew Y ork 35

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, NY 36

37

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ent of De fen s e 39

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P e t e r G

. S ch u l ze 41

D epa r t m

ent of De fen s e 42

U S A r m

y CB R N S chool 43

44

M i c h a e l S ch wa r t z 45

C en t e rs for D i s e ase C o n t r ol and P r e v en ti o n 46

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i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

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2012 M

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e l and S ecu r it y 17

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E r i k A uf d e r H e i de 20

C en t e rs for D i s e ase C o n t r ol and P r e v en ti o n 21

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rd A

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34

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e l and S ecu r it y 37

O ff

i ce o f H e a lt h A ff

a i r s 38

39

M i c h a e l C a s t i llo 40

D epa r t m

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e l and S ecu r it y 41

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ent A g ency 42

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. C a t l e tt 44

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e l and S ecu r it y 17

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i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

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a i r s 30

31

R obert G i s t 32

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K a n sas C it y , MO 34

35

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ou t h U n i v e r s i t y 37

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Office of the A ss i s t a n t S e cr e t a ry for P u b li c A f

f a i rs 41

42

D an H an f

li ng 43

INO V A H ea lt h S y s t e m s 44

45

R obert H oo k s 46

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i ce o f H e a lt h A ff

a i r s 8

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Wh i t e H o u se, Of f i ce o f S ci ence a nd T e chn o l o g y P o li c y 11

C he m

i cal and B i o l o g i c a l C oun t e r m easur e s 12

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B e t h K en n edy 14

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ent of De fen s e 15

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Mark K

i rk 17

D epa r t m

ent of H o m

e l and S ecu r it y 18

O ff

i ce o f H e a lt h A ff

a i r s 19

20

J o hn K o e rn e r 21

D epa r t m

ent of H e al t h and H u m an S er v i ces 22

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess and R espon s e 23

24

R it a K

renz 25

U n i v ers i t y of V i r g i n i a E m er g ency D epar t m

ent 26

27

J o hn K u l i f ay 28

D epa r t m

ent of De fen s e 29

O ff

i ce o f t h e S e c r e t a

ry of D efen se 30

31

J u d i t h W o l fe L a n ey 32

D epa r t m

ent of H e al t h and H u m an S er v i ces 33

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess and R espon s e 34

35

A dam D

. L eary 36

C on t r a ct S upp o rt 37

D epa r t m

en t of H e al t h and H u m an S er v i ces 38

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess and R espon s e 39

40

Ja m

es L ee 41

D epa r t m

ent of De fen s e 42

N a ti o n al G u ard B u r e au 43

44

B il l Ma y f

i e l d 45

Me m

or i al H e a lt h S y s t e m s 46

47

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113 Jan i s M c C a r

ro l l 1

D epa r t m

ent of H o m

e l and S ecu r it y 2

F ede r al E m

er g ency M ana g e m

ent A g ency 3

4

Ja m

es Mc G u y er 5

D epa r t m

ent of De fen s e 6

N a ti o n al G u ard B u r e au 7

8

C har l es M c K ay 9

A m

er i c a n C o l l e g e of Me d i cal T o x i c o l o g y 10

11

G re t c hen M i c ha e l 12

D epa r t m

ent of H e al t h and H u m an S er v i ces 13

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess and R espon s e 14

15

J o n a t han N e w m ark 16

D epa r t m

ent of De fen s e 17

J o i n t P ro g ram E xec u ti v e O ff i ce for C h e m

i cal a nd B i o l o g i cal De fen s e 18

19

G re g ory G

. N o l l 20

S ou t h C e n t r al T ask F or c e ( P A ) 21

U S A F F i re & E m er g ency S er v i ces 22

23

T ed O

. P ad g e t t 24

D a ll a s F i re

- R escue D e p a rt m ent 25

D a ll a s, T X 26

27

R i ch a

rd P a t r i ck 28

D epa r t m

ent of H o m

e l and S ecu r it y 29

O ff

i ce o f H e a lt h A ff

a i r s 30

31

P aul P e nn 32

I n t ers t a t e C he m i c a l T h r e a t s Wor k i ng G roup 33

E nMa g i ne 34 35

S a ll y P h i l l i ps 36

D epa r t m

ent of H o m

e l and S ecu r it y 37

O ff

i ce o f H e a lt h A ff

a i r s 38

39

L i nda P re s s l ey 40

D epa r t m

ent of H o m

e l and S ecu r it y 41

F ede r al E m er g enc y Mana g e m

ent A g ency 42

43

Je f

fery R ace 44

F i re D epa r t m en t

, C i t y of N ew Y ork 45

N ew Y ork C it y

, NY 46

47

K e v i n R e i l ly 48

D epa r t m

ent of H o m

e l and S ecu r it y 49v. 1 7



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114 S c i e n ce & T e c hno l o g y 1

2

H il l ary S ad o ff 3

C on t r a ct S upp o rt 4

D epa r t m

ent of H o m

e l and S ecu r it y 5

O ff

i ce o f H e a lt h A ff

a i r s 6

7

P e t e r G

. S ch u l ze 8

D epa r t m

ent of De fen s e 9

U S A r m

y CB R N S chool 10

11

M i c h a e l S ch wa r t z 12

C en t e rs for D i s e ase C o n t r ol and P r e v en ti o n 13

N a ti o n al C en t er for E n v i r o n m en t al H e a lt h 14

15

D a v e S i e g el 16

D epa r t m

ent of H e al t h and H u m an S er v i ces 17

N a ti o n al I

ns t i t u t e o f H e a lth 18

19

T

. M i c ha e l S e l f 20

U S D epar t m ent o f V e t e r an A ff

a i rs 21

V A M e d i c al C en t er

– We s t P a l m B each 22

23

T e r r

i S p e ar 24

D epa r t m

ent of H e al t h and H u m an S er v i ces 25

S ubs t ance A b u se and M en t al H e a l t h S er v i c es A d m i n i s t r a t i on 26

27

Mark S t

. Ma r i e 28

U S D epar t m ent o f V e t e r an A ff

a i rs 29

30

B e t t i na S t o p ford 31

C on t r a ct S upp o rt 32

D epa r t m

ent of H e al t h and H u m an S er v i ces 33

O ff

i ce o f t h e A s s i s t a n t S e cr e t a ry for P rep a

red n ess and R espon s e 34

35

Je r

ry D

. T ho m as 36

C en t e rs for D i s e ase C o n t r ol and P r e v en ti o n 37

N a ti o n al C en t er for E n v i r o n m en t al H e a lt h 38

39

F rank W a lt er 40

C en t e rs for D i s e ase C o n t r ol and P r e v e n ti o n 41

N a ti o n al C en t er for E n v i r o n m en t al H e a lt h 42

43

B ern i ce Z a i d e l 44

D epa r t m

ent of H o m

e l and S ecu r it y 45

F ede r al E m er g ency Mana g e m

ent A g ency 46

47

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115 R epor t i n g S t r u c t u r e 1

T he M a ss H u m an C he m ical D eco n t a m

i na t i on Wor k

i n g G roup rep o r t s t o t he S ub c o m m itt ee on S t an d ar d s

2

CBR N E , u nder t he C o m m itt ee o n H o m

e l and and N a t i o nal S e cu r it y of t he N a t i on a l S c i e n ce a nd 3

T e chn o l o g y C ounc i l wi t h i n t he E x ec u ti v e O f f i c e of t he P re s ide n t

. T h e WG a l so w or k s c l o se l y w i t h t he 4

Wh i t e H o u se Na ti o n al S ec u r i t y S t a f f t h rou g h t h e D o m

es t i c C he m

i cal P r e pa r edn e ss and R es p onse S ub

5

I n t era g ency P o li cy C o m m itt ee. 6v. 1 7



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116 

## Appendix B : Le x i c o n 1

2

G e n eral D e

f i n i ti o n s 3

4

C o n ta m i n a n t : 5

A ny ha z ardous che m i c a l (s o li d, l i qu i d, or g as) t hat i s c apab l e o f ca u s i ng h a rm t o l i fe or he a l t h and fou n d 6

i n t h e a

rea aro u nd t he p e rs o n, i n t er n a l l y , or on t he pe rs on’s b ody or c l o t h es. 7

8

P a t i e n t D e c o n t a m i n a t i o n : 9

A ny process, m e t ho d , or a c ti on t h a

t l ea d s t o a r edu c t i o n, re m o v a l , neu t r a li z a t i on o r i n ac t i v a t i on o f 10

con t a m

i n a ti o n on o r i n t h e pa t i e n t i n or d er t o: pre v ent or m iti g a t e ad v erse he a l t

h e ff e c t s t o t he pa t i e n t ; 11

pro t ect e m

er g ency f i r s t r e s ponde r s, h e a l t h c are f a c i l i t y f i rst r e ce i v e r s and o t h er p a ti e n t s f r om second a

ry 12

con t a m

i n a ti o n; a nd r edu c e t

he po t en t i a l f

or s econ d ary c on t a m

i na t i on o f resp o nse a

nd he a lt h c a

re 13

i n f

ra s t r u c t u re. 14

15

P a t i e n t D e c o n t a m i n a t i on P r i o r i t i z at i o n : 16

A ny m

e t hod used by resp o nders or re c e i v ers i n an e f f ort t o e n su r e t hat pa t i e n t s w ho ha v e a h i g her r e l a ti v e 17

r i sk of con t a m i na t i on o r a r e i n a h i g her m ed i c a l t r i a g e c a t e g ory are deco n t a m i n a t ed ahead of l o w er r i sk 18

pa t i e n t s o r t h ose w it h a l o w er m ed i c a l t r i a g e ca t e g or y

. T h i s m ay be part of t he b r o ader t r i a g e e ff o rt u sed 19

t o d e t e r m

i ne m ed i cal n ee d s

. 20

21

F i r s t R es p o n d er: 22

A n approp r i a t e l y t ra i n ed m e m ber of a respo n se or g an iz a ti on d i sp a t ch e d t o t he i n c i de n t sce n e for p u rpo se s 23

of i n c i d ent m ana g e m e nt 24

• E

xa m p l e s: F i re a nd R e scue ser v i c es; E me rge n cy Me d i cal S er

v i c e s; H A Z M A T T e c hn i c i an; L aw 25

E

n f or c e m e n t o

f f i cer 26

27

F i r s t R ec e i v e r: 28

A n approp r i a t e l y t ra i n ed me m ber of a hosp i t al o r o t h e r hea l t h c a re f a c i l i t y w ho m a y encoun t er a n d w ork 29

w it h c on t a m i na t ed or p o t e n ti a ll y co n t a m i na t ed p a t i en t s from a ha z ardo u s m a t e r i a l s i n c i de n t 30

• E

xa m p l e s: m e m b er o

f ho s p i t al d eco n t a mi na t i on t ea m ; e m erge n cy d epa r t m e n t pe rs onne l ; s ecu r i t

y 31

o

f f i c e r 32

33

P a t i e n t: 34

T he WG i de n t i f i e d t h e t erm pa t i e n t t o re p r e se n t any i n d i v i dual w h o m ay requ i re d e con t a m i n a ti o n. I n t h i s 35

g u i dance docu m en t

, a “ p a t i en t ” i s d e f

i n ed a s: 36

37

A ny i nd i v i dual w ho w as at or n e ar t he l oc at i on o f a h a z ardo u s m a t e r i a l s r e l e ase a n d w ho w as p o t e n t i a l ly 38

expos e d and t h e r e fo r e p o t e n t i a l l y con t a m i n a t ed a nd m ay requ i re s o m e form of ca r e (e. g

., deco n t a m i na t i on, 39

supp o r t i v e m ed i cal ca r e, l i f

esa v i ng i n t er v e n ti o n s, a n t i do t al t h er ap y

, co m m un i ca ti o n and rea s su r anc e ). 40

• N ot a l l p at i e n t s wi l l re q u i re fo l l o w

- on t re a t m ent or e v a l u a ti on at a h e a l t h c a re f a cil it y

. 41

• S o m e pa ti e n t s w i l l l ea v e t h e i n c i d e nt s ce n e p r i or t o re s ponde r s a r r i v i ng ( i .e., s e l f

- e v acua ti o n). 42

• S o m e i nd i v i du a l s, w ho wer e not at o r n e ar t he sc e ne, a re n o t l i k e l y t o ha v e b e en c on t a m

i na t ed, o r 43

m a y not req u i r e any m ed i c a l a s s i s t a n ce, m ay s ti l l p re se nt f o r e v a l u a t i on and t

r e a t m en t up t o and 44

i n c l ud i ng requ e s t i ng deco n t a m i na ti on (S e e G u i d ance S t a t e m ent 1.1). 45

46

This definition does not imply that all decontamination will be conducted by hospital or medical 47

personnel, and does not imply that by conducting decontamination the patient m ust be transported to or 48

evaluated in a healthcare facility. 49

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Spot decontamination: 2

As opposed to decontamination of the entire body, this decontamination te chnique involves the removal 3

of visible contamination from small areas of exposed skin (e.g., h and or po rtion of the arm or leg). This 4

t ech n i q u e m ay be w a t er

- based o r u t i l i z e so m e of t he al t er n a t i v e dec o n t a m i na n t s d i scus s ed i n t h i s g u i d an c e 5

docu m

ent (e. g

., RS D L ®). S pot d e co n t a m i na t i on c an b e pe r for m

ed i n a l l t hr e e t i er s of d eco n t a m i na t i on, 6

and c a n a l so be us e d as an a l t er n a t i v e m e t hod for dec o n t a m

i na t i on. 7

8

P

a t i e n t C a t eg o r i es 9

10

A m bu l a tor y : 11

P a t i en t s w ho can w a l k w it h o ut as s i s t a n ce o r w it h m i n i m al ass i s t a nce, f

o l l o w res p ond e r o r rec e i v er 12

d i r e c t i on s

, and co n du c t c e r t a i n d e con t a m i na t i on t a s k s w it ho u t a s s i s t a nce f rom resp o nd e rs or rec e i v ers 13

(e. g ., re m

o v e c l o t h i n g ). 14

15

S o m

e pa ti e n t s i n t h i s c a t e g ory m a y requ i r e budd y

- he l p or r esp o nd e r / rec e i v er a ss i s t a n ce t o co m p l e t e t he 16

deco n t a m

i na t i on p ro c edu r e. 17

• T h e se p at i e n t s m ay i nc l u d e: m

i no r

- t o

- m odera t e l y w ounded ( e. g

., ocu l a r i n j u r i es

, l ac e r a ti o ns, b r ea k s 18

or s t r a i n s ) ; m e m bers of a t

- r i sk pop u l a t i ons (e. g

., pe d i a t r i c s

, s i g ht an d / o r h e a r i ng i m

pa i re d

, e l d e r l y ) ; 19

and p a t i en t s wi t h m i nor s y m p t o m s. 20

21

N o n

- am b u l a t or y : 22

Mob i l i t y i m pa i red (e. g

. S t

re t ch e r, w hee l ch a i r boun d ) pa t i e n t s. T h i s ca t e g ory of pa t i e n t m a y requ i r e 23

resp o nse p e r sonn e l t o co m p l e t e d e con t a m

i n a t i on a c t i o n s w it h l i m

it ed, i f a n y , ass i s t ance from t he p a t i e n t

. 24

• D econ t a m i na t i on of t h e se pa t

i e n t s i s v ery reso u r c e and t i m e i n t en s i v e and t y p i c a ll y req u i r es 25

spe c i a l i z ed e q u i p m ent ( e. g . ro l l e rs, c he m

ical re s i s t a n t bac k

boar d s). 26

• A dd i t i on a l p e rs o nn e l m ay b e r e q u i red t o d e con t a m i na t e a s i n g l e non

- a m

bu l a t ory p a ti e nt. 27

28

D esc r

i p t o rs o f S c a l e 29

30

I nd i v i du al P a t i e n t D eco n t am i n a t i o n: 31

D econ t a m

i na t i on ac t i v i t i es conduc t ed f or a s i n g l e c o n t a m

i na t ed pa t i e n t

. T h e se ac ti v i t i e s shou l d a l m ost 32

a l w a y s f

a l l w it h i n t he r es o urce and c a pa c it y li m

i t a t i o ns of t he p rop e r l y pr e pa r ed resp o nd i ng or re c e i v i ng 33

or g an i z a t i on. 34

35

M u l t

i

- P a t i e n t D eco n ta mi n at i on ( R e s o u rce S u ff i c i e n t): 36

D econ t a m

i na t i on a c ti v i ti e s condu c t ed for m u l t i p l e co n t a m

i na t ed p a t i en t s i n a s it u a

ti on i n w h i ch r eso u rc e s 37

are n o t li m it i n g

. R eques t s for add it i on a l re s our c es or ass i s t a n ce sho u l d n o t be r equ i red f o r t h i s l e v el o f 38

deco n t a m

i na t i on. T h e nu m

ber o f patients t h a

t co n s ti t u t es m

u lt i

- patient deco n t a m

i na ti on i s d epen d ent on 39

t he j u r i sd i c t i on, resp o n d i ng a g enc y , and s y s t em capac i t y

. 40

41

Mass P a t i e n t D eco n t a m i n at i o n : 42

D econ t a m

i na t i on a c t i v it i es condu c t ed f o r a nu m ber of co n t a m

i n a t ed p a t i e n t s t

h a t exc e eds t he t y p i c al 43

resp o nse c a pa c it y o f an or g an i z a t i on, w h i ch m ay requ i re ad d i t i on a l r e sou r ces or p e rso n nel f rom 44

sur r oun d i ng j u r i sd i c t i ons a nd req u i r e s t h a

t p a ti e n t s b e pr i o ri ti z ed f o r t he d e co n t a

m i na ti on p r oce s s. M a ss 45

deco n t a m

i na t i on g en e r a ll y req u i r e s m uch h i g h e r l e v e l s of r e sou r c e co o rd i n a t i on t han m u lt i

- patient or 46

i nd i v i d u al de c on t a m i na t i on s i t u a

t i ons. T he nu m

ber o f patients t h a

t c on s t i t u t es m ass deco n t a m i na t i on i s 47

depen d ent on t h e j u r i s d i c t i o n, re s pon d i ng a g enc y , and c apa c it y

. 48

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118 T i ers of P a t i e n t D eco n t

a m i n a ti on 1

2

S e l f

- C ar e: 3

A c t i o n s t hat a p a t i ent can p erf o rm for h i m

/ hers e l f, i n c l ud i ng d i s t a n c i ng h i m / he r s el f f r om t he s i t e o f 4

re l ea s e, r e m o v i n g c l o t h i n g , and w i p i ng v i s i b l e co n t a m i na t i on f rom s k i n and c l o t

h i ng i n ord e r t o r e duce 5

h i s / her o w n co n t a m i na t i on l e v el i mm

ed i a t e l y

, w it ho u t w a i t i ng for a f o r m al dec o n t a m

i na ti on pr o ce s s t o be 6

set u p. A p e rce p ti v e p a t i e n t or o ne e xpe r i e n c i ng a c u t e d i s t r e ss from t he c he m i cal con t a m

in a ti o n m ay 7

exec u t e se l f

- care e v en b e f

o re r espo n de r s a

r r i v e; ho w e v er, m

ost p a t i en t s wi l l n eed i ns t r uc t i o n s. 8

9

G ross p a t i e n t d e co n t a m i n at i o n : 10

A c ti o n s l i k e l y t o be pe r f

o r m ed by or w it h t he a s s i s t a n ce of f i r s t r espo n de r s or f

i r s t r e c e i v ers i n or d er t o 11

ach i e v e a g ross o r h a s t y re d uc t i on i n co n t a m

i na t i on, s i g n i f

i c a n t l y redu c i ng con ta m

i n a ti on on s k

i n or 12

c l o t h i n g , as soon as p o s s i b l e a f t er co n t a m

i na t i on h as o ccu r

red. 13

14

T ec hn i c al p a t i e n t d eco n t a m i n a t i o n : 15

P l ann e d and s y s t e m a ti c a c t i ons, l i k e l y t o be pe r f

o r m ed under t he g u i d an c e of, or w it h t he as s i s t a n ce o f 16

f

i r st r e spond e rs or f

i rst r e c e i v ers, t o a c h i e v e c o n t a m i n a t ion re d

uc t i on t o a l e v el t h a t i s as l ow as po s s i b l e. 17v. 1 7



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119 

## Appendix C : G l o s s a ry 1

2

A c u te S t re s s R ea c t i o n 21 : An anxiety disorder precipitated by an experience of intense fear or horror whil e 3

exposed to a traumatic (especially life

- threatening) event. The disorder i s characterized by dissociative 4

symptoms; vivid recollections of the traumatic event; avoidance of stimul i associated with the traumatic 5

event; and a constant state of hyper

- arousal which lasts at least two days an d no longer than four weeks. If 6

symptoms of Acute Stress Diso rder persist for greater than 1 month, a dia gnosis of post

- traumatic stress 7

disorder (stress disorders, post

- traumatic) is more appropriate. (For more informatio n see Bryant 2011, 8

and Diagnostics and Statistics Manual V) 9

10

A t

- R i sk P o pu l a t i o n s 22 : 11

T h o se w ho h a v e nee d s i n o ne or m ore o f t h e f

o l l o w i ng fun c ti o nal a r ea s : co mm un i ca t i on, m

ed i c a l c a r e, 12

m a i n t a i n i ng i nde p end e nce, super v i s i on, and t r ansp o r t a t i on. A t

- r i sk g roups m ay i nc l ude ch i l d r en, s en i or 13

c i t i z ens, a nd p re g nant w o men, as wel l as p eo p l e w ho h a v e d i sa b i l i t i e s, l i v e i n i n s t i t u t i on a li z ed se tt i n g s, are 14

from d i v erse cu l t u res, h a v e li m it ed E n g l i sh p ro f

i c i e ncy or a r e n on

- E n g li sh sp ea k i n g , are t ra n sp o r t a t i o n

15

d i sad v an t a g e d, ha v e chr o n i c m ed i cal d i s ord e rs, o r ha v e ph a r m aco l og i cal d e pen d enc y

. 16

17

A u t h or i ty H a v i n g J u r i s d i ct i o n 23 : 18

T he pu b li c a g ency or i t s d e l e g a t e t h at h as l e g al res p on s i b i l i t y and a u t h o r i t y for re s pond i ng t o an i nc i de n t

, 19

based on p o l i t i cal or g eo g r a ph i c a l (e. g ., c i t y , coun t y

, T r i b a l

, S t a t e, or F ed e ral bou n dary li n e s ) or fun c ti o n al 20

(e. g

., l aw en f or c e m en t , p ub l i c h ea l t h ) r a n g e or sp h e r e of au t ho r it y

. 21

22

C r i s i s a n d E mer g e n cy R i s k C omm u n i c a t i o n 24 : 23

T he e f

fo r t by exp e r t s t o pr ov i de i n f or m a ti on t o a l l ow a

n i n d i v i dua l

, s t a k

eho l d er, o r an e n t i re co m m un it y t o 24

m a k

e t he be s t po s s i b l e d ec i s i o n s ab o ut t h e i r we ll

- be i ng w it h i n n e a r l y i m poss i b l e ti m

e con st ra i n t s and he l p 25

p eo p l e u l t i m a t e l y t o ac cept t he i m perf e ct na t ure of cho i ces d

u r i ng t he c r i s i s. 26

27

E v i d e n c e

- b a s ed g u i d a n c e : 28

A s app l i ed i n t h i s g u i da n ce docu m en t , e v i de n c e

- based re f

ers t o t he con s c i e n t i ous, def i n i ti v e and j u d i c i ou s 29

use o f c u rre n t s c i en t i f i c e v i dence an d

/ or sound t e c hn ic al i nput f r om su b j e c t m a tt e r exp e r t s i n d e v e l o p i ng 30

pa t i e n t de c on t a m i na ti o n r e c o m menda ti ons for t he c a re of p a t i en t s, b o t h i nd i v i d u a ll y and i n a m asscasu a lt y 31

c h e m

i cal i nc i de n t

, i n o r der t o sa v e li v es ( S ac k e t t et a l

., 199 6 ). 32

33

34

21 A cc o r d i n g t o t h e International Classification of Diseases

- 10 (Effective Date: Oct 1, 2014), Acute Stress Reaction is defined as:

A n anxiety disorder precipitated by an experience of intense fear or horror while exposed to a traumatic (especially life

threatening) event. The disorder is characterized b y dissociative symptoms; vivid recollections of the traumatic event;

avoidance of stimuli associated with the traumatic event; and a constant state of hyper

- arousal which lasts at least two days

and no longer than four weeks

. If symptoms of Acute Stress Di s order persist for greater than one month, a diagnosis of post

traumatic stress disorder (stress disorders, post

- traumatic) is more appropriate. (For more information see Bryant 2011, and

Diagnostics and Statistics Manual V)

22 Note that this term is used t hroughout the document and is representative of all similar terms to include: special needs,

vulnerable populations, and access or functional needs. The use of this term is consistent with the Pandemic and All

- Hazards

Preparedness Act of 2006 (PAHPA), Pub . L. No. 109

- 417 (Dec. 19, 2006) This definition can be found on the HHS/ASPR

website at: h tt p :/

/ ww w

. p h e. g ov / P re p are d n e ss/ p l a n n i n g / a b c / P a g e s/ a t r i s k .a s p x

. 23 As defined by the Department of Health and Human Services (HHS) in the PREP Act, Declaration for Pandemic Flu

(2009)

24 Note that this definition is from the CDC’s Crisis and Emergency Risk Communication Manual which can be found at:

h tt p : // ww w

. b t .c d c. go v

/ cerc /

.v. 1 7



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120 

## Appendix D : T ox i c Ch e m ic a l S y nd r o m e Le x ic o n 1

2



### Introdu c ti o n 3

Military and civilian emergency response communities use a “toxic syndrome” (toxidrome) approach to 4

quickly assess victims and determine the best immediate treatment when information on chemical 5

exposures is limited. Toxidromes provide a common language to describe and recognize the clinical 6

manifestations of toxic chemical exposures which can be defined by a unique group of clinical 7

o bservations, such as vital sign abnorm alities, mental status, pupil size, mucous membrane irritation, and 8

lu ng and skin examinations. Once the toxidrome is recognized, emergency responders and hospital first 9

r eceivers can consider a list of chemicals, exposure to which may manifest that toxid rome, as possibly 10

cau sing the incident at hand. The USDHHS National Library of Medicine provides a comprehensive, 11

user

- fr iendly, web

- based resources for first responders and hospital first receivers. Chemical Hazard 12

Emerg ency Medical Management (CHEMM) a nd Wireless Information System for Emergency 13

Responders (WISER) prov ide lists of potential chemical that align with specific toxidromes. 14

15

T he D ep a

r t m ent o f H o m

e l and S ec u r i t y ( DH S ) O f

f i c e o f H e a l th A ff

a i r s ( OHA ), w i t h t h e N a t

i o n al L i b r ary of 16

M ed i c i n e ( N L M ), s p on s ored a t e ch n i c a l w or k shop on May 8

- 9, 2012 t o d i sc u s s and d e v e l op a cons i s t ent 17

l e x i c o n t o de s c ri be t o x i c che m i cal s y ndro m

es or t o x i dr o m

e s 25

. T he g o a l a i m

ed at c ons e nsus on a l i st of 18

s y nd r o m

es, t h e i r d e f

i n i t i ons, and d e s i g na t ed s y ndro m e na m es t o e s t a b l i sh a co m m on l an g ua g e for che m i cal 19

d ef

e nse p l a nne r s, po l i cy m a k

ers, f i r s t r espo nd ers, f

i r s t r e c e i v ers a n d ha za

rdous m a t e r i a l s ( HA Z M A T ) 20

s t a k

eho l de r s. T he s y ndro m

e li s t a i m s t o p ro v i de t h i s co m m on l ex i c o n t o a s s i st k ey s t a k eho l der 21

co m m

un it i es i n qu i c k

l y and a ccu r a t e l y i d e n t i f

y i ng t he b road che m

i cal a g ent c a t e g ory ( i f n o t t he s pe c i f i c 22

c he m

i cal a g ent t y pe i n v o l v ed) by w h i ch a pa t i e n t w as e xpo s ed i n or d e r t o ra p i d l y d e t e r m

i ne appro p r i a t e 23

e m

er g ency t re a t m

en t

. C o m prehen s i v enes s , acc u rac y , and c l ear und e r s t an d i ng of t he l ex i con ser v ed as t h e 24

p r i m ary cr i t e r i a i n de v e l o p i ng t h i s l e x i c o n. 25

26



### Ba c kground 27

T e n s o f t h o usa n ds o f che m i ca l s a r e h a r m ful t o hu m ans and k

no w i ng t he s pe c i f

i c t o x i c e f f ec t s o f e v en a 28

l ar g e p o r t i on o f t he p o ss i b l e che m i c a l a g en t s w ou l d be an i m poss i b l e t a s k

. T o x i c che m i ca l s can o f

t en b e 29

g rouped i n t o c l a ss e s, w he re by a l l t he c h e m i ca l s i n a g i v en c l a s s ca u se s i m il ar t y p e s of a d v erse h e a lth 30

ef

f ec t s. T h e se c on s t e l l a t i o n s of t o x i c e ff e c t s or s y ndr o m

es co m pr i se a s e t o f c li n i c al ‘ ‘ f

i n g er p r i n t s ’’ for 31

g roups o f t o x i ns. Mo r eo v er, a l l t he t o x i c c h e m i ca l s a s soc i a t e d wi t h a g i v en t o x i c s y ndro m e are t re a t ed 32

s i m

il a r l y

. H ence, du r i ng t h e ea r l y p h a s es o f a t ox i c c h e m i cal e m er g enc y

, w hen t h e exa c t c he m i cal i s of t e n 33

un k

no w n, i d en t i f

i c a ti on of t he t o x i c s y ndro m es t hat a r e p r e se n t can be a us e ful d e c i s i on m a k i ng t ool t h a t 34

can o v erco m e m a n y of t he p ro b l e m s asso c i a t ed w i t h t he l ack of i n for m a ti o n o n che m i cal i d e n t it y

. 35

36

T o x i c s y ndro m es are ea s il y i de n t i f

i ed wi t h o n l y a few obser v a t i o n s, s u ch a s : 37

• V i t a l s i g ns 38

• Men t al s t a t u s 39

• P up i l s i z e 40

• Muco u s m e m brane i r r i t a t i o n 41

• L ung exam for w hee z es o r ra l es 42

• S k

i n for b u rn s

, m

o i s t u r e, a nd co l or 43

44

T o x i c s y ndro m e reco g n i t i o n i s i m

por t a n t b e cau s e i t p r o v i des a t o o l f o r r ap i d d e t e c t i on of t he su s pe c t ed 45

cause and can foc u s t h e d i f f ere n t i al d i a g no s i s t o co n s i d er a ti on of o n l y a f ew che m i ca l s w i t h s i m

il ar t o x i c 46

25 Wo r k s h o p a tt e n d ees a g reed t h at t h e t e r m s t o x i c s yn d r o m e a n d t o x i d r o m

e can b e u s ed i n t erc h a n g ea b l y as t o x i d r o m e i s a

c o n t rac ti o n o f “ t o x i c s yn d r o m e.”v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

, 2 01 3

121 ef f ec t s. B y foc u s i ng on c er

t a i n che m i c a l s, spe c i f

i c d i a g nos ti c t e s t i ng and e m p i r i c t he r ap i es can b e rend e red 1

ba s ed on ob

j e c t i v e c l i n i c a l e v i de n ce. S p e c i fi ca l l y , dur i ng a m ass e x pos u re, r eco g n i ti on can pro v i de a t r i a g e 2

t ool for i d e n t i f y i ng t ox i c e f

fe c t s and al so pro v i d e a co mm on ‘‘ l a ng ua g e’’ so t h at a l l pers o nn e l

, f rom 3

e m

er g ency res p ond e rs on t he sc e ne t o t he h o sp i t a l e m er g ency depar t m en t

, c an c l e a r l y co m m

un i ca t e a 4

c l i n i c a l m

essa g e ( F i g u re 1). W i t h t he e x t r a or d i n a ry nu m ber of c h e m

i ca l s i n use, t h i s t o o l does n o t a p p l y t o 5

e v ery ch e m

i cal but t o m

ost o f t h e c o m m

on l y encoun t er e d ch e m

i ca l s r e po r t ed i n HA Z M A T i nc i de n t s. T h e 6

use o f t o x i c s y ndro m es as a d i a g nos t i c t o o l i s f u nda m en t a l t o an e f

f ec t i v e and ti m

e l y m ed i cal r espo n se. 7



### Figure 1: T

oxidr o m e N

a m e s and De s c riptio n s 8

T o x i d rome N a me T o x i d rome De sc r i p t i o n s

T o p i c a l Imm ed i a t e e f f e c t s r an g e f

r o m m i nor i r r i t a t i on t o s e v ere s k i n, e y e, and m

ucos a l

Irr i ta n t / C o r ro s i ve m

e m brane ef f e c t s, w h i ch m ay p ro g ress t o r ap i d s y s t e m i c t ox i c i t y

.

I nh a l a t i on Imm ed i a t e e f f e c t s t o t h e r e s p i r a t o r y

/ pu l m onary t r act p r ese n t i ng as re s p i ra t ory

Irr i ta n t / C o r ro s i ve d i s t r e ss, c ou g h i n g

, w hee z i ng , and / or n as a l a n d o r al se c re t i on s

, w h i c h m ay

pro g ress t o ra p i d s y s t e m

i c t ox i c it y

.

O r a l I n g es t i on Imm ed i a t e e f f e c t s t o t h e o r ophar y nx and g as t r o i n t e s t i n al ( G I ) t r act pr e se n ti ng

Irr i ta n t / C o r ro s i ve as b u rns, n aus e a, v o m iti n g , d i a r rh e a, a n d dr o o l i n g

, w h i ch m ay pro g ress t o

rap i d s y s t e m

i c t ox i c i t y

.

K n oc kd o w n

/ A lt e red s t a t e o f c o ns c i ou s n ess, p ro g re s s i ng f r om fa ti gu e and li g h t h eade d ne s s

A s ph y x i a n ts t o co m a, w it h pos s i b l e s e i z ures and c ar d i ac s i g ns, sec o ndary t o d i s rup t ed

ce l l u l ar o x yg en de li v ery a n d / or u t i l i z a t i on.

A n t i co a g u l a n ts A lt e ra t i on of t he b l ood co a g u l a ti o n t h at re s u l t s i n ab no r m al b l e e d i n g

, i nd i c a t ed by ex c es s i v e br u i s i n g , b l e ed i ng from m ucous m e m branes, a n d

l on g er b l ee d i ng from o t h e r soft t i ss u e t rau m a.

C h o l i n e rg i c Overstimulation of cholinergic receptors leading to first activation and then

fatigue of tar get organs, leading to pinpoint pupils (miosis), seizing, wheezing,

muscle twitching, as well as urination, bronchorrhea, and copious secretions

(tearing, runny nose, salivation) muscle twitching, as well as urination,

bronchorrhea, and copious secretions (tearing, runny nose, salivation)

C e ll u l a r

- A s ph y x i a I nab ilit y t o u se ox yg en, l ea d i ng t o a c u t e

- onset g asp i n g , con v u l s i ons, l o s s of

( C ya n i d e

- l i k e) cons c i ou s ne s s, b r e a t h i ng c e ssa t i on, and car d i a c a r r e s t

.

C o n v u l sa n t C N S d i s i n h i b i t i on o r e xc i t a ti o n ( g l y cine o r GA B A an ta g on i s m

, g l u t a m a te

a g on i s m ) l ea d i ng t o g ene r a l i z ed con v u l s i ons.

O p i o id O p i o i d a g on i sm l ea d i ng t o p i np o i nt pu p il s, and ce n t r a l ner v ous s y s t em ( C N S )

and r es p i r a t ory de p re s s i o n.

S tre s s

- Re s p o n s e/ S t r e ss

- or t o x i ca n t

- i nduced ca t e ch o l a m i ne e x cess or C N S exc i t a ti on l e ad i ng t o

S ym p at h o m i m e t

i c conf

u s i o n , pa n i c, and i nc re ased p u l s e, r es p i r a t i on, a n d b l ood p r e ssu r e.

A n t i c h o li n er g ic U nder

- s ti m u l a t i on o f ch o l i n er g i c r ece p t o rs l ea d i ng t o d i l a t ed pu p i l s ( m y dr i a s i s ) , de c re a sed s we a t i n g , e l e v a t ed t e m per a t u re, and m

en t al s t a t u s

chan g es, i nc l ud i ng ch a

r a c t e r i s t i c h a ll u c i n a t i o n s.

A c u te E x p os u re to D ecr e ased l e v el o f c ons c i o usne s s ( p ro g re s s i ng t o co m a i n s o m e case s ),

S o l ve n ts, A n e st h e t i cs, depr e ss e d r e sp i r a ti o ns, a nd i n so m e ca s es a t a x i a (d i f

f i c u lt y ba l an c i ng and

or S e d a t i v es w a l k i n g ) from acu t e ex p o s ure t o s o l v en t s, i n h a l at i on a l ane s t h e t i cs, o r

sed a ti v e

- h y pno ti c co m

pounds.v. 1 7



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122 

## Appendix E : Le v el o f C o n f idence ( L O C) R a n k in g s 1

2

Pu rpose 3

A for m al pr o ce s s f o r e v a l u a ti ng and sco r i ng t he q u a l i t y and qu a n t it y of e v i d ence t o sub s t a n ti a t e each 4

g u i dance s t a t e m ent w as e st ab l i shed by t he W G

. 5

6

B ackgro un d 7

A L e v el of C o n f i d ence ( L O C ) sc o re for each g u i d an c e s t a t e m ent r e f l e c t s t he W G ’s exp e rt j ud g m ent of t h e 8

s t r en g t h of e v i den c e un d er p i nn i ng t he r eco mm enda ti o n

. T h e L O C i s not a v a l ue j u dg m en t

. T h e L O C i s 9

a l so not a m easure of a

ppr o pr i a t e n ess of a g i v en pra c t i ce: t he c i rcu m s t an c es o f a p ar t i c u l a r che m i c a l 10

i n c i de n t and a f t e r m a t h de te r m

i ne t he p ro p er c ou r se o f ac t i on for suc c es s f u l p a ti e n t de c on t a m

i na ti o n. A 11

reco mm

enda ti on o f L O C I V o r V m ay sa v e li v es e v e r y day e v en i f s t r ong sc i e n t i f ic e v i d e nce t o 12

sub s t a n ti a t e i t i s not a v a il a b l e. R a t h e r, t he L O C r e pr es en t s t he s t ren g t h, b r e ad t h

, q

ua l it y , and q u an t it y of 13

e v i dence ( i nc l ud i ng l i t er a t u re, c u r r ent g u i d an c e and b e st p ra c t i ce d o cu m en t s, a n d su b

j e ct m a t t er exp e rt 14

i np u t ) s upp o r t i ng a pa r t i cu l ar r eco mm

ended prac t i c e. 15

16

R a ti n g S ca l e 17

T h ree m a i n s ou r ces o f k no w l ed g e w ere u sed t o g e t h er t o e s t a b l i sh a r a ti ng s c a l e t h at h e l ps t o d i s t i n g u i sh 18

g u i dance s t a t e m en t s b as e d on t he s t

ren g t h o f t he s upp o r t i ng e v i denc e : pu b l i shed li t e r a t u re, cu r re n t 19

pra c t i ce a n d S ME o p i n i on a nd exp e r i enc e

. 20

21

D ef

i n i t i o n s 22

L i te r at u r e Q u a l i ty

- A pub l i shed a r ti c l e wa s a s s i g ned one of t h e f o ll o w i ng qua l i t y l e v e l s: 23

A = s t

rong c l i n i cal (hu m an or t

r i al d a t a ) o r f

i e l d r es e a r ch sup p o r t s s t ud y ’s c on c l u s i on s ; 24

B = s t

rong ba s i c s c i e nce ( i n v it ro o r i n v i v o m ode l s) r e sea r ch s u ppo r t s s t u d y ’s co n c l u s i o n s; o r an 25

uncon t

r o ll e d s t ud y , f

i e l d r e port of a n a c t u a l r esp o nse, or f i n d i n g s from an e x er c i s e; 26

C = con s ens u s pa n el reco mm enda ti ons w h en n o t b a sed on o r i g i nal r e se a rc h ; or re v i ew of o t h er s t u d i e s, 27

ed i t o r

i a l , or op i n i on pap e r. 28

29

C u rre n t p ra c t i c e

– A s p e c i f i c p r i n c i p l e o r o p er a t i on a l e l e m ent i s c o ns i de r ed c u r r ent p ra c t i ce i f i t i s 30

suppo r t ed i n t w o o r m ore of t h e e i g ht pre v i o u s l y pu b l i shed g u i d a nce o r b e st

- pra ct i ce d ocu m en t s i n c l uded 31

i n t h e c ross w a l k an a l y s i s ( f or m ore i n for m a ti o n, s e e M e t hod o l o g y sec t i on). 32

33

S ME C o n se n s u s

- D ef i ned as a g roup de c i s i on

- m a k i n g process t h a t s ee k s t h e co n sen t

, not ne c ess a r i l y t he 34

a g ree m

en t , of p a r ti c i p a n t s a nd t he r e so l u t i on o f o b j e c t i ons. F o r t h e 2012 S y m pos i u m , consensus wa s 35

ach i e v ed t h rou g h one o f t h e fo l l o w i ng r e su l t s : 36

a. S t

rong co n sen s us

– T w o

- t h i rds or m ore o f t h e p a

r t i c i p a t i ng re v i e w ers a l l v o t e, i n w r i t i n g

, in 37

suppo r t o f t h e p a r t i c u l a r g u i dance s t a t e m

en t ; 38

b. S i m p l e con s ens u s

- 50% or m ore of t he pa rt i c i pa t i ng r e v i e w ers a l l v o t e, i n w r i t i n g

, i n s u ppo r t o f 39

t he p a r ti c u l a r g u i da n ce s t at e m

ent. 40

41

L O C R a ti n gs D e f i n i ti o n s 42

L O C I

- T he h i g he s t r e co mm enda ti on i s s uppo r t ed by s t r o ng sc i e n t i f i c e v i d e nce, i nc l u d i ng c l i n i cal or f i e l d 43

res e a r ch, i n ad d i t i on t o c u r r ent p ra c t i ce a nd S ME con se nsus. 44



### a

. S ubs t an t i a t ed by s t rong s ci en t i f

i c li t e r a t u re ( i n c l u d i ng at l ea s t o n e L e v el A a r t i c l e )

, 45



### b. C urre n t p ra c t i ce, 46



### c

. S t rong S ME c ons e nsu s

. 47v. 1 7



### DRAFT/FOR PUBLIC COMMENT 2 1 F ebruary 2014

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123 L O C I I

- T he s econd t i er r e co m m enda ti on i s supp o r t ed by so m e sc i en t i f i c e v i d en c e w h i ch i s not d e f in it i v e 1

or w he r e m

e t hod o l o g i c a l p r ob l e m s li m i t t he u t il it y of t

he s t a t ed co n c l u s i o ns, b u t w h i ch i s c u r r ent pr a c t i ce 2

and f

o r w h i ch t he r e i s s t

ro n g S ME conse n sus. 3

a. S ubs t an t i a t ed by a de q ua t e s c i e n t i f i c l i t er a t u re ( > t h r e e L e v el B a r ti c l e s), 4

b. C urre n t p ra c t i ce, 5

c. S t

rong S ME c ons e nsu s

. 6

7

L O C II I

– T he t h i rd ti e r r e c o m menda ti on i s o n e f o r w h i ch v ery li m

it e d s c i e n t i f

i c li t e r a t u re i s i nf

o r m a t i v e, 8

but f

or w h i ch t h e re i s p re ce dent i n c u r r ent pr a c t i ce and for w h i ch t h e re i s m a j o r it y S ME co n sen s us. 9

a. S ubs t an t i a t ed by l i m it ed s c i en t i f

i c li t e r a t u re (at l e a s t o n e L e v el B a r t i c l e), 10

b. C urre n t p ra c t i ce, 11

c. A t l e ast m a j o r i t y S ME co n s ensus. 12

13

L O C I

V

- T he fou r t h t i er r e co m m enda ti on i s supp o r t ed by at l e ast m a j o r i t y S ME c onsen s us a n d c u rr e nt 14

pra c t i ce b u t li t t l e o r no s c ie n t i f i c l i t er a t u r e. 15

a. S ubs t an t i a t ed by v ery li m i t ed s c i e n t i f

i c l i t er a t u r e ( no L e v el A or L e v el B e v i den c e supp o rt t he 16

s t a t e m en t ), 17

b. C urre n t p ra c t i ce, 18

c. A t l e ast m a j o r i t y S ME co n s en sus. 19

20

L O C V

- T he f i f t h ti e r r e f l e c t s an a b sen c e of l it e r a t u r e and p r ece d en t ; S ME co n s e nsus for m s t he so l e b a s i s 21

for t he re c o m m enda ti on. 22

a. N o L e v el A

, B , or C a r t i c l e s, 23

b. N ot a c u r r ent pr a c t i ce, 24

c. A t l e ast m a j o r i t y S ME co n s ensus. 25

26

T he WG c o n t e nds t h a t t o v ar y i ng de g rees, a dd i ti o nal p r i m ary rese a rch (b a s i c, e p i d e m

i o l o g i ca l

, c l i n i c a l 27

t r i al or o b s e r v a ti o n a l ) i s n e eded for a l l of t he pr e se n t g u i da n ce s t a t e m en t s. A d d i ti onal s t udy co u l d v a li d a t e 28

a p a r

t i cu l ar reco mm

enda ti on, and i t s L O C m

i g ht t he r ef

o re r i se. A d d i t i o n al r es e ar c h m ay a l so l ead t o t he 29

con c l u s i on t h a t a pa r t i cu l ar p r a c t i ce i s n ot s c i e n t i f i c a ll y supp o r t ed, i n w h i ch c ase i t s L O C w ou l d f a l l and 30

t h e r e co mm enda t i on w o u l d b e r eco n s i d ered. T he L O C s c ore r e f l e c t s t he c u r r ent s t a t e of e v i dence on 31

w h i ch a g u i d a n ce s t a t e m ent i s ba s ed. A ny g u i dance s t a t e m ent i n t h i s d ocu m

ent m ay be a m

ended as 32

s c i e nce l e a ds t o be t t e r und e r s t an d i ng of t h e be s t p r a c ti c es for m ass p a ti e nt c he m

i cal deco n t a m

i na t i on. 33