DRAFT/FOR PUBLIC COMMENT

1

2

 i

Patient Decontamination in a

Mass Chemical Exposure 

Incident:

National Planning Guidance 

for Communities

DRAFT / 

FOR PUBLIC 

COMMENT
DRAFT/FOR PUBLIC COMMENT

1

1 Federal Points of Contact

2

3 Susan M. Cibulsky, PhD

4 Medical Countermeasure Strategy & Requirements Division

5 Office of Policy & Planning

6 Office of the Assistant Secretary for Preparedness & Response

7 US Department of Health and Human Services

8 susan.cibulsky@hhs.gov

9

10 Mark A. Kirk, MD

11 Program Director, Chemical Defense

12 Health Threats Resilience Division, Office of Health Affairs

13 US Department of Homeland Security

14 mark.kirk@hq.dhs.gov

15

16 Primary Authors

17

18 Susan M. Cibulsky, PhD

19 Medical Countermeasure Strategy & Requirements Division

20 Office of Policy & Planning

21 Office of the Assistant Secretary for Preparedness & Response

22 US Department of Health and Human Services

23

24 Mark A. Kirk, MD

25 Program Director, Chemical Defense

26 Health Threats Resilience Division, Office of Health Affairs

27 US Department of Homeland Security

28

29 Joselito S. Ignacio, MA, MPH, CIH, CSP, REHS

30 Captain, US Public Health Service

31 Deputy Program Director, Chemical Defense

32 Health Threats Resilience Division, Office of Health Affairs

33 US Department of Homeland Security

34

35 Adam D. Leary, MA, MS

36 Medical Countermeasure Strategy & Requirements Division

37 Office of Policy & Planning

38 Office of the Assistant Secretary for Preparedness & Response

39 US Department of Health and Human Services

40

41 Michael D. Schwartz, MD

42 Commander, US Public Health Service

43 Office of Environmental Health Emergencies

44 National Center for Environmental Health

45 Centers for Disease Control and Prevention

46 US Department of Health and Human Services
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1 Executive Summary

2

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

4 and the guidance revised and finalized.

5

6 Introduction

7 Each day, substantial quantities of hazardous chemicals are produced, transported, stored, and used for

8 industrial or household purposes. Stockpiles of chemical weapons around the world, while currently

9 being destroyed, still exist. Various terrorist organizations and non-state actors have shown interest in

10 procuring or developing and using chemicals in terrorist attacks. In each instance, these chemicals pose

11 significant risk to public health due to the potential for accidental or intentional release that could harm

12 large numbers of people. Civilian first responders (e.g., fire, HAZMAT, and emergency medical service

13 responders) and health care first receivers (e.g., health care facility-based and other clinical personnel),

14 along with emergency managers, public health practitioners, law enforcement officials, and risk

15 communication experts, must be prepared to respond to such incidents.

16

17 The potential for a large-scale chemical release resulting in the need to decontaminate an overwhelming

18 number of people has garnered wide interest among policy makers and emergency planners. Guidance

19 and best-practice documents have been published and specialized equipment has been purchased.

20 However, decontamination practices have evolved based on sparse evidence. Limited research has been 

21 conducted on decontaminating civilians. Patient decontamination, like other aspects of disaster response, 

22 medicine, and public health, could benefit from an assessment of the body of evidence, enhance 

23 incorporation of the evidence into planning and practice, and additional study to generate needed

24 evidence. Furthermore, many current guidance and best-practice documents do not address the full

25 spectrum of issues that a community may face when large-scale patient decontamination is necessary in a 

26 mass chemical exposure incident.

27

28 The need for examination of current patient decontamination practices was identified by experts in the

29 emergency response and medical communities. The White House National Security Staff followed with a

30 request for an evidence-based national planning guidance for mass patient decontamination in a large31 scale chemical release. Efforts to enhance preparedness for patient decontamination in a mass exposure

32 incident may also benefit the care that is provided to individual contaminated patients in other

33 circumstances.

34

35 Audience, Scope, and Intent

36 The intended audience includes senior leaders, planners, incident commanders, emergency management

37 personnel, and trainers of local response organizations and health care facilities. Though the guidance

38 was developed with this specific audience in mind, it may be of value to other audiences, including first

39 responders and first receivers, community leaders, scientists, and researchers, as well as others from the

40 response and emergency management fields. A basic assumption of this document is that mass patient

41 decontamination takes place at the level of the local affected community. Due to the need for chemically42 contaminated patients to be decontaminated as soon as possible, the federal government will likely not be 

43 able to participate directly in the response immediately following the release. Therefore, this guidance is 

44 directed primarily at local officials.

45

46 The subject matter considered here is limited to external contamination of living people (henceforth 

47 defined as patients; see Lexicon, p. 114) with toxic industrial chemicals, toxic industrial materials, or

48 chemical warfare agents in a mass casualty incident resulting from an accidental or intentional release. 

49 This guidance attempts to address the full spectrum of the decontamination response operation, from

50 initial assessment and decision-making through evaluation of decontamination effectiveness. Further, the

51 entire affected community is considered, with emphasis on coordination between on-scene and health care
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1 facility-based response activities and communication on multiple levels.

2

3 Patient decontamination principles are set forth here from a strategic perspective, rather than a tactical

4 one. The principles are meant to guide, but not specify, operational practices. The guidance is evidence5 based to the extent possible and the supporting evidence is documented and briefly discussed.

6

7 The approach in this guidance is flexible and scalable according to the resource and capability

8 limitations of the organization. The recommendations should be adapted as each unique community

9 sees fit.

10

11 Examples of how the guidance might be used include:

12 • Planners: incorporate current evidence-based recommendations during development or revision of

13 an organization’s response plans.

14 • Community leaders, public health officials: enhance system-wide coordination and develop plans

15 for communicating with patients and the whole community.

16 • Trainers: develop, improve or augment training of response personnel for patient decontamination

17 operations, using current evidence-based recommendations.

18 • Emergency managers: generate policy and plans to address issues related to system-wide

19 coordination, the whole community response, and crisis and risk communications, as well as other

20 overarching issues.

21 • Researchers: identify knowledge gaps and conduct research to investigate them.

22

23 Guidance Statement (GS) Format and Quick Reference Guide

24

25 In Section III, each of the guidance statements is described in full along with associated information in the

26 following format:

27 Functional Area Identifies one of the six functional areas represented.

28

29 Guidance Statement Full text of the guidance statement.

30

31 Considerations Additional factors that should be considered when implementing

32 the guidance statement.

33

34 LOC Level of Confidence rating (described in Appendix E) for the

35 evidence on which the GS is based.

36

37 Discussion Briefly describes the evidence applicable to the guidance statement, 

38 from reviews of the scientific literature, current practices, and

39 subject matter expert opinion and experience.

40
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GS # Guidance Statement Page #

Functional Area 1: Determining the Need for Patient Decontamination

1.1 Indicators to assist in the decision to decontaminate 18

1.2 Decontamination should be performed if there is a reasonable risk of exposure to first responders/receivers

or contamination of critical infrastructure

21

1.3 Likelihood of adverse consequences of gross or technical water-based decontamination 23

Functional Area 2: Optimized Technical Practices

2.1 Use risk-based approach to determine the appropriate response level and associated strategies and tactics 25

2.2 The tiered response approach to patient decontamination 26

2.3 Self-care and/or gross patient decontamination actions should occur as quickly as possible, without delay,

while a technical patient decontamination corridor is established

29

2.4 Attempt to immediately decrease ongoing exposure by removing all patients out of the area of release and

provide an area of refuge

31

2.5 Clothing removal for patients who have been visibly contaminated 33

2.6 Privacy for patients 35

2.7 Water is the preferred decontaminant 37

2.8 Technical parameters for water-based decontamination 40

2.9 Use of mild soap 43

2.10 The use of a non-abrasive sponge or washcloth 45

2.11 Alternative practices or decontaminants 47

Functional Area 3: Evaluating the Effectiveness of Decontamination

3.1 Indicators to help determine whether contamination has been reduced to a level where additional

decontamination is not necessary

50

3.2 Rapid pace must be balanced with quality and consistency of patient care 52

Functional Area 4: Patient Prioritization for Medical Care and Decontamination

4.1 Immediate, lifesaving medical care and/or antidotal therapy should not be delayed by patient

decontamination, as resources allow

53

4.2 Prioritize patients for decontamination by estimating relative risk and grouping patients into immediate and

delayed decontamination groups

55

Functional Area 5: System-wide Coordination of Patient Decontamination

5.1 Decontamination should be performed as soon as possible, preferably at the scene if safety considerations

permit

58

5.2 Develop a coordinated whole community response plan to manage the entire spectrum of patients to address

patients self-evacuating from the scene

60

5.3 Responding and receiving organizations should plan for both ambulatory and non-ambulatory patients

simultaneously

62

5.4 At-risk populations require additional assistance and special tactics 63

5.5 A formal rapid communication procedure should be utilized to provide advance notice to area health care

facilities

66

5.6 Notification, by visual, written, or verbal means should be used to record scene decontamination practices 68

5.7 Considerations for PPE selection, training, and use 70

5.8 Waste management, facility safety and environmental impact issues 72

Functional Area 6: Crisis and Emergency Risk Communication

6.1 Incorporating crisis and emergency risk communication into all stages of disaster management 74

6.2 Develop a strategic communications plan for delivering various types of messages during an incident.

Prepare as much material in advance as possible

77

6.3 A strategic plan for pre-event communication to enhance community preparedness should be developed to

include information about patient decontamination

81

6.4 Incorporate effective two-way communication during and after an incident 83
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Acronym Description

ACGIH American Conference of Governmental Industrial Hygienists

ASL American Sign Language

ASPR Office of the Assistant Secretary for Preparedness and Response, Department of Health and

Human Services

ASTM American Standards of Testing and Materials

ATSDR Agency for Toxic Substances and Disease Registry, Department of Health and Human

Services

CAL-OES California, Office of Emergency Services

CBRN Chemical, Biological, Radiological, and Nuclear

CDC Centers for Disease Control and Prevention, Department of Health and Human Services

CERCLA Comprehensive Environmental Response, Compensation, and Liability Act

CHEMM-IST Chemical Hazard Emergency Medical Management – Intelligent Syndromes Tool

CHEMTREC Chemical Transportation Emergency Center

CMAS Commercial Mobile Alert System

CONOPS Concept of Operations

CPR Cardiopulmonary Resuscitation

CWAs Chemical Warfare Agents

DHS Department of Homeland Security

DOD Department of Defense

DOT Department of Transportation

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

ECBC Edgewood Chemical Biological Center, Department of the Army

ED Emergency Department

EMS Emergency Medical Services

EPA Environmental Protection Agency

FDA Food and Drug Administration, Department of Health and Human Services

FEMA Federal Emergency Management Agency

FOSC Federal On-Scene Coordinator

GS Guidance Statement

HAZMAT Hazardous Materials

HAZWOPER Hazardous Waste Operations and Emergency Response

HCF Hospital Care Facility

HHS Department of Health and Human Services

HIV Human Immunodeficiency Virus

IAW In Accordance With

ICS Incident Command System

ICU Intensive Care Unit

ID Identification

IOM Institute of Medicine

IPAWS Integrated Public Alert Warning System (FEMA)

LD50 Lethal Dose for 50% of the population

LEPC Local Emergency Planning Committee

LOC Level of Confidence

LRN-C Laboratory Response Network - Chemical

LT50 Lethal Time for 50% of the population

MIST Man-In-Simulant Test

MSDS Material Safety Data Sheet

NFPA National Fire Protection Association

NIMS National Incident Management System
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NIOSH National Institute for Occupational Safety and Health, Centers for Disease Control and

Prevention, Department of Health and Human Services

NRF National Response Framework

OHA Office of Health Affairs, Department of Homeland Security

ORCHIDS Optimization through Research of Chemical Incident Decontamination Systems

OSHA Occupational Safety and Health Administration, Department of Labor

PEG Polyethylene glycol

PHMSA Pipeline and Hazardous Materials Safety Administration

PIO Public Information Officer

PPE Personal Protective Equipment

RSDL® Reactive Skin Decontamination Lotion®

SARA Superfund Amendments and Reauthorization Act (EPA)

SARS Severe Acute Respiratory Syndrome

SDS Safety Data Sheet

SME Subject Matter Expert

SOP Standard Operating Procedure

START Simple Triage & Rapid Treatment/Transport

TIC Toxic Industrial Chemical

TIM Toxic Industrial Material

TLV Threshold Limit Value

TRANSCAER Transportation Community Awareness and Emergency Response

TSWG Technical Support Working Group, Department of Defense

WISER Wireless Information System for Emergency Responders

UK United Kingdom

US United States

VX VX nerve agent

WG Working Group

WHO World Health Organization

WMD Weapon of Mass Destruction
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1 Table of Contents

2

3 Executive Summary............................................................................................................2

4 Acronyms List ..........................................................................................................5

5 Table of Contents.....................................................................................................6

6 I. Introduction .............................................................................................................. 7

7 Purpose............................................................................................................................................ 7

8 How this work is unique .......................................................................................................................8

9 Audience and intent...............................................................................................................................8

10 Scope ............................................................................................................................................... 8

11 Methodology.......................................................................................................................................... 9

12 Rating the evidence ....................................................................................................................... 11

13 Future plans................................................................................................................................... 12

14 II. Guiding principles .............................................................................................13

15 Defining patient and patient decontamination............................................................................... 13

16 Patient decontamination is a medical countermeasure .................................................................. 13

17 Desired end points for patient decontamination ............................................................................ 14

18 Patient decontamination is a whole community issue ................................................................... 15

19 Tiered risk-based response approach............................................................................................. 16

20 Practices in mass casualty incidents.............................................................................................. 17

21 III. Guidance Statements........................................................................................18

22 Functional Area 1: Determining the Need for Patient Decontamination....................................... 18

23 Functional Area 2: Optimized Technical Practices ....................................................................... 25

24 Functional Area 3: Evaluating the Effectiveness of Decontamination .......................................... 50

25 Functional Area 4: Patient Prioritization for Medical Care and Decontamination......................... 53

26 Functional Area 5: System-wide Coordination of Patient Decontamination................................. 58

27 Functional Area 6: Crisis and Emergency Risk Communication .................................................. 74

28 Bibliography...........................................................................................................85

29 Appendix A: Working Group Charter and Membership .....................................102

30 Appendix B: Lexicon ..........................................................................................114

31 Appendix C: Glossary .........................................................................................117

32 Appendix D: Toxic Chemical Syndrome Lexicon ..............................................118

33 Appendix E: Level of Confidence (LOC) Rankings ...........................................120
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1 I.Introduction

2

3 Purpose

4 Whether as a result of an accidental release at a chemical plant, a transportation accident, or an intentional

5 military or terrorist action, the threat of exposure of the public to hazardous chemicals is real. An

6 accidental gas leak at the Union Carbide chemical plant in Bhopol, India, resulted in the release of

7 methyl isocyanate into the environment exposing thousands (Zaidi, 1986). The Iraqi military used 

8 chemical warfare agents (CWAs) against Iran and Iraqi Kurds (Ghanei et al., 2010; Darchini9 Maragheh et al., 2012). Aum Shinrikyo, a religious cult, produced and released sarin, a nerve 

10 agent previously possessed only by nations, on multiple subway cars in Tokyo, Japan (Okumura et

11 al., 1996). In Graniteville, South Carolina, a rail car accident resulted in the release of chlorine gas

12 in a populated area (Duncan et al., 2011). In each of these cases, significant numbers of people

13 were killed or sickened.

14

15 Each day, large quantities of hazardous chemicals are produced, transported, stored, and used for

16 industrial and household purposes. During each of these activities, there is risk that the chemicals could

17 be released into the environment due to an accident or intentional act to cause harm. Stockpiles of

18 chemical weapons around the world, while currently being destroyed, still exist. Additionally, various

19 terrorist organizations and individuals have indicated interest in developing and using chemicals as

weapons. Moreover, chemical suicide

1

20 , both abroad and in the United States (US), is a troubling recent

21 trend affecting not only the patients but also creating risk for the first responders and first receivers

22 rendering assistance. Civilian first responders and health care first receivers, along with emergency

23 managers, public health practitioners, law enforcement officials, and risk communications experts must

24 be prepared to respond to incidents involving the release of chemical agents.

25

26 The threat of a chemical release carries with it the possibility that workers, bystanders, or others may

27 become contaminated. These contaminated individuals (i.e., patients) require assessment for

28 decontamination needs and then potentially, decontamination at the scene of the incident and/or at a

29 health care facility. In recent years, the potential for a large-scale chemical release requiring

30 decontamination of an overwhelming number of people has attracted increased interest. In response,

31 methods and procedures for civilian mass patient decontamination have been developed largely through

32 extrapolating techniques used on hazardous waste site personnel and hazardous materials responders in

33 personal protective equipment (PPE) (NIOSH, 1985) and military personnel in protective gear (DOD FM

34 3-11.5, 2006). Information sharing among fire and emergency services, hazardous material response,

35 medical, and Department of Defense (DOD) chemical, biological, radiological and nuclear (CBRN)

36 defense communities improved these practices. Decontamination practices evolved rapidly and industry

37 responded with customized equipment but not necessarily with the benefit of evidence to guide such

38 efforts (Levitin et al., 2003; Stopford et al., 2005). Limited research has been conducted on

39 decontaminating people and much of what has been done is based on the military perspective:

40 decontaminating trained professional service members with the end goal being to return them to the

41 operational environment so that they can continue a mission.

42

43 Mass patient decontamination, like other aspects of disaster response, medicine, and public health, could 

44 benefit from an assessment of the body of evidence, enhanced incorporation of the evidence into planning

45 and practice, and additional study to generate needed evidence (IOM, 1999; Levitin et al., 2003; Stopford

46 et al., 2005; Auf der Heide, 2006). Various organizations have published guidance and best-practice

47 documents but these generally do not categorize recommendations as evidence-based or not, nor do they

48 describe the pertinent evidence. Furthermore, many current guidance and best-practice documents do not

 

1

Chemical suicides (also dubbed “detergent suicides” by the media) are specific acts carried out by the patient through the

mixing of household chemicals to produce toxic chemical
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1 address the full spectrum of issues, such as coordination and communication, which a community may

2 face when patient decontamination is necessary in a mass chemical exposure incident.

3

4 The need for examination of patient decontamination practices was identified by experts in the emergency

5 response and medical communities. The US Government followed with a request for an evidence-based

6 national planning guidance for mass patient decontamination in a large-scale chemical release. Efforts to

7 enhance preparedness for patient decontamination in a mass exposure incident may also help to improve

8 the care that is provided to individual contaminated patients in other circumstances.

9

10 How this work is unique

11 “Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for

12 Communities” differs from previous planning, guidance, and best-practice documents in two significant

13 ways:

14 1. The guidance is evidence-based to the extent possible and that evidence, or lack thereof, is

15 documented and briefly discussed. As applied in this guidance document, “evidence-based” refers 

16 to the conscientious, definitive, and judicious use of current scientific evidence and/or sound 

17 technical input from subject matter experts in developing patient decontamination

18 recommendations for the care of patients, both individually and in a mass casualty chemical

19 incident, in order to save lives (Sackett et al., 1996).

20 2. This document attempts to address the full spectrum of an incident, from initial assessment and

21 decision-making through evaluation of decontamination effectiveness. Further, a comprehensive

22 approach is taken to the entire affected community with emphasis on coordination between on23 scene and health care facility-based response activities and communication on multiple levels.

24

25 Audience and intent

26 The main intended audience includes senior leaders, incident commanders, planners, and trainers for

27 emergency response organizations and health care facilities, as well as emergency managers and military

28 personnel supporting domestic responses. Though the guidance was developed with this specific audience

29 in mind, it may be of value to other audiences, including first responders, first receivers, and leaders of

30 public health organizations.

31 The guidance sets forth patient decontamination principles from a strategic standpoint, rather than a

32 tactical one. It is meant to guide, but not specify, operational practices. The approach is flexible and

33 scalable according to the resources and capability limitations of planning and response organizations in a

34 community. The guidance statements comply with the National Response Framework (NRF) and do not

35 promote any additions or changes to the National Incident Management System (NIMS) or the Incident

36 Command System (ICS).

37

38 Scope

39 The subject matter considered here is limited to external contamination of patients in a mass casualty

40 incident resulting from an accidental or intentional chemical release. Contamination of patients with

41 chemicals, including toxic industrial chemicals, toxic industrial materials, and chemical warfare agents, is

42 the present focus. Radiological materials and biological agents also pose important risks. Many of the

43 concepts presented here may apply to those agents; in future work, this guidance can be built upon to 

44 address radiological and biological agents. While this guidance is aimed at mass casualty chemical

incidents, the recommendations and principles may be applied to individual patients or multi-patient

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 Multi-Patient 

decontamination indicates a large scale incident that requires mutual aid from neighboring jurisdictions; this may also 

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

patients versus 500.
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1 incidents as well. 

2

3 Methodology

4 A federal interagency expert working group, the Mass Human Chemical Decontamination Working Group 

5 (WG), developed this national planning guidance with the advice of a larger group of federal and non6 federal subject matter experts in emergency response, emergency medicine, toxicology, risk

7 communication, behavioral health, and other relevant fields. The WG was established at the request of the

8 White House National Security Staff and co-chaired by the Department of Health and Human Services

9 (HHS), Office of the Assistant Secretary for Preparedness and Response (ASPR) and the Department of

10 Homeland Security (DHS), Office of Health Affairs (OHA).

11

12 In order to define the problem, core questions considered essential to performing patient decontamination

13 and most likely to influence on-scene and health care facility approaches were identified. Core questions

14 and their sub-questions naturally fell into three categories, which follow a logical response progression:

15 1. risk assessment and decision making

16 2. decontamination process and procedure

17 3. evaluation of results and patient follow-up

18

19 Core questions were further divided so that the three categories were each applied to two distinct

20 situations: individual patient decontamination, in which one to a few potentially contaminated patients

21 present for assessment and local resources are not overwhelmed; and mass patient decontamination,

22 when a mass casualty incident results in numerous potentially contaminated patients and local response

23 capabilities may be overwhelmed. These two circumstances allowed the WG to separately consider: (1)

24 questions pertinent to an incident in which significant resources and attention can be brought to bear on a

25 single patient or small number of patients and therefore, optimal methods can be assumed; and (2)

26 questions unique to a mass casualty situation, when patient needs are likely to exceed available resources

27 and thus prioritization will be necessary and crisis standards of care will need to be considered. See Table

28 2 for the core questions and their organization.

29

30 An extensive search of the published literature for answers to the resulting six core questions was

31 conducted. The following databases were searched, although this is not an exhaustive list: PubMed,

32 SCOPUS, Web of Science, and Google Scholar. Additional searches were conducted through the

33 National Institutes of Health’s National Library of Medicine. Initial search terms were limited to: human;

34 chemical; decontamination. Additional search terms were topic dependent. Examples include:

35 • triage; assessment; decision to decontaminate

36 • risk communication; emergency communication; crowd behavior; disaster crowd management

37 • hospital preparedness; health care facility response

38 • detection capabilities; portalsensortechnology

39 • effectiveness criteria; determination of clean

40

41 Only articles in English were evaluated and no limits were placed on the publication date. Once an initial

42 search was completed, the references sections of reviewed articles were used as sources of additional 

43 material for evaluation. Throughout this process the WG has sought the assistance of subject matter

44 experts in identifying additional references, unpublished data, and ongoing studies.

45

46 The literature review results were summarized and presented, along with the core questions and sub

47 questions, to a group of emergency responders, emergency medicine clinicians, toxicologists, researchers,

 
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and other relevant experts at the Symposium on Chemical Decontamination of Humans 2010

3

1 hosted by

2 the Department of Homeland Security (see list of participants in Appendix A). Symposium participants

3 helped to identify additional sources of evidence, refine the summaries of the evidence, and initiated lists

4 of knowledge gaps or research needs for each core question.

5

6 With strong summaries of the available evidence, as well as the important knowledge gaps identified, an

7 initial draft guidance was created. The guidance follows the path set by the core questions, which define

8 the essential information needed to conduct patient decontamination. For the guidance, each core

9 question has been converted to a functional area (see Table 2). Each distinct principle is described as a

10 guidance statement, with associated considerations if applicable. Guidance statements are based on

11 published evidence if available, and have been additionally shaped by other guidance and best practice

12 documents, expert opinion, and experience.

13

 

3

The Symposium on Chemical Decontamination of Humans was held in Washington, DC on December 6-7, 2010. The

symposium was co-sponsored by DHS/OHA and HHS/ASPR. The final summary can be found at:

http://www.phe.gov/Preparedness/mcm/Documents/summary-chemdecon-20June12.pdf
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1 Table 2: Key Elements of Patient Decontamination

2

Core Question Stage of Response Functional 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 

decontamination 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 techniques can be used for 

assessment and triage of patients (both at

the scene and at health care facilities) to 

prioritize decontamination and medical 

treatment?

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

4 As evidence of current practice, the WG performed an analysis of six current guidance or best practice

5 documents for recommendations that address one of the six core questions. The following documents 

6 were included in the analysis:

7

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

9 Registry (ATSDR). (2000)Managing hazardous materials incidents – Vol. I (EMS) and Vol. II

10 (Hospital Emergency Departments)

11 Agency for Toxic Substances and Disease Registry (ATSDR)

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

13 Center (ECBC) and CBRN School. (2009)Guidelines for mass casualty decontamination during a

14 HAZMAT/Weapon of Mass Destruction Incident (Vol. I and II)

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

16 (2005)Best practices for hospital-based first receivers of patients from mass casualty incidents

17 involving

18 the release of hazardous substances

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

20 (2005)Best practices for protecting EMS responders during treatment and transport of patients of

21 hazardous substances releases

22 • California Governor’s Office of Emergency Services (OES). (2006)Multi-casualty mass
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1 decontamination guidance document for first responders

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

Best practices and guidelines for CBR mass personnel decontamination 2

nd 3 edition.

4

5 The initial draft guidance statements, their considerations, and the supporting evidence were presented to

a group of subject matter experts at the Mass Human Chemical Decontamination 2012 Symposium

4

6

7 hosted by the Department of Homeland Security (see list of participants in Appendix A). Participants

8 reviewed, discussed, suggested revisions, and voted their approval or rejection of each guidance

9 statement. The evidence to substantiate each guidance statement was also reviewed. Following the

10 symposium, guidance statements were significantly revised, the supporting evidence was summarized,

11 and a level of confidence (LOC) (see Rating the evidence section below and Appendix E) – which

12 reflects the amount and quality of evidence supporting a recommendation - was assigned to each guidance

13 statement. In addition, extensive stakeholder review of this guidance document has been conducted,

14 including through professional societies and publication in the Federal Register for public comment, 

15 before finalization and distribution to the target audience.

16

17 The WG also developed a lexicon for civilian patient decontamination, as a step toward standardizing the

18 terms used across varied organizations (included as Appendix B).

19

20 Rating the evidence

21 A Level of Confidence (LOC) score is assigned to each guidance statement. This confidence rating (based 

22 on a five point scale) gives the reader a sense of the strength of evidence substantiating a particular

23 guidance statement. The following list provides a synopsis of the LOC scale (additional information can

24 be found in Appendix E)

25  LOC I – The highest recommendation is supported by strong scientific evidence, including clinical 

26 or field research, in addition to current practice and strong SME consensus.

27

28  LOC II – The second tier recommendation is supported by some scientific evidence which is not

29 definitive or where methodological problems limit the utility of the stated conclusions; current

30 practice and strong SME consensus also substantiate the recommendation.

31

32  LOC III – The third tier recommendation is one for which very limited scientific literature is

33 informative, but for which there is precedent in current practice and for which there is majority

34 SME consensus.

35

36  LOC IV – The fourth tier recommendation is supported by at least majority consensus and current

37 practice but little or no scientific literature.

38

39  LOC V - The fifth tier reflects an absence of literature and precedent; SME consensus forms the

40 sole basis for the recommendation.

41

42 Since this is designed to be a living document, LOC scores may change in future versions when new 

43 evidence becomes available to inform the guidance statements. Additionally, the LOC scoring system

44 helps to identify those topics requiring additional research.

45

 

4

The Mass Human Decontamination 2012 Symposium was held in Washington, DC on 24-26 January 2012. The symposium

was co-sponsored by DHS/OHA and HHS/ASPR.
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1 Future plans

2 As the evidence-based principles for conducting patient decontamination set forth here are implemented,

3 response plans and operational practices should themselves become more evidence-based. During

4 development, a variety of gaps in the evidence were identified, many of which are outlined in the guidance

5 statement discussions. These knowledge gaps will be formulated into a research road map describing

6 and prioritizing questions for which evidence-based answers could help to improve the effectiveness of

7 patient decontamination (see Desired end points section below). The research road map will be directed at

8 grant and contract awarding entities and members of the research community. Subsequent revisions to

9 this guidance will reflect updated recommendations based on completion of research studies as well as

10 widely accepted changes to current field practices.

11

12 It is crucial to integrate this guidance into training curricula and the WG intends to work closely with

13 federal partners to do so. Ideally, this guidance will be part of an iterative process of updating training

14 programs, operational response plans, and response standards during their normal revision cycles.

15 Additionally, it is important to ensure that the intended audience is aware of the guidance. Promotion will

16 be necessary upon this document’s release and subsequent updates. To support this socialization and

17 periodic updating, a web-based version of the guidance document may be designed and published.

18

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

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

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

22 additional work.
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1 II. Guiding principles

2

3 Defining patient and patient decontamination

4 For the purpose of this guidance, any individual who may require decontamination is considered a patient.

5

6 “Patient” is defined here as:

7 Any individual who was at or near the location of a hazardous materials release and who was potentially

8 exposed and therefore potentially contaminated and may require some form of care (e.g. decontamination,

9 supportive medical care, lifesaving interventions, antidotal therapy, communication, and reassurance).

10 • Not all patients will require follow-on treatment or evaluation at a health care facility;

11 • Some patients will leave the incident scene prior to responders arriving;

12 • Some individuals, who were not at or near the scene, are not likely to have been contaminated, or

13 may not require any medical assistance, may still present for evaluation and treatment,

14 including requesting decontamination (see Guidance Statement 1.1).

15

16 Use of the term “patient” to refer to a potentially contaminated individual was decided upon following

17 extensive discussion among WG members, symposia participants, and a special sub-group of subject

18 matter expert first responders, first receivers, emergency managers, policy analysts, and military

19 personnel. The term was carefully chosen to reflect the principle that decontamination of a person is a

20 first aid measure that can save lives and reduce other adverse health effects. Candidacy for a preventive 

21 medical intervention based on significant risk of exposure to a toxic chemical should qualify a person as a 

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

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

24 evaluated in a healthcare facility.

25

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

27 a formal provider-patient relationship. The WG has found no formal definition of patient which would 

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

29 term patient avoids negative connotations potentially associated with other terms such as victim or

30 casualty.

31

32 “Patient decontamination” is defined here as:

33 Any process, method, or action that leads to a reduction, removal, neutralization – by partitioning or 

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

35 - or inactivation of contamination on or in the patient in order to: prevent or mitigate adverse health effects

36 to the patient; protect emergency first responders, health care facility first receivers, and other patients

37 from secondary contamination; and reduce the potential for secondary contamination of response and 

38 health care infrastructure.

39

40 This definition is similar to other published definitions of decontamination (e.g., DOD FM 3-11.5, 2006;

41 NFPA 472, 2013) but uniquely focuses on human health outcomes. The importance of decontaminating a

42 potentially contaminated patient for protecting that patient’s health, the health of the responders and

43 receivers treating that patient, the health of other community members, and the integrity of the emergency

44 response and health care systems are explicit in the definition. Since numerous actions such as distancing

45 oneself from the site of a chemical release, wiping visible contamination from skin and clothing, and

46 removing clothing can reduce or remove contamination from a patient, they are considered patient

47 decontamination. Our definition is therefore broad and includes steps that a patient can take on his/her

48 own, even before first responders arrive, to protect the health of him/herself and others (see also Tiered

49 risk-based approach section below and Guidance Statement 2.2).

50

51
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1 Patient decontamination is a medical countermeasure

2 When conducted within the appropriate time window (which is relatively short for most chemical

3 exposures) and using appropriate strategies (see Functional Area #2: Optimized Technical Practices),

4 patient decontamination can limit the patient’s exposure and the toxicities that follow from chemical

5 contamination. Therefore, patient decontamination is an essential early step in the response to a chemical

6 incident and can be considered a type of first aid – an initial action that potentially reduces morbidity and

7 mortality. Life safety is always the highest priority. Patient decontamination should also ideally not

8 delay other life saving measures or therapies.

9

10 Patient decontamination can save lives directly by preventing or reducing chemical agent absorption. 

11 Secondarily, it facilitates the expeditious movement of patients into the health care system where they can 

12 be treated by receivers in a reduced level of personal protective equipment (PPE); the higher levels of PPE

13 worn by responders or receivers treating potentially contaminated patients can inhibit patient care by 

14 reducing visual, auditory, and tactile senses.

15

16 Secondary contamination leading to adverse health effects in responders and receivers who handle

17 patients in a chemical incident is a well-documented phenomenon (Merrit and Anderson, 1989; Huff, 

18 1991; Nozaki et al., 1995; Okudera et al., 1997; Okumura et al., 1998a/b; Zeitz et al., 2000; Geller et al., 

19 2001; Kim, 2001; Horton et al., 2003, 2008; Okumura et al., 2005; Scanlon, 2010). Proper use of PPE can 

20 minimize the risk of secondary contamination and the associated health consequences. However,

21 especially for health care facility-based receivers, decontamination of the patient prior to entry into patient

22 care areas may be the most appropriate way to reduce the potential for secondary contamination.

23 Similarly, secondary contamination of facilities and equipment, which can cause significant disruptions to 

24 emergency health care for an entire community (Huff, 1991; Burgess et al., 1997, 1999; Kim, 2001; 

25 Horton et al., 2008), is preventable by decontaminating patients before they come into contact with such 

26 facilities and equipment.

27

28 The health benefits of patient decontamination – mitigating adverse health effects in the patient;

29 permitting faster access to medical care; protecting the health of responders and receivers; and protecting 

30 health care infrastructure integrity – warrant its identification as a medical countermeasure. It should be 

31 addressed with the urgency appropriate for a medical countermeasure and integrated into planning for 

32 other medical countermeasure utilization.

33

34 Desired end points for patient decontamination

35 A long-time weakness in the practice of patient decontamination is the lack of well-defined, outcome36 based goals. Complete removal of chemical contamination could be considered one end point, one that 

37 requires considerable effort, time, and resources. However, if performing such complete patient 

38 decontamination led to no difference in the short-term or long-term health outcome for the patients, did 

39 not prevent any secondary contamination of responders and their equipment or receivers and their

40 facilities, or contribute to the safety and resiliency of the community, would complete decontamination be 

41 worth the effort? Military decontamination doctrine has a well-defined and well-recognized goal:

42 restoration of personnel and materiel to operational status in order to accomplish the mission. This goal

43 drives planning, resource and time allocation, informs performance of a less than absolute level of 

44 decontamination necessary, and provides for a measure of effectiveness (i.e., the ability to resume and 

45 complete the mission).

46

47 Without a health outcome-based goal for mass patient decontamination, then absolute decontamination 

48 itself becomes the end point – clean for clean’s sake. This belief in turn drives research, education, and 

49 process development and refinement towards the end point of “clean” without questioning whether desired 

50 goals – such as reductions in morbidity or mortality, or prevention of secondary contamination – are 

51 actually being achieved.
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1 The risks of adhering to this model are:

2 1. The same suite of processes, tools, and techniques will be used in every contamination incident,

3 regardless of the specifics of the situation;

4 2. Certain processes (e.g., water-based decontamination) will be applied without questioning whether

5 the process itself is causing harm (e.g., environmental illness, decontamination-related injuries,

6 and psychological stress inherent in the process);

7 3. Future efforts in the patient decontamination field will be driven towards getting more people

8 cleaner, more quickly, and with improved tools and equipment, even as the evidence that it

9 improves health remains uncertain.

10

11 This national guidance has departed from previous efforts by focusing on evidence-based determinants of

12 successful patient decontamination which deliver measurable, positive impact on health, infrastructure,

13 and community outcomes. In doing so the WG has identified, not exclusively, the following:

14

15 Goals of Patient Decontamination:

16 I. Achieving an improvement in patients’ acute health outcomes by reducing short-term morbidity and 

17 mortality;

18

19 II.Achieving an improvement in patients’ long-term health outcome by preventing delayed morbidity;

20

21 III. Protecting the health and functioning of responders and receivers by preventing their secondary 

22 contamination;

23

24 IV. Assuring the best health outcome for the most patients. This might result in a departure from

25 the current paradigm by allowing for decontamination to a less than complete level but which 

26 ensures everyone will get timely decontamination so that:

27 a. those patients requiring supportive or definitive medical care receive it in a timely

28 fashion;

29 b. the majority of minimally exposed patients may be able to bypass medical evaluation,

30 preserving medical resources for those with the most urgent needs

31

32 Patient decontamination is a whole community issue

33 “A Whole Community approach attempts to engage the full capacity of the private and nonprofit sectors,

34 including businesses, faith-based and disability organizations, and the general public, in conjunction with

35 the participation of local, tribal, state, territorial, and Federal governmental partners”(FEMA, 2011).

36

37 Patient decontamination as described in this document aims towards such an approach. The response to a

38 chemical release, regardless of circumstances, requires a concerted effort from multiple organizations,

39 which may include 9-1-1 first responders, first receivers, emergency management, public health, poison 

40 centers, analytical laboratories, and members of the public. Response to and recovery from these incidents 

41 can also require action from the private sector (e.g., emergency medical services providers, health care

42 facilities, chemical companies, transportation companies) as well as from multiple levels of government

43 and may necessitate requesting resources from surrounding jurisdictions through mutual aid.

44 Communication and coordination among these groups is essential, yet evidence from past incidents

45 suggests that improvements are needed. For example, basic information about an incident is not always

46 shared in a timely and efficient manner between responders at the scene and receivers at health care

47 facilities (Auf der Heide, 2006; Kirk and Deaton, 2007). One of six functional areas of this guidance is

48 dedicated to system-wide coordination of patient decontamination in order to ensure that the community

49 acts as a whole to provide care, information, and other support to all members in need.

50

51 The critical importance of risk communication with the public is also recognized, with it being the subject

52 of another of the six functional areas. Risk communication before, during and after an incident supports
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1 response and recovery by enhancing preparedness, increasing the likelihood that appropriate protective

2 actions will be taken and inappropriate or potentially harmful actions will not be taken by community

3 members, and mitigating the stress, anxiety and dysfunction that can result from a disaster.

Recommendations to plan for the needs of at-risk populations

5 5

4 are incorporated at every appropriate 

5 point in this guidance. Such planning requires identification and understanding of the specific needs and

6 vulnerabilities of all individuals within a community. Similarly, the concept that response plans will work

7 only if they are based on the actual resources and capabilities available in a community at the time they

8 are needed is repeated throughout the guidance. This guidance’s emphasis on communication,

9 coordination, and understanding a community’s needs and capabilities reflects the view that planning for

10 mass patient decontamination must involve a whole community, a view which is being fostered by the

11 Federal Emergency Management Agency’s (FEMA) current initiative on a whole community approach to

12 emergency management (FEMA, 2011).

13

14 One of the major aims of this guidance is to aid local planning for mass patient decontamination in a

15 manner that supports community resilience and self-sufficiency. Resilient communities have been

16 identified as one of the keys to national health security by the Department of Health and Human 

17 Services (HHS, 2009, 2012). Through informed and empowered individuals, a resilient community is 

18 able to withstand, mitigate the consequences of, and recover from a disaster to at least its previous

19 level of functioning (Chandra et al., 2011; FEMA, 2011; HHS, 2012). It is assumed here that patient

20 decontamination in a mass casualty chemical incident will be executed entirely by a local community,

21 perhaps with assistance from neighboring jurisdictions. Due to the fast-acting nature of hazardous

22 chemicals, the federal government will most likely not be able to participate directly in the patient

23 decontamination response; rather, the knowledge provided here represents a tool to be added to a

24 local planner’s toolbox.

25

26 Several pieces of this tool directly address actions that contribute to resilience. Risk communication with

27 the public is a mechanism for informing and empowering individuals and was identified as a core

28 component of community resilience in a study by the RAND Corporation (Chandra et al., 2011).

29 Providing for the physical and behavioral health needs, functional needs, and social well-being of all

30 community members, as is recommended at all relevant points of this guidance, is necessary for

31 community resilience. Finally, the decontamination response strategy recommended here is a tiered

32 approach that includes a self-care tier devoted to actions that a patient can take to protect him/herself from

33 the toxic effects of chemical contamination before first responders arrive at the scene (see section on

34 Tiered risk-based response approach section below and Guidance Statement 2.2). Integration of the whole 

35 community, including the general public, into disaster planning, response, and recovery is supported by a 

36 wealth of empirical evidence that the public have the capabilities, the willingness, and actually have made 

37 significant contributions to disaster management (Schoch-Spana, 2012).

38

39 Tiered risk-based response approach

40 The general approach to patient decontamination presented here is a tiered response strategy designed to

41 match the nature and extent of decontamination to the characteristics of the incident, including the type

42 and extent of patient contamination, and the capabilities of the responding and/or receiving organizations.

43 Rather than prescribe a specific protocol for all incidents, this approach allows flexibility and a scalable

44 response. The three tiers (self-care, gross patient decontamination, and technical patient decontamination)

45 represent a progression from relatively limited actions that can be taken without first responder or first

46 receiver assistance and without specialized equipment and supplies, to a more involved, systematic 

 

5 Note that this term is used throughout 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 in the glossary and on the HHS/ASPR website at: www.phe.gov/Preparedness/planning/abc/atrisk.aspx
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1 process that will require equipment and supplies. 

2

3 In some situations, the approach may be executed in a stepwise manner, such that a patient undergoes all

4 three decontamination tiers. In other situations, stepwise completion of all three tiers may not be required.

5 Self-care and gross patient decontamination tiers aim to reduce contamination as early as possible, while

6 technical patient decontamination aims at reducing contamination to a level as low as necessary to

7 improve health outcomes while preventing secondary contamination. Patients who are minimally

8 contaminated may require only self-care, for example, while other patients may proceed from self-care 

9 directly to technical patient decontamination. This approach is described more fully in Guidance

10 Statement 2.2.

11

12 This flexible tiered approach to patient decontamination complements the risk-based response strategy for

13 hazardous materials incidents promoted, for example, by the National Fire Protection Association

14 (NFPA):

15 “Risk-based response process is defined as a systematic process by which responders

16 analyze a problem involving HAZMAT/weapons of mass destruction (WMD), assess the

17 hazards, evaluate the potential consequences, and determine appropriate response actions

18 based on the facts, science, and circumstances of the incident.” NFPA 472, 3.3.55 (2013 ed.)

19

20 Both strategies recommend evaluation of the situation followed by tailoring of the response to the needs

21 and available resources for that specific situation. This should result in the most effective and efficient

22 response possible under the circumstances.

23

24 Practices in mass casualty incidents

25 As with any other mass casualty incident, an incident involving mass patient decontamination will likely

26 present challenges with resource constraints. There will presumably be more patients than can be

27 adequately provided the same standard of care as under normal circumstances. Responders and receivers

28 will need to prioritize patients for decontamination as well as triage for medical care. One of the

29 fundamental principles of responding to mass casualty incidents applies here as well: Do the best you can

30 for the most people with the resources you have.
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1 III. Guidance Statements

2

3 Functional Area 1: Determining the Need for Patient Decontamination

4 For the case of a single potentially contaminated patient, Guidance Statements 1.1-1.3 provide information

5 to help a responding organization, whether in the field or at a health care facility, make decisions on the

6 need for and the extent of decontamination. They include key indicators that the patient may be

7 contaminated, as well as risks to the patient, responders and receivers that should be considered.

Guidance Statement 1.1

The decision to decontaminate should take into account a combination of key indicators, including (but

not limited to):

• Signs and symptoms of exposure displayed by patients;

• Visible evidence of contamination on the patient’s skin or clothing;

• Proximity of the patient to the location of the release;

• Contamination detected on the patient using appropriate detection technology;

• The chemical identity (if known) or physical state, characteristics, and behavior (if unknown);

• Request by the patient for decontamination, even if contamination is unlikely.

Considerations:

• Signs and symptoms of chemical exposure may present as a recognized toxidrome (see Appendix D)

 or as individual symptoms.

• Some signs and symptoms may not reflect actual chemical exposure, but manifest as a result of fear,

an acute stress reaction

6

, or somatization due to the patient’s presence at the incident itself.

• Environmental detectors are available for many Toxic Industrial Chemicals (TICs), Toxic Industrial

Materials (TIMs), and Chemical Warfare Agents (CWAs) but are not readily adaptable to or available

for the detection of contamination on patients likely to be encountered in a hazardous materials

incident.

Level of Confidence: III

8

9 Discussion:

10 Overall, there is little empirical or experimental evidence in the literature that would indicate there is one

11 best means to assess the decontamination needs of all patients. However, each of the indicators described

12 in the guidance statement is represented in the literature, other guidance, and best-practice documents. In

13 addition, SMEs indicated, to varying degrees, the importance of each of these factors in determining the

14 need to conduct decontamination. The assertions in this guidance statement may be difficult to evaluate

15 with a controlled, prospective trial. Assessment of the role of the key indicators in influencing the

16 accuracy of decision making should be obtainable, however, through retrospective studies, other analyses

17 of actual incidents, and exercises.

18

19 Signs and Symptoms

20 The factor receiving the most attention in the literature is symptomatology – the use of a patient’s apparent

 

6 According to the International Classification of Diseases-10 (Effective Date: Oct 1, 2014), Acute Stress Reaction is defined as:

An anxiety disorder precipitated by an experience of intense fear or horror while exposed to a traumatic (especially lifethreatening) 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 Disorder persist for greater than one month, a diagnosis of posttraumatic stress disorder (stress disorders, post-traumatic) is more appropriate. (For more information see Bryant 2011, and 

Diagnostics and Statistics Manual V)
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1 signs and symptoms of chemical exposure to determine the need for decontamination. Toxidromes are

2 clusters of symptoms that can help to identify a broad chemical agent category, and sometimes a more

3 specific chemical agent type, to which a patient may have been exposed. They represent a tool for rapid

4 triage and determination of appropriate emergency treatment of a patient (Kirk et al., 1994; Markel et al.,

5 2008). Symptomatology is a frequently cited criterion for determining whether a patient is contaminated

6 and requires decontamination; equipment is not required, although responders and receivers must be

7 trained in the recognition of toxidromes (Kirk and Deaton, 2007). However, some research suggests that

8 individuals who have a low probability of being contaminated can still exhibit symptoms that do not have

9 an organic origin (Kirk and Deaton, 2007), indicating that additional information should be used in

10 determining the need to decontaminate. Multiple existing guidance documents identify symptomatology

11 as a factor that should be considered in deciding on the need for decontamination (DOD TSWG, 2004;

12 OSHA-FR, 2005; CAL-OES, 2006; ECBC, 2009; OSHA-EMS, 2009). A majority of SMEs, especially

13 first receivers, who commented on this guidance statement, indicated that signs and symptoms are a major

14 consideration in determining the need for patient decontamination.

15

16 Visible

17 Visible evidence of chemical contamination on the patient or the patient’s clothing indicates an ongoing

18 exposure with accumulating contact time and should also be used when deciding if a patient needs

19 decontamination (Okumura et al., 2005; Kirk and Deaton, 2007; Ramesh and Kumar, 2010). Various

20 existing guidance documents list visible contamination as a main factor in determining the need for

21 decontamination (DOD TSWG, 2004; OSHA-FR, 2005; CAL-OES, 2006; ECBC, 2009; OSHA-EMS,

22 2009).

23

24 Proximity

25 It has been suggested that individuals in close proximity to the release site may need to be

26 decontaminated; at the very least, this factor should be included in the evaluation of the need for

27 decontamination (Vogt and Sorensen, 2002). Patients who are closer in proximity to a release site are

28 suspected of having received a higher dose of contaminant and therefore having a greater need for

29 decontamination than a patient further from the release site (Kirk and Deaton, 2007). Proximity to the

30 release site is recommended as one of the factors to consider when determining decontamination needs

31 (Ramesh and Kumar, 2010).

32

33 Detection

34 Although environmental detection technologies are available and are used by first responders (e.g., fire

35 fighters, HAZMAT responders) to characterize hazardous environments, there is little discussion in the

36 literature regarding the use of these devices in determining decontamination requirements. Raber et al.

37 (2001, 2004) and Volkland (2000) used exposure guidelines to assess the potential of using detection

38 capabilities to determine the efficacy of decontamination, but reached the conclusion that current detection 

39 assets were neither sensitive enough nor broad enough to use with patient decontamination.

40

41 Known Chemical Identity

42 Some chemical incidents may not necessitate patient decontamination (Kenar and Karayilanoglu, 2004).

43 If the identity of a chemical contaminant is known, as in the case of a properly placarded truck or rail-car

44 accident, then this information should be utilized in deciding whether to decontaminate a patient. The

45 chemical identity would allow responders and health care receivers to use information about the physical

46 and chemical characteristics from a number of sources (e.g., DOT Emergency Response Guidebook,

47 2012), which would assist in determining appropriate emergency actions (Kirk and Deaton, 2007). It is

48 unlikely, however, that the identity of the chemical will be confirmed within the initial period of a terrorist

49 attack or an accidental release, and even then, the information may be incorrect (Okumura et al., 1998a/b;

50 Zeitz et al., 2000). Communication challenges between responders and receivers can also prevent the 

51 health care facility staff from learning the chemical identity before patients arrive (Kirk and Deaton,

52 2007). The physical state of a chemical, even if the identity is not known, can help determine the need for
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1 decontamination (e.g., liquid versus gas contaminant) (Houston and Hendrickson, 2005). Subject matter

2 experts (SMEs), especially first responders, indicated that the identity and/or physical state of the

3 contaminant are important considerations when determining the need to conduct decontamination.

4

5 Patient Request

6 Participants in the Mass Human Chemical Decontamination Symposium 2012 recommended, based on

7 their experience with chemical incidents, using patient perception of their own need for decontamination

8 as an indicator for the need for decontamination. Patients who perceive their risk for contamination as

9 high, or who request or decontamination, should be provided with this opportunity. Somatization is

10 frequent in acute stress reactions and may manifest as non-physiologically-based symptoms the patient

11 nonetheless expects from the perceived exposure (Fetter, 2005). Additionally an acute stress reaction

12 may occur when a person has been exposed to a traumatic event in which both of the following were 

13 present: (1) the person experienced, witnessed, or was confronted with an event or events that involved 

14 actual or threatened death or serious injury, or a threat to the physical integrity of self or others and (2)

15 the person's response involved intense fear, helplessness, or horror (Bryant, 2011). Despite the 

16 occurrence of acute stress reactions and/or somatization – each of which could result in unexposed 

17 patients nonetheless requesting or undergoing decontamination for symptoms perceived to represent

18 toxic effects - most authors have demonstrated that panic, or anxiety responses and behaviors which are 

19 maladaptive, do not occur frequently in disasters, conventional terrorist attacks, and bioterror incidents

20 (Auf der Heide, 1989; Murakami, 2000; DiGiovanni, 2003; Fetter, 2005; Sheppard et al., 2006; Sullivan 

21 and Bongar, 2007).

22
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Guidance Statement 1.2

Decontamination should be performed if the potential contamination on a patient requiring transport to, 

or care in, a health care facility poses a reasonable risk of exposure to first responders, first receivers, 

other patients or contamination of critical infrastructure.

Considerations:

As a sole criterion, prevention of secondary contamination alone may not justify patient decontamination;

patients meeting all of the following criteria are unlikely to pose a significant risk to responders and

receivers:

• Displaying neither signs nor symptoms of chemical exposure;

• No visible contamination on skin or clothing;

• History that makes exposure unlikely (i.e., not near the location of release).

Level of Confidence: III

1

2 Discussion:

3 The potential for secondary contamination of responders, receivers, and critical infrastructure is well

4 discussed in the literature and best-practices guides. The evidence supporting this recommendation

5 amounts to documented cases of responders or receivers becoming exposed to chemical contaminants

6 from patients they were treating. The recommendation is also based on subject matter expert opinion and

7 other published guidance.

8

9 First responders and receivers must be cognizant of the potential risk of secondary contamination to both

10 themselves and other people. Secondary contamination of responders and receivers was well documented

11 following the sarin attacks in Japan (Nozaki et al., 1995; Okudera et al., 1997; Okumura et al., 1998a/b;

12 Okumura et al., 2005; Scanlon, 2010) and from hazardous materials incidents in the US (Merrit and

13 Anderson, 1989; Huff, 1991; Zeitz et al., 2000; Geller et al., 2001; Kim, 2001; Horton et al., 2003, 2008).

14 Typically, the greatest risk of secondary contamination is during transportation of contaminated patients

15 by emergency medical services (EMS) providers, who are confined within the enclosed environment of an

16 ambulance. However, the potential of exposing receivers at health care facilities remains a high

17 likelihood, particularly with self-evacuating patients (Cone and Koenig, 2005). Several existing guidance

18 documents (HHS ATSDR-ED, 2000; OSHA-FR, 2005; ECBC, 2009; OSHA-EMS, 2009) emphasize the

19 necessity of patient decontamination due to the risk of secondary contamination.

20

21 Published literature cites the need for patient decontamination in order to prevent contamination of critical

22 infrastructure, including health care facilities (Huff, 1991; Burgess et al., 1999; Kim, 2001). There is a

23 history of emergency departments (ED) closing and evacuating due to secondary contamination, resulting

24 in loss of a community medical care resource and other essential medical services. Subject matter experts

25 indicated that the potential for contaminated patients to effectively shut down an ED or health care facility

26 should be considered when determining the need for decontamination.

27

28 While these factors must be taken into account when determining the need to decontaminate a patient, the 

29 risk of secondary contamination must also be weighed against the needs of an individual patient. Such a 

30 risk-based response approach would involve:

31 • A determination of the need for decontamination by applying the criteria described in Guidance

32 Statement 1.1.

33 • Assessing the risk of adverse outcomes resulting from decontamination process itself (see 

34 Guidance Statement 1.3).

35 • Considering alternative decontamination practices described in Guidance Statement 2.11.

36 • Considering relevant chemical and exposure information from the incident scene and unique to the

37 incident, including whether the properties of the contaminant pose a risk of secondary

38 contamination.

39
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1 Subject matter experts generally agreed that a patient who is not exhibiting symptoms, has no visible signs 

2 of contamination, and is neither likely to be contaminated due to his/her location relative to the release site 

3 is unlikely to require decontamination nor to pose a significant risk for secondary contamination.

4
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Guidance Statement 1.3

If the likelihood of adverse consequences from gross patient or technical patient decontamination

methods outweighs the likely health outcome gains of decontaminating a patient with water-based

decontaminants, then decontamination should be performed using alternative practices.

Considerations:

• Patient decontamination is not without risk; appropriate measures should be taken to mitigate these

risks and to reduce the negative impact on patients.

• Refer to Guidance Statement 2.11 for alternative practices.

• Adverse consequences might be caused by severe weather (e.g., hypothermia due to cold

temperatures), chemical reactivity (e.g., water-reactive chemicals or metals, such as lithium or

sodium), delay in lifesaving care, or psychological trauma.

Level of Confidence: III

1

2 Discussion:

3 The decision to perform decontamination should take into consideration any and all potential

4 consequences. A risk-based response (as outlined in Guidance Statement 2.1) is necessary to ensure that

5 the health outcome benefit of decontamination efforts outweigh the potential consequences of adverse

6 health effects for patients. Responders and receivers must consider environmental conditions, chemical

7 reactivity with water, the potential for mechanical injuries (e.g., slips, trips, falls), and the psychological

8 impact on patients of conducting decontamination (Levitin et al., 2003; Freyberg et al., 2008). Elements

9 of this guidance statement have support in the available literature or could be considered current practice.

10 The assertions in this guidance statement would be difficult to evaluate in a comparative human trial, but

11 may be evaluated in a retrospective study and subsequent analysis. In addition to information presented in 

12 the literature, the potential for adverse consequences is discussed in various existing guidance documents 

13 (ATSDR-EMS, 2000; DOD TSWG, 2004; OSHA-FR, 2005; ECBC, 2009; OSHA-EMS, 2009).

14

15 Environmental conditions

16 Traditionally, patient decontamination has implied water-based showering. However, other

17 decontamination strategies are better suited for certain conditions and may achieve similar outcomes as

18 traditionally implemented decontamination methods. These alternative strategies include the removal of

19 patients from the contaminated area, removal of clothing, and/or use of an implement (i.e., clean rag) for

spot

7

20 decontamination (Feldman, 2010). These methods may prove especially relevant when

21 environmental conditions present risk of cold weather injuries or other extreme weather (e.g., freezing

22 rain, icy conditions) (Lepler and Lucci, 2004). Decontamination should be scalable and flexible. If the

23 risks of water-based decontamination in an extremely cold environment are too great, then disrobing a

24 patient and providing uncontaminated covering in the short term may be sufficient to substantially reduce

25 the risk of chemical-specific health outcomes without inducing cold weather injuries.

26

27 In colder environments, decontamination may require alternative locations in lieu of alternative

28 techniques. Using indoor swimming pools, gymnasiums, or other large shower facilities (e.g., arenas,

29 schools, hotels) have been considered in existing guidance documents (ECBC, 2009); response

30 organizations’ plans should consider these as potential alternatives to outdoor decontamination.

31

32 Chemical reactivity

33 Alternative decontamination methods should be considered for chemicals that are deemed water-reactive.

 

7

Spot decontamination - As opposed to decontamination of the entire body, this technique involves the removal of visible

contamination from small areas of exposed skin (e.g., hand or portion of the arm or leg). This technique may be water-based

or utilize some of the alternative decontaminants discussed in this guidance document (e.g., RSDL®).
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1 Water-reactive substances undergo a dangerous chemical reaction when they come into contact with

2 water. This reaction may release a gas that is either flammable or presents a toxic inhalation hazard. In

3 addition, the heat generated when water activates such materials is often enough for the material to 

4 spontaneously combust or explode, causing severe burns. The US DOT’s Emergency Response

5 Guidebook (DOT, 2012) provides a list of water-reactive chemicals that produce toxic-by-inhalation 

6 gas(ses) when spilled in water. In addition to this list, several alkali metals are violently reactive with

7 water, as also referenced in the Emergency Response Guidebook (DOT, 2012)

8
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1 Functional Area 2: Optimized Technical Practices

2 Guidance statements in Functional Area 2 describe techniques, methods, and practices to optimize the

3 performance of patient decontamination. Functional Area 2 includes methods for reducing, removing,

4 neutralizing or inactivating contamination on an individual patient, assuming, for the most part, that

5 resources and capabilities are not challenged by a mass exposure scenario.

Guidance Statement 2.1

A risk-based approach should be employed by a responding or receiving organization to determine the

appropriate response level and associated strategies and tactics (including PPE, medical interventions and

decontamination

Considerations:

• Appropriately trained supervisory personnel (e.g., see Hazardous Waste Operations and Emergency

Response (HAZWOPER) standards, 29 CFR 1910.120(q) or NFPA 472/473, 2013) should perform a

situational assessment.

• PPE determination should be based upon the unique circumstances of the event, in consultation with

applicable guidance and regulations (OSHA, NIOSH, and NFPA – see Guidance Statement 5.7).

Level of Confidence: IV

6

7 Discussion:

8 The risk-based approach allows HAZMAT responders and first receivers’ flexibility in adapting response

9 capabilities to dynamic situations. This approach deviates from standard practice-based response

10 operations by allowing responders and receivers to make critical decisions based on an assessment of the

11 hazards and risks associated with a particular incident. The risk-based response is a systematic approach

12 to responding to an incident that incorporates the knowledge and experience of the responder, the unique

13 circumstances of an event, and the risk analysis in order to make informed response decisions. Responders

14 and receivers should incorporate these principles into their planning and training for decontamination 

15 operations, using knowledge of the chemical (if available), site-specific information, environmental 

16 monitoring, patient signs and symptoms, and other clues for decision making.

17

18 Risk-based response has become a common practice of HAZMAT response following its evolution from

19 street-smart tactics, and is incorporated as a core competency in NFPA 472: Standard for Competence of

20 Responders to Hazardous Materials/Weapons of Mass Destruction Incidents (2013), as well as textbooks

21 and training guides. Subject matter experts strongly encouraged guidance which reflects the risk-based

22 response approach as a key element of planning for mass patient decontamination. Though a risk-based

23 response is a current standard of practice and SMEs support its use and inclusion, there is a paucity of

24 evidence in the published literature evaluating its effectiveness.

25
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Guidance Statement 2.2

A tiered approach to patient decontamination allows responders and receivers to base the nature and level

of decontamination on the type and extent of contamination, as estimated through a risk-based 

assessment of the incident, as well as available resources. The tiered decontamination response is

flexible and adaptable to various types of incidents; each tier can be executed either at the scene or at a

health care facility.

Recommended patient decontamination tiers

Self-care: actions that a patient can perform

for him/herself, including distancing

him/herself from the site of release,

removing clothing, and wiping visible

contamination from skin and clothing in

order to reduce his/her own 

contamination level immediately, 

without waiting for a

formal decontamination process to be set

up. A perceptive patient or one

experiencing acute distress from the 

chemical contamination may execute

self-care even before responders arrive;

however, most patients will need

instructions.

8

Self-care can be conducted without equipment or

supplies; it mainly depends on patients knowing

what to do either on their own or through 

instructions from responders.

Gross patient decontamination: actionslikely

to be performed by or with the assistance 

of first responders or first receivers in 

order to achieve a gross or hasty 

reduction in contamination, significantly

reducing contamination on skin or

clothing, as soon as possible after

contamination has occurred.

9

Gross patient decontamination is 

performed with minimal equipment, 

products or implements, and can be set up 

quickly. Examples include the Ladder Pipe 

Decontamination System to provide a high 

volume, low pressure water shower from

fire apparatus (ECBC, 2009) and spot 

decontamination using a product such as 

Reactive Skin Decontamination Lotion ®

(RSDL) (Schwartz et al., 2012)

Technical patient decontamination: planned

and systematic actions, likely to be

performed under the guidance of or with

the assistance of first responders or first

receivers, to achieve contamination

reduction to a level that is as low as 

possible.

10

Technical patient decontamination is 

achieved through a well-defined, multi-step 

process that includes evaluation of the

results and, if necessary, repetition of the 

process. It usually involves a high volume, 

low pressure water shower, with the 

addition of soap, especially for an oily

contaminant, and gentle rubbing with a soft

cloth or sponge. The shower may be 

provided by a number of different types of

equipment or facilities.

 

8

Self-care is similar to the concepts of self or emergency decontamination (DOD TSWG, 2004; OSHA - First Receivers,

2005; OSHA-EMS, 2009), emergency decontamination (NFPA 472, 2013) and immediate decontamination (DOD FM 3-11.5, 

2006)

9 Gross patient decontamination is similar to the concept of field-expedient decontamination (DOD TSWG, 2004;

OSHA- First Receivers, 2005; OSHA-EMS, 2009)) and to DOD’s concept of operational decontamination (DOD FM 3-

11.5, 2006) and consistent with NFPA’s concept of gross decontamination (NFPA 472, 2013).

10 Technical patient decontamination is similar to the concepts of thorough decontamination (DOD TSWG, 2004; OSHAFirst Receivers, 2005; OSHA-EMS, 2009) and definitive decontamination (HHS ATSDR Vol. I, 2000)
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Mass decontamination can occur at any of the patient decontamination tiers; it is defined as reducing or

removing surface contamination from large numbers of patients in potentially life-threatening situations

in the fastest time possible.

Considerations:

• The patient decontamination tiers are not necessarily a step-wise system that requires

conduct of each in order. They should be applied in a manner that meets the needs of each specific

situation.

• Some health care facilities may require that a patient has been technically decontaminated before 

he/she enters the facility. In this case, local plans should incorporate a technical patient

decontamination capability either at the health care facility or on-scene with first responders that will

be accepted as sufficient by health care facility personnel.

Level of Confidence: III
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1 Discussion:

2 In the tiered approach to patient

3 decontamination, the methods and goals depend

4 on the details of the exposure and the resources

5 available. Self-care and gross patient

6 decontamination are primarily first aid

7 measures. These steps are aimed at saving a

8 patient’s life and mitigating adverse health 

9 effects by reducing the level of contaminant in

10 the patient’s immediate environment, thereby

11 reducing the amount absorbed and the dose 

12 received (Hamilton et al., 2004; Preston et al., 

13 2008; Amlôt et al., 2010; Braue et al., 2011a/b;

14 Feldman, 2010). Self-care and gross patient

15 decontamination are the most time-sensitive of

16 the three tiers. Given this, for maximum

17 benefit, they should be performed as soon as 

18 possible after contamination has occurred 

19 (Hamilton et al., 2004; Braue et al., 2011a/b).

20 The primary objective of technical patient

21 decontamination is to reduce a patient’s

22 contamination to a level that is as low as 

23 possible in order to minimize the potential for

24 secondary contamination of responders,

25 receivers, other people, equipment, and 

26 facilities. Once a patient has undergone

27 technical decontamination, contamination is

28 reduced to a level which allows responders and

29 receivers to handle the patient, evaluate, and 

30 administer medical care while operating in a 

31 reduced level of PPE. Technical patient

32 decontamination may also save lives and reduce

33 adverse health effects among patients by

34 limiting additional absorption of surface 

35 contaminants, depending on how soon it is

36 executed.

37

38

39

40

41 Example (at the scene):

42 A mass chemical exposure occurring in a 

43 jurisdiction with limited resources, where

44 first responders must wait on mutual aid

45 support, may require sequential completion 

46 of all three tiers:

47

48  First responders arrive at the scene and 

49 instruct patients to move to a specific 

50 area upwind of the area of release, 

51 remove at least outer layers of clothing, 

52 and wait (Self-care).

53

54  Shortly thereafter, patients are guided 

55 through a decontamination corridor 

56 established at the scene using a Ladder 

57 Pipe Decontamination System (Gross).

58

59  Subsequently, patients undergo technical 

60 decontamination in a mobile tent system 

61 also set up at the scene (Technical).

62

63 In a well-equipped jurisdiction, the tiers 

64 may be completed nearly simultaneously:

65

66  First responders arrive on-scene and 

67 direct patients to move to a specific area 

68 upwind of the site of release, instruct 

69 patients to remove clothing and proceed 

70 through a mobile tent system for 

71 technical patient decontamination

72

73 Many other sequences of events are 

74 possible; these examples illustrate how the 

75 tiered approach can be flexibly applied to 

76 specific situations as part of a risk-based 

77 response.
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1

2 Example (at health care facility):

3 A significant proportion of

4 patients may leave the scene

5 without being decontaminated or

6 evaluated by responders and

7 either proceed directly to a health

8 care facility or not seek care right

9 away.

10

11 These patients will have performed

12 some, but perhaps not all possible,

13 self-care actions and then undergo

14 gross patient and/or technical

15 patient decontamination at the

16 health care facility.

17

18 Note: In some mass exposure 

19 scenarios, such as one involving

20 only a gas or vapor contaminant,

21 self-care may be sufficient.

22

23

24

25 The tiered approach is used to tailor the 

26 decontamination response to the specific incident. It is 

27 not meant to suggest that decontamination must be a

28 sequential process where self-care is conducted first, 

29 followed by gross patient and then technical patient 

30 decontamination, though some incidents may proceed 

31 in such a manner.

32

33 Technical patient decontamination requires more 

34 resources and time than gross patient decontamination, 

35 which requires more resources and time than self-care. 

36 The capability to perform each tier of decontamination 

37 depends on the availability of those resources. The 

38 more resource intensive practices can provide greater 

39 privacy and comfort, as well as potentially allowing for 

40 further removal of contaminants from patients.

41

42 Several existing guidance documents (HHS ATSDR, 

43 2000; DOD TSWG, 2004; OSHA-FR, 2005; DOD FM

44 3-11.5, 2006; OSHA-EMS, 2009; NFPA 472, 2013)

45 promote a tiered or phased approach to patient 

46 decontamination that is consistent with the

47 recommendations of this guidance document.

48 The specific terms used differ and, in some

49 cases, two rather than three tiers are identified

Nevertheless, the concepts and the rationales are basically the same between the existing guidance 

documents and this guidance document. Most importantly, prior guidance emphasizes the urgency of

reducing exposure and removing large amounts of chemical contamination from patients as soon as 

possible with readily available resources (i.e., self-care and gross patient decontamination). Prior 

guidance documents also describe a more technical and organized type of decontamination designed to 

reduce contamination to a level that is as low as possible or as clean as possible in order to limit the spread 

of contamination and protect responders, receivers, equipment and facilities (i.e., technical patient 

decontamination).

The approach is also established in the National Fire Protection Association’s (NFPA) Standard for

Competence of Responders to Hazardous Materials/Weapons of Mass Destruction Incidents (NFPA 472,

2013), which widely impacts first responder practices. A similar tiered approach is implemented by the

DOD (DOD FM 3-11.5, 2006). A controlled prospective study of the effectiveness of a flexible, three 

tiered approach as defined here may be difficult to execute. However, such a study or evidence of

successful application of the approach in real incidents or even in exercises would be a welcomed addition 

to the field.
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Guidance Statement 2.3

Self-care and/or gross patient decontamination actions should occur as quickly as possible, while a

technical patient decontamination corridor is established.

Considerations:

• A determination of the need for technical patient decontamination, or any contraindications 

necessitating an alternative practice, should be decided according to the guidance in Functional Areas

1 and 2.

• Non-ambulatory or mobility impaired patients may not be able to perform self-care.

Level of Confidence: II

1

2 Discussion:

3 The importance of early decontamination to reduce contact time and therefore reduce the opportunity for

4 absorption of the contaminant and the subsequent dose received by the patient, cannot be overstated. The

5 duration of the time window for effective patient decontamination is not precisely known. Evidence

6 suggests that it varies with the identity of the contaminant, the dose of the contaminant, and probably other

7 factors. Compared to biological and radiological contaminants, the time window is short: minutes to 

8 hours in most cases. Despite the lack of precise, or in many cases even rough, delimitation of the effective 

9 time window for decontamination of chemicals, several studies provide evidence that the efficacy of

10 patient decontamination in saving lives and/or mitigating adverse health effects diminishes over time.

11 This time frame ranges from a few minutes to many hours, depending on the specific contaminant.

12

13 Data on the time window for effective decontamination of some toxic industrial chemicals are available

14 from a series of studies by Wester and colleagues (1990, 1991, 1992, 1999) using in vivo exposure of

15 rhesus monkeys. The efficacy (directly measured as a proportion of surface contamination removed) of

16 washing the skin with soapy water declined as time increased post-exposure. Methylene bisphenyl

17 isocyanate, glyphosphate, alachlor and Aroclor 1242 exhibited different decontamination time sensitivities

18 in separate studies. Braue and colleagues (2011a/b), studied the ability of several decontaminants to

19 prevent death in guinea pigs that had been exposed to 5xLD50 of either VX or soman; studies investigated

20 the effect of immediate and delayed decontamination on lethality. The LT50 – the latest decontamination 

21 time at which half of the contaminated animals subsequently died (at xx hours) – was 26, 48 and 31

22 minutes for soapy water, dilute bleach and RSDL decontamination of VX-exposed animals, respectively, 

23 suggesting a short time window for decontamination (26 minutes for soapy water). The window for

24 effective decontamination of soman-exposed animals was much shorter: the LT50 for decontamination 

25 with RSDL was four minutes; this reflects the rapid aging (irreversible enzyme inactivation) of soman 

26 specifically. In another in vivo study of VX exposure, decontamination of domestic pigs with soapy water

27 or dilute bleach was less effective at preventing death and mitigating signs of severe intoxication when

28 performed at 45 minutes than at 30 minutes post-exposure (Bjarnason et al., 2008). Retrospective analysis

29 of chemical burn patients at the Baltimore Regional Burn Center from 1976-1985 demonstrated that

30 initiating a water-only washing of the site of chemical exposure within three minutes significantly reduced 

31 the extent of skin injury, mean length of hospital stay and delayed complications compared to the 

32 consequences in patients whose decontamination was initiated later (Moran et al., 1987; Leonard et al., 

33 1982).

34

35 The tiers of decontamination (self-care, gross patient decontamination and technical patient

36 decontamination) all differ in the amount of preparation, time, and resources needed. Early and

37 expeditious forms of decontamination sacrifice thoroughness for the speed with which each can be

38 instituted. Self-care, including removing oneself from the source of exposure, wiping chemical off the

39 skin and removing contaminated clothing, may occur instantly, be executed by patients using what they

40 have with them, such as a handkerchief or scarf, and be performed before first responders arrive. Gross

41 patient decontamination may be executed by providing patients with rapid access to a high volume of

42 water, such as from a fire hose, in an effort to quickly terminate contact with the chemical contaminant.
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1 Lastly, technical patient decontamination usually involves showering with, ideally, soapy water and a

2 wash item, in an effort to remove an unabsorbed chemical to as low a level as possible, thereby

3 terminating further dosing.

4

5 The importance of rapidly implementing self-care and gross patient decontamination is described by Kirk

6 and Deaton (2007) who likened decontamination to a first aid procedure. Moran et al. (1987) also equate

7 the washing of chemical burns with copious water starting within three minutes of exposure with first aid.

8 Several prior guidance documents describe rapidly initiating decontamination actions, such as disrobing

9 (DOD TSWG, 2004; ECBC, 2009), as the best means of rapidly reducing contamination.

10
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Guidance Statement 2.4

Attempt to immediately decrease ongoing exposure by removing all patients out of the area of chemical

release and provide an area of refuge.

Considerations:

• First responders should not enter contaminated areas of release (i.e., hot and warm zones) without

appropriate PPE and training.

• A determination of the subsequent need and level of decontamination may be decided according to

criteria in Guidance Statement 1.1.

Level of Confidence: II

1

2 Discussion:

3 One of the first steps in contamination reduction is to terminate ongoing exposure by removing patients

4 from the hot zone. Scientific review substantiating this first step among patients is primarily focused on

5 the effects among first responders and hospital first receivers. The study of the 1982 Hanover County,

6 Virginia incident (involving pentaborane release) recommended that first responders “back away” from a

7 scene (once a hazardous materials incident had occurred) until appropriate chemical protective clothing

8 and respiratory protection is donned (Huff,1991). Preventing contamination protects personnel and

9 resources (e.g., ambulances, emergency departments) from secondary contamination (Kirk et. al, 1994).

10 Occupational health and safety principles also justify guidance to immediately decrease exposure among

11 patients. When evaluating methods of controlling human exposures in a workplace from workplace

12 hazards, the pathway for the hazard to travel from the source to the receiver (i.e., patient, first responder,

13 hospital first receiver) requires examination. In a chemical incident, the source is uncontrolled (at least

14 initially) and methods such as isolation or physical enclosures are not necessarily practical in the short15 term. Thus, the next location to control human exposure is the pathway from source to receiver.

16 Increasing physical distance between the release source and people and/or placing people in a safe refuge

17 (e.g., shelter-in-place order at home or work, or evacuation upwind and/or upstream from the source) is an

18 effective contingency (Plog, B.A., Niland, J., Quinlan, P.J, National Safety Council (1996). No

19 decontamination practice is of use if performed in an environment in which patients will continue to be

20 exposed.

21

22 Determining the size of an affected area, or the evacuation distance, is most often based on a guideline

23 such as the suggested evacuation radii referenced in the 2012 DOT Emergency Response Guidebook. In

24 an attempt to illustrate the influence of the nature of a contaminant (liquid or vapor) on the size of the hot

25 zone, while establishing the French emergency response plans, Laurent et al. (1999) estimated the likely

26 affected hot zone based on the physical properties of a chemical threat. It was noted that a liquid hazard

27 area extended 350 ft. diameter. On the other hand, a vapor hazard area – with winds <1 m/s – rarely

exceeded a radius of 1700 ft. and extended downwind in a 20

o

28 arc.

29

30 Preston et al. (2008) examined 2,930 chemical incidents in which decontamination was infrequent,

31 occurring during only 10% of the incidents. Of the 2,930 incidents, 7.7% resulted in evacuation. When

32 controlled for decontamination, it was determined that those incidents in which there was an evacuation

33 resulted in fewer patients per event than those incidents for which there was not evacuation however, the

34 difference in number of patients was only significant (p<0.05) for incidents involving gasses or vapors

35 (specifically, chlorine, ammonia, and acid gasses).

36

37 While removal from ongoing exposure in the hot zone is supported by several existing guidance

38 documents, including DOD TSWG (2004), OSHA/EMS (2009), and ECBC (2009), the idea of evacuation

39 as a decontamination strategy is not described. Specific reference is made to moving patients out of the

40 hot zone, preferably upwind of the release, to a safe refuge while a decision on decontamination and

41 preparations for decontamination are made (ECBC, 2009).
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1

2 Patients may evacuate themselves to a location they feel is safe and this may occur prior to the arrival of

3 first responders. Once patients are distanced from the possibility of ongoing exposure, determination of

4 the need for additional decontamination may commence.

5

6 Having patients guided towards a location may ease the evaluation of large numbers to ascertain the need

7 for decontamination, issuance of instructions, and to conduct decontamination processes. However,

8 experts also conveyed the concern of increasing secondary contamination when patients are grouped

9 together in a location before decontamination is conducted.

10

11 Lastly, as self-evacuation is likely, and since a proportion of those retained at the scene may ultimately be

12 told they do not require decontamination, communication is critical. Instructions to patients who are not

13 decontaminated, but held at the scene, must emphasize appropriate follow-up measures. Communication

14 to those who may have already left and who subsequently either (1) develop symptoms, (2) become

15 worried about their own health, or (3) are concerned about exposing family members, is just as important,

16 since they may request decontamination or other assistance from any number of different health care

17 facilities. These and other risk communication issues are addressed more extensively in Functional Area

18
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Guidance Statement 2.5

Clothing removal for patients who have been visibly contaminated or who are suspected of having been

contaminated is an essential aspect of decontamination. For patients who can remove their own clothing,

it can be a part of self-care. Efforts should be made to collect and account for clothing and personal

items removed during patient decontamination.

Considerations:

• If clothing removal is to be conducted outside, be mindful of environmental risks and, if applicable,

ensure warming or cooling methods are available (e.g., warming tent, indoor location, shaded area).

• Some patients may require assistance with removing clothing.

• Ensure proper levels of modesty (e.g., separate lines for males and females and cover from bystanders;

cultural and religious practices should be taken into consideration during planning).

• Clothing and personal items should be handled in such a manner to address the following priorities:

o Protecting the health and safety of patients, responders and receivers;

o Evidence collection for law enforcement;

o Consistency with logistical capabilities;

o Allow patients to retain essential personal items (e.g., prescription eyeglasses, hearing 

aids, canes);

o Returning valuables to patients if possible and safe;

o Analyzing clothing for contaminants to confirm exposure and/or provide an estimate of

degree of exposure.

• Be aware of the potential for concealed secondary improvised explosive devices or other weapons that

may be hidden in clothing or other personal items.

• Patients should be allowed to retain a form of identification that can withstand the decontamination

process (e.g., laminated ID card or driver’s license, Medic-alert bracelet, “dog tags”) and will not

retain contamination if adequately decontaminated.

• Provisions should be in place to accommodate law enforcement equipment/weapons.

• If the incident is suspected to be an intentional act, clothing and personal items may become evidence;

law enforcement should be incorporated into response planning to develop SOPs for collecting

contaminated material and ensuring chain of custody in accordance with (IAW) jurisdictional 

guidance

Level of Confidence: II

1

2 Discussion:

3 Quantitative claims have been made frequently in the literature about the efficacy of clothing removal in

4 reducing contaminants on a patient. It is often stated that removing clothes may reduce contamination on

5 a person by approximately 80-90% (Cox, 1994; Koenig, 2003). References are sometimes included and

6 authors seem to imply that there is evidence to support this quantitative claim. However, cited references

7 usually repeat the same estimated percentage of contaminants removed through disrobing without

8 describing any evidence. In fact, there is currently no published study that directly evaluates the question

9 of how much contamination can be removed from a person after chemical exposure by removing the

10 person’s clothing. Such a study could be performed by exposing human subjects to a chemical simulant,

11 or by exposing mannequins or laboratory animals to a toxic chemical, and measuring contaminant levels

12 before and after clothing removal. The Standard Test Method for Man-In-Simulant Test (MIST) for

13 Protective Ensembles (ASTM F 2588-06) could provide a useful starting point for such studies. The

14 results are likely to vary depending on the specific chemical, its physical state (i.e., solid, liquid, vapor or

15 gas), the method of dispersal, and the clothing being worn.

16

17 There is compelling indirect evidence to suggest that clothing should be removed from a patient who has

18 been exposed to a chemical in order to minimize the amount of contaminant that may potentially be

19 absorbed. Several studies have demonstrated that clothing absorbs and retains chemicals to which it has

20 been exposed. In an in vitro study that measured the amount of liquid contaminant absorbed by fabric-
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1 covered human skin, Csiszar et al. (1998) reported that the fabrics absorbed most of the applied

2 contaminant (85-95%) and retained it for at least eight hours, resulting in absorption through the skin of

3 only a very small amount of the contaminant (0.1-0.2%). Feldman (2010) also provided evidence that

4 clothing absorbs and retains chemicals, but additionally demonstrated that significant off-gassing can

5 occur. In the Feldman (2010) study, a variety of civilian clothing articles were exposed to the chemical

6 agent simulant methyl salicylate, which has similar physical properties to sulfur mustard, in vapor form.

7

8 After the exposure was terminated, methyl salicylate vapor was detected near each article of clothing.

9 Off-gassing continued for several minutes longer for heavier clothing (e.g., jackets and sweaters) than

10 the few minutes noted for lighter clothing (e.g., jeans and t-shirts), suggesting that patients and

11 responders may receive additional exposure from clothing that is not removed and isolated after

12 exposure. Two other studies support the concept that clothing provides some protection for its wearer

13 by reducing chemical absorption through human skin; however, some skin absorption still occurred

14 from the contaminated fabrics (cotton sheets and fabric of military uniforms) in this in vitro 

15 experimental system. This additionally supports the potential benefit of complete clothing removal as 

16 opposed to over-reliance on street clothing to provide significant protection from chemical exposure

17 (Wester et al., 1996; Wester et al., 2000).

18

19 Simulated secondary exposure of hospital-based receivers to chemical vapors and dust from clothing on

20 chemically contaminated mannequins provides evidence that receivers can be at risk of receiving

21 dangerous doses of chemical contaminants during patient decontamination (Schultz et al., 1995).

22 Concentrations of vapor or particulate chemical contaminants in the breathing zones of two receivers per

23 “patient” were measured before and during clothing removal from a contaminated mannequin. When the

24 measured levels of the relatively harmless chemicals used in the study were extrapolated to highly toxic

25 chemicals, the estimated concentrations were high enough to cause severe health effects in receivers not

26 wearing appropriate PPE. These results suggest that clothing on contaminated patients can put patients,

27 responders and receivers at risk of toxicities from chemical contaminants.

28

29 Reports of secondary contamination of responders or receivers also indirectly support the recommendation

30 that clothing be removed from contaminated patients. In one of the most cited cases, 13 of the 15 

31 physicians who treated patients in a Tokyo emergency department, after the sarin release on subway trains

32 in 1995, experienced symptoms of sarin exposure. Since none of the patients were decontaminated, it has 

33 been deduced that the physicians were exposed through off-gassing of sarin from the patients’ clothing

34 (Nozaki et al., 1995).

35

36 Existing guidance documents reviewed in the crosswalk analysis recommend the removal of clothing for

37 any person suspected of having been exposed to a chemical (HHS ATSDR-ED, 2000; HHS ATSDR38 EMS, 2000; DOD TSWG, 2004; OSHA-FR, 2005; CAL-OES, 2006; ECBC, 2009; OSHA-EMS, 2009). 

39 Some of the documents, such as the ECBC (2009) guidance, also provide specific instructions on how

40 clothing should be removed. There is strong experimental work and other indirect evidence that supports

41 the concept that clothing removal may eliminate a significant amount of a chemical contaminant from a

42 patient, thereby reducing the potential for additional absorption by the patient, as well as the potential for

43 secondary contamination of responders, receivers, other people, equipment or facilities. The data, current

44 practice, and SME consensus justifies a LOC rating of II. Well designed and controlled clinical trials

45 and/or field research to directly test the efficacy of clothing removal in reducing patient contamination, or

46 on other outcomes, are needed to substantiate commonly made assertions. In the meantime, this guidance

47 document endorses clothing removal as an important decontamination step that can be performed without

48 equipment or supplies and in many cases, without the assistance of responders.

49
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Guidance Statement 2.6

Privacy for patients should be incorporated throughout the decontamination process, within the resource

limitations of the responding or receiving organization, to include:

• Privacy during clothing removal

• Segregation of males and females during decontamination

• Materialsforredressingfollowing decontamination

Considerations:

• Responding and receiving organizations must balance concerns surrounding patient privacy and the

urgency of decontamination needs.

• Families, including caretakers, should be permitted to remain together during the decontamination

process.

• Patients and/or their family members may not be comfortable with the patient being decontaminated

by staff of the opposite gender.

• Allowances for these concerns may not be appropriate in a life or death situation.

Level of Confidence: IV

1

2 Discussion:

3 Privacy is not directly related to a patient’s medical outcome; however, efforts to provide privacy may

4 enhance patient compliance with recommended decontamination practices, which can influence patient

5 outcome. An assessment of simulated patients’ perceptions during field exercises involving mass patient

6 decontamination in the United Kingdom revealed that lack of privacy was a common concern. In

7 feedback from a total of 402 participants in five exercises, requests for greater privacy during various

8 aspects of the decontamination process were submitted. Some participants explained that they felt

9 embarrassed due to the lack of privacy and one person refused to be decontaminated because of modesty

10 (Carter et al., 2012).

11

12 Evidence from actual incidents – based on news reports, after action reports, and anecdotes –demonstrates

13 that when patients perceive that they have not been afforded sufficient privacy, they may express

14 dissatisfaction with the decontamination process or the overall way they were treated by responders or

15 receivers. In the suspected biological and chemical incident at B’nai B’rith Headquarters in Washington,

16 DC in 1997, some police officers who were instructed to undergo decontamination initially refused, and

17 tensions ensued between police and EMS personnel, due to the live broadcasting of pictures of the

18 incident scene from news cameras on top of a nearby building (United States Fire Administration, 1997).

19 In some cases, lawsuits have been filed against emergency response organizations alleging that patients’

20 privacy and other rights were violated during decontamination, for which they were requested to disrobe

21 in view of responders of the opposite gender and/or bystanders (Gong et al., 1996). Anecdotes suggest

22 that patients may become upset if separated from family members during decontamination. Furthermore,

23 parents may fear that the privacy, safety and welfare of their children are not adequately protected if they

24 are cared for by responders of the opposite gender during decontamination. During a drinking water

25 contamination incident in Spencer, MA in 2007, local fire departments only conducted decontamination

26 with response personnel of the same gender as the patients. However, an insufficient number of female

27 personnel were deployed to the incident, resulting in delays in decontamination of female patients and

28 female personnel having to work longer shifts than male personnel (FEMA, 2007).

29

30 Providing for privacy during decontamination requires resources. Curtains or barriers to segregate people, 

31 at least by gender if not by individual, can allow for protection of modesty. In a case study of the

32 effectiveness of hospital-based patient decontamination during a simulation, 83% of subjects reported that

33 they felt they were provided a high level of modesty protection while using a fixed decontamination

34 shower setup with multiple curtains (Hood et al., 2011). If some type of simple clothing, such as hospital
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1 garments, or blankets or sheets, with which patients can cover up are available, this may not only help to

2 maintain privacy but also provide some comfort, possibly mitigating negative psychological consequences

3 resulting from a patient having been involved in a traumatic mass exposure incident(Holloway, 1997;

4 DiGiovanni, 1999; Fetter, 2005).

5

6 Documentation of the importance of protecting patient privacy during decontamination is inadequate.

7 There is little evidence in the scientific literature demonstrating that protection of privacy influences

8 patient outcome or compliance. However, findings from actual incidents and exercises suggest that the

9 level of privacy provided to patients during decontamination can significantly influence their comfort and

10 psychological well-being and potentially their compliance with the process. Seven of the eight current

11 guidance documents included in our crosswalk analysis recommend that patients’ privacy be maintained

12 as resources allow. SMEs unanimously supported this guidance statement while emphasizing the

13 importance of not delaying urgently needed decontamination for the purpose of waiting for materials or

14 equipment to provide privacy.
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Guidance Statement 2.7

In the absence of specific information about the contaminant, water is the preferred decontaminant in the

case that gross patient and/or technical patient decontamination is deemed appropriate.

Considerations:

• Depending on the decontamination system, water parameters (e.g., pressure, flow and temperature)

may or may not be easily manipulated.

• Water-based decontamination may be contraindicated or delayed due to concerns for weather-related

and/or environmental injuries, such as cold weather injuries and heat illness (see also Guidance

Statement 2.11 for alternative practices).

o For ambient temperatures between 36 - 64° F, indoor methods for water-based 

decontamination should be considered and indoor post-decontamination activities should 

be implemented

11

.

o For ambient temperatures at and below 35° F, water-based decontamination should only be

conducted indoors (e.g., showers and swimming pools at gyms, schools or other facilities)

and

indoor post-decontamination activities should be implemented.

• Water used for decontamination may be subject to local or state environmental regulations regarding

storage and disposal (see Guidance Statement 5.8).

• The efficacy of decontamination may be improved by the addition of mild soap to water (See

Guidance Statement 2.9).

• Water-based decontamination should be avoided when water-reactive chemicals are involved.

Level of Confidence: I

1

2 Discussion:

3 A variety of decontamination solutions have been demonstrated to either significantly reduce the amount

4 of a contaminant on skin or mitigate adverse health effects and therefore, be useful as decontaminants.

5 Many of these solutions are water-based but contain an additional ingredient such as soap. Studies that

6 have assessed water alone as a decontaminant are relatively limited. Nevertheless, a significant amount of

7 data demonstrating the efficacy of water alone as a decontaminant has been published. A large proportion 

8 of the data has been compiled from chemical burn cases, usually an accidental exposure of a person to a 

9 caustic chemical in the workplace or home. Retrospective analyses of such cases have found that patients

10 whose skin was rinsed with copious water within minutes of exposure experienced less severe injuries and 

11 needed less extensive medical care than patients who were not decontaminated with water shortly after

12 exposure (Leonard et al., 1982; Moran et al., 1987). Hall and Maibach (2006) conducted an extensive 

13 review of the literature on water decontamination of chemical burns, including occupational reports,

14 epidemiological studies, case reports and animal experiments. They concluded that early water

15 decontamination reduces the severity of chemical burn injuries, although it does not prevent all harmful

16 effects and additional decontamination solutions and/or strategies are needed.

17

18 In two studies utilizing human subjects, a water shower significantly reduced levels of simulated chemical

19 contaminants on the subjects. A water-only shower in the first stage of a hospital decontamination system

20 almost completely removed the relatively water-soluble ethyl lactate (a simulant for sarin) and also greatly

21 reduced the amount of the less water-soluble methyl salicylate (a simulant for sulfur mustard) on subjects 

22 (Torngren et al., 1998). Moffett et al. (2010) found that an oil-based simulant applied to subjects’

23 forearms was completely removed from all subjects by a water shower of 90 seconds duration and from

24 90% of subjects with a shower of only 30 seconds duration. This result is contrary to the hypothesis that

25 oily chemical agents require soapy water or another solution for effective decontamination. However, the

26 applicability of experiments on decontamination of simulants to incidents involving toxic industrial

 

11 The temperature ranges listed in this Guidance Statement are based on existing ECBC (2009) guidance, the literature

review, and Subject Matter Expert (SME) input during the 2012 symposium.
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1 chemicals or chemical warfare agents is not clear.

2

3 A series of in vivo studies of decontamination efficiency for several different industrial chemical

4 contaminants applied to the skin of rhesus monkeys suggest that washing with water alone can 

5 remove a significant proportion of the initial amount of contaminant (Wester et al., 1991; Wester

6 et al., 1992; Wester et al., 1999). Decontamination efficiency was dependent on the specific 

7 chemical contaminant and the time after chemical exposure. Glyphosphate, a relatively water

8 soluble herbicide, was the most amenable to removal with water, while alachlor (also an 

9 herbicide) and methylene bisphenyl isocyanate, which are much less water-soluble, were more

10 resistant to water decontamination. The efficiency of water decontamination of each of these

11 three chemicals decreased as the delay following chemical exposure increased, although more 

12 than one-third of the initially applied amount was still removed with decontamination conducted

13 several hours after exposure. It should be noted that decontamination was conducted in these 

14 studies by washing the skin with cotton that had been wetted with water; skin was wiped multiple

15 times with the wet cotton. This procedure differs from the showering used in some other studies.

16

17 Finally, the results of several in vitro studies, using different experimental setups, lend support to water as

18 an effective decontaminant. Formaldehyde was recovered from human cadaver skin by washing with

19 water with an efficiency that was high at one minute post-exposure but declined with increased

20 decontamination delay (Zhai et al., 2007). Using a model decontamination shower, Reifenrath and

21 colleagues (Reifenrath, 1980; Reifenrath et al., 1984) achieved significant decontamination of pig and

22 human cadaver skin that had been contaminated with diethyl malonate, thickened diethyl malonate, soman 

23 or thickened soman, by showering the skin with water alone. Decontamination efficiency varied

24 depending on several factors, including water pressure and temperature, shower duration, and the specific

25 contaminant.

26

27 Together, the studies described above build a case that water has good efficacy in removing contaminants

28 from skin and mitigating chemical contaminant-induced injuries. The data are based on a variety of

29 chemical contaminants and specific decontamination methods, such as the parameters determining how

30 water is applied to skin. Water has several additional advantages that make it the preferred decontaminant

31 for gross and technical patient decontamination: wide availability, low cost, stability under a wide range 

32 of environmental conditions, ease of storage, and safety. All of the existing guidance documents included

33 in the crosswalk analysis recommends water as a decontamination solution.

34

35 When considering using water as a decontaminant, first responders and first receivers need to be cognizant

36 of the risks. Water-based decontamination conducted outdoors may introduce risk from weather-related

37 injuries including cold weather injuries; heat illness may also be a concern if patients remain outside, 

38 unshaded on a hot day for prolonged periods following decontamination. The American Conference of

39 Governmental Industrial Hygienists (ACGIH) publishes annual Threshold Limit Values (TLV) guidelines, 

40 which include guidance on cold injury prevention practices (ACGIH, n.d.). Hypothermia is a serious cold 

41 injury; the risk of which increases when people are exposed to water and left to remain wet (even in fairly

42 temperate conditions such as 75oF). This is particularly true of certain patients – such as the very young

43 and very old – who may be susceptible to hypothermia even when healthy adults typically would not be

44 due to their body composition (infants) and impaired thermoregulation (the elderly). The US Department

45 of the Army has published Medical Technical Bulletin on Prevention and Management of Cold-Weather

46 Injuries (TB Med 508, 2005); their studies suggest that convective heat loss is about 25 times greater in 

47 water than air. For example, wet clothing and immersion in water increase heat loss substantially, 

48 increasing the likelihood of hypothermia. Chemical incidents occurring in cold temperature conditions

49 require planning to care for patientssubjected to water-based decontamination. Plans should include

50 capabilities to provide warm shelters, dry blankets, dry towels, dry clothing, and/or immediate removal

51 from the scene
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Guidance from the US Army Soldier and Biological Chemical Command

12 1 (2002) suggests that

2 firefighters can decontaminate the general population utilizing water when the ambient temperature is at or

3 above 65oF with a minimal risk of incurring cold weather related injuries, provided that patients are not

4 required to stand outside unprotected from the environment for extended lengths of time. The same

5 guidance recommends water decontamination outdoors from 36oF to 64oF if the patient is then directed to

6 a heated enclosure after decontamination. Below 35oF, water decontamination in a heated enclosure or a

7 form of dry decontamination is recommended.

8

 

12 The US Army Soldier and Biological Chemical Command was renamed the Research, Development and

Engineering Command effective 9 October, 2003.
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Guidance Statement 2.8

In the absence of specific information about the contaminant, the following parameters are recommended

for water-based decontamination:

• Low pressure (~50 – 60 psi)

• High volume

• Tepid (slightly warm, not hot) temperature

• Duration no longer than three minutes; ensure thorough soaking

Considerations:

• Optimal parameters for water-based decontamination have not been uniformly established.

• There is some evidence that increased pressure, duration, and/or temperature can lead to increased

absorption or penetration of some chemicals; this is known as the wash-in effect.

• Water pressure for pediatric and geriatric populations may need to be adjusted to minimize additional

harm.

• Based upon the class, characteristics, and amount of the chemical contaminant, the duration of the

shower may vary.

Level of Confidence: III

1

2 Discussion:

3 Systematic investigation of the influence of the variables that determine how water is delivered to patients

4 for decontamination on the efficacy of decontamination has been limited. Reifenrath (1980) conducted

5 the most extensive study, varying water pressure, nozzle type, shower duration, decontamination solution

6 temperature, and the addition of a detergent to water. Pressure had the greatest effect on decontamination

7 efficacy in an in vitro model of a patient decontamination system in which human cadaver skin was

8 contaminated with one of two radiolabeled chemical simulants. Efficacy was determined by measuring

9 the amount of simulant removed from the skin surface by the decontamination shower. The varied

10 decontamination solution temperatures, nozzle types, and addition of Triton X-100 detergent did not affect

11 decontamination efficacy. Longer shower duration improved efficacy but only at the lowest water

12 pressure studied.

13

14 Other studies have suggested that increasing shower or wash duration beyond a minimally effective length 

15 of time has little or no effect on decontamination efficacy. In a study of a mass patient decontamination 

16 system, doubling shower duration from three to six minutes did not result in a change in the effectiveness 

17 of the shower in removing a fluorophore from the skin of volunteer patients (Amlôt et al., 2010). An oil18 based fluorescent simulant applied to a forearm of volunteer patients was completely removed, or at least

19 undetectable, in 90% of patients after a 30-second shower and in 100% of patients after a 90-second

20 shower (Moffett et al., 2010). A recent comparison of a newly recommended method for mass patient

21 decontamination (the ORCHIDS protocol) with a previous standard method suggests that an increase in 

22 shower duration from 1.5 to three minutes does not enhance efficacy as measured by survival and

23 reduction of clinical effects in pigs exposed to a supralethal dose of VX (Misik et al., 2012). The

24 ORCHIDS protocol, which includes the shorter 1.5 minute duration shower, was significantly less

25 effective than the standard protocol, which includes a three minute shower, in preventing a reduction in

26 cholinesterase activity, although the unreliability of cholinesterase activity in predicting clinical effects has 

27 been documented previously. There were additional differences between these two decontamination

28 protocols and the results of varying shower duration from this study alone should be interpreted with them

29 in mind. By contrast, an analysis of patient decontamination efficacy during a simulated mass chemical

30 exposure found that a shower of > six minutes duration resulted in removal of a significantly greater

31 amount of a simulant, which could be visualized and quantitated under a black light, from patientsthan a 

32 shower of < four minutes duration (Hood et al., 2011). The authors concluded that shower duration

33 should be at least five minutes.

34
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1 Otherwise, limited information can be gleaned from studies that provide a single data point for a water

2 parameter that is associated with effective decontamination. For example, in the study by Moffett and

3 colleagues (2010), water at 35°C and a pressure between 60 and 70 psi applied to patients for 30-90

4 seconds resulted in complete removal of an oily contaminant. A hospital-based decontamination system

5 utilizing water at 30°C significantly reduced chemical simulant contamination on patients after a three

6 minute shower and further reduced contamination after an additional five to ten minute shower with soap;

7 water pressure was not reported (Torngren et al., 1998). These studies provide support for particular water

8 temperatures, pressures and durations in effectively decontaminating patients. However, it must be

9 assumed that such results may be dependent on other factors within each of the specific decontamination

10 systems or methods and comparison between studies should be made with caution. The best approach to

11 estimating the optimal parameters for water-based decontamination is to vary the parameters of interest

12 one at a time while controlling as best as possible for all other variables, using the same system or method

13 for decontamination – more such studies are urgently needed. It should also be noted that the optimal

14 water parameters may depend on the specific chemical contaminant; studies should be conducted using a

15 range of types of chemical agent and simulant contaminants.

16

17 Several of the authors cited above mentioned the importance of identifying the minimal conditions that

18 will lead to effective patient decontamination in order to (1) maximize the patient throughput rate for a

19 mass exposure incident (Amlôt et al., 2010; Misik et al., 2012) and (2) minimize the potential for wash-in

20 of contaminants (Reifenrath, 1980). The risk of wash-in, which is defined by Moody and Maibach (2006)

21 as “an enhancement of percutaneous absorption elicited specifically by skin decontamination,” has long

22 been a concern. However, data suggesting that skin decontamination can cause wash-in comes mostly

23 from in vitro studies and the mechanisms are not understood. Increased humidity and temperature have

24 been shown to promote percutaneous absorption of acetylsalicylic acid through excised human skin

25 (Fritsch and Stoughton, 1963) and high relative humidity (above 85%) significantly increased absorption

26 of parathion through excised pig skin (Chang and Riviere, 1993). Percutaneous absorption of caffeine

27 through excised human skin could also be enhanced by application of pressure to the skin, which was

28 meant to mimic massage (Treffel et al., 1993). Since humidity, temperature and pressure are all likely to

29 be elevated on or near a patient’s skin by water-based decontamination; some experts have suggested that

30 water-based decontamination can produce a wash-in effect. This hypothesis, however, has not been

31 validated through in vivo experiments. More research is needed to identify conditions under which the

32 risk of wash-in may be significant.

33

34 Among the previous guidance documents included in the crosswalk analysis, few specific

35 recommendations are provided regarding the parameters for water-based decontamination, reflecting the

36 lack of data in this area. The US Army ECBC (2009) recommends water delivered in high volume and

37 low pressure (∼60 psi) for 30 seconds to three minutes. The DOD TSWG (2004) recommends high

38 volume, low pressure and lukewarm water. An initial rinse of at least one minute with tepid water

39 followed by a more thorough washing with soap and water are recommended by both of the HHS40 ATSDR guidance documents (2000) and both OSHA guidance documents (2005,2009). The OSHA

41 guidance documents also cite several other sources that recommend varied durations of decontamination

42 (2005, 2009).

43

44 The guidance provided here is aimed at achieving a balance between the parameters for water-based

45 decontamination that should provide for effective patient decontamination and those that should minimize

46 the risk of patient harm due to wash-in, based on all of the available evidence. There may be

47 circumstances in which shower time or use of a specific decontaminant is advised by a credible source 

48 (e.g., manufacturer Material Safety Data Sheet [MSDS] or Safety Data Sheet [SDS] or Chemical

49 Transportation Emergency Center [CHEMTREC] technician).

50
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Guidance Statement 2.9

When water-based decontamination is indicated, mild soap, if available, should be added to water for

gross patient and technical patient decontamination, especially if the contaminant is thick, oily, or

otherwise difficult to remove by water alone.

Considerations:

• Do not delay decontamination efforts in order to acquire mild soap.

• Examples of mild soap include items suitable for daily contact with skin.

• Do not use dishwasher detergent, laundry detergent, cleaning products, abrasive cleaners, or anything 

not suitable for daily contact with skin; consult the MSDS (or SDS) for potential products.

Level of Confidence: II

1

2 Discussion:

3 The efficacy of decontamination may be improved by the addition of mild soap to the water; however,

4 studies comparing the effectiveness of water alone versus soapy water are limited. Soap can increase the

5 partitioning of oily or viscous contaminants away from the skin better than water alone. Bjarnson et al.

6 (2008) noted that soapy water has been a top “decontaminant of choice” in cases of mass chemical

7 exposure, citing the inexpensive and universal availability. Bjarnson et al. (2008) also showed that soapy

8 water was effective in preventing the onset of severe symptoms after exposure to VX in domestic swine.

9

10 Soapy water is particularly efficacious when attempting to decontaminate areas affected by lipid-soluble

11 chemicals (Hall & Maibach, 2006). However, the unavailability of soap should not delay water-only

12 decontamination, nor should water-only decontamination be considered inferior or sub-standard care even

13 if a contaminant is known to be oily or waxy.

14

15 While several of the studies from the literature review were extremely well designed, they did not provide

16 a head-to-head comparison of water to soapy water; they only used control groups exposed and not

17 decontaminated. Wester, et al. (1992) decontaminated alachlor, an herbicide, with either a 50% liquid

18 soap (1:1 v/v of soap to water), or water alone, on rhesus monkeys. The combination of soap and water

19 reduced the percutaneous absorption of alachlor more than water alone after the first wash (73% vs. 36%)

20 and after three washes (82% vs. 50%). In a small study, Moffett et al. (2010), showed the effectiveness

21 (as measured by the time necessary to complete decontamination) of water alone for an oily (e.g.,

22 vesicant) agent. This study used a fluorescently-labeled simulant (baby oil) applied to volunteers’ arms,

23 after which, a decontamination shower (60-70 psi, 35oC) was effective in removing 100% of the simulant

24 after 90 seconds. The study by Wester clearly demonstrated the efficacy of soapy water in a rhesus

25 monkey/alachlor model, revealing greater effectiveness than water alone. The small study by Moffett

26 using a simulant suggests that water alone is effective, even with an oily contaminant, and should not be

27 delayed or withheld in an effort to add soap.

28

Braue et al (2011a/b) demonstrated an increase in the LD50 29 13 of VX using 1% soapy water over no

30 decontamination in guinea pigs. However, most of this increase in the LD50 was likely due to the

31 performance of ANY decontamination; the study did not test a water-only control. Thus, because the

32 study did not test for a water-only control, the efficacy of soapy water versus water alone could not be

33 directly assessed.

34

35 A previously released guidance document (DOD TSWG, 2004) highlights the increase in decontamination 

36 efficacy that soap provides:

37 a. Soap can aid in dissolving some of the oilier chemical agents like VX or blister agents.

 

13 An increase in LD50 indicates that more contaminant is required to cause lethality in 50% of subjects.
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1 b. “Liquid rather than solid soaps should be used because they are quicker to employ, reduce the need

2 for mechanical scrubbing, and could reduce secondary contamination risks.”

3 c. Limitations to soap include the need to have it immediately available and the time required for

4 mixing; decontamination should not be delayed while waiting for soap to become available.

5

6 OSHA Guidance for Protecting EMS First Responders (2009) recognizes the utility of soap and water as

7 efficacious in decontamination: “soap and water remains the best practice for most contaminants under

8 most circumstances of mass decontamination”.

9

10 ECBC (2009) guidance suggests that water is often used for initial decontamination, but that soap and

11 water may be needed for a technical decontamination, especially involving the removal of oily liquid

12 agents. Soap can improve decontamination efficacy by increasing degradation of a chemical agent and

13 “aids in dissolving oily substances like blister and nerve agents”.

14

15 SME input strongly supported the addition of soap to water for decontamination when possible and

16 specified that soap refers to a mild, non-abrasive, liquid soap and not a detergent. There should be no

17 delay of water-based decontamination in an effort to procure or prepare soap and water solutions. No

18 ideal percentage for a soap and water solution has been determined scientifically nor is widely accepted in

19 practice. Subject matter experts recognized the limitations of extrapolating the results of studies based on

20 animal models to humans.

21
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Guidance Statement 2.10

The use of a non-abrasive sponge, washcloth, or similar wash item may enhance water-based

decontamination by increasing the physical removal of a contaminant through lightly rubbing

contaminated areas.

Considerations:

• Technical patient decontamination should not be delayed to acquire specific wash items.

• Sufficient quantities of wash items should be available to avoid reuse and contamination transfer.

• The wash item used for rubbing will itself become contaminated and may be disposed of as hazardous

waste in accordance with jurisdictional guidance.

• Wash items should be different than items that may have been used for self-care (e.g., cloths,

handkerchiefs, baby wipes).

• Scrubbing too hard can abrade the skin and lead to enhanced chemical penetration.

Level of Confidence: I

1

2 Discussion:

3 The use of a washing item, such as a sponge or washcloth, may enhance decontamination; use of a

4 washcloth or sponge may improve the mechanical removal of thick, heavy contaminants that are more

5 adherent to the skin. However, the use of a sponge or washcloth immediately raises several issues,

6 including abrasion of skin due to scrubbing, which can increase absorption, and risk of transferring

7 contamination between patients if there is insufficient availability of clean wash items. Additionally, use

8 of a wash item may transfer contaminant to a relatively uncontaminated body part, such as from the hands

9 to a clean torso. Further, instructions provided to patients on the proper use of a washing item require

10 time, which is a critical factor during decontamination. Lastly, all wash items require appropriate disposal

11 following the incident.

12

13 The literature on use of a washcloth or sponge is limited. Amlôt et al. (2010) conducted a human study of

14 decontamination effectiveness using a three-way interactive design (i.e., no washcloth, washcloth, and

15 washcloth with instructions on its use) after application of a chemical simulant. The exposure model and

16 unbiased measurements of residual contamination, using infrared imaging, were the study’s strengths. Use 

17 of a washcloth resulted in a 20% reduction in contamination versus no washcloth. A slight decrease of

18 effectiveness was seen when verbal and pictorial instructions were provided on use of the washcloth; the 

19 study’s authors subsequently determined that the decrease in effectiveness was due to two factors: (1)

20 subjects spent some of their time in the shower reviewing the instructions instead of washing and (2) adult

21 subjects misinterpreted the pictorial instructions (Winfield, 2011).

22

23 Several existing guidance documents and manuals also support the use of an implement to assist with

24 contaminant removal. DOD TSWG (2004) emphasized the importance of replacing sponges or

25 washcloths between every patient. In addition, ECBC (2009) acknowledges the utility of a soft cloth or

26 sponge and that gentle friction may assist with the removal of chemical vapors and aerosols. However,

27 there is the theoretical risk that the use of an implement may spread oily contaminant, such as mustard

28 agent, and, thus, care must be exercised to use only gentle friction in the localized area of contamination

29 (ECBC, 2009). OSHA’s Best Practices for First Receivers (2005) warned against using a wash item,

30 which could damage the skin and facilitate chemical penetration (e.g., stiff brush, abrasive pad).

31

32 SME input was that use of a wash item improves decontamination effectiveness with the understanding

33 that decontamination should never be delayed in order to procure wash items. Instructing patients in

34 proper decontamination technique with a wash item should emphasize (1) gentle rubbing, (2) avoidance of

35 traumatizing the skin, and (3) localized rubbing when there is risk of spreading viscous or oily

36 contaminant (e.g., blotting). Sufficient numbers of wash implements are needed in order to avoid cross37 contamination between patients by using the same item. It must be emphasized that in the absence of

38 wash items, decontamination with water alone should never be delayed. Additionally, the use of
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1 washcloths or sponges for decontamination incurs the issue of waste disposal.
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Guidance Statement 2.11

Alternative practices or decontaminants should be incorporated into the decontamination process when

water-based decontamination is contraindicated (e.g., due to weather/environmental concerns, chemical

reactivity) or delayed (e.g., due to resource or capability limitations or logistics). This planning should

include identifying possible alternative locations (e.g., showers at a gym or swimming pool) for waterbased decontamination when necessary.

• Alternative decontamination practices in lieu of water-based decontamination include: Alternative

practices may include:

o Delaying water-based decontamination

o Non-water based decontamination techniques

• Alternative decontaminantsinclude:

o Approved neutralizing agents (e.g., partitioning and chelating agents)

o Chemical specific decontaminants (e.g., polyethylene glycol for phenolic compounds)

o Absorbent materials (e.g., spill pads, oil-dry, kitty litter, Fuller’s Earth)

o Adsorbent materials (e.g., activated carbon)

Considerations:

• Reactive Skin Decontamination Lotion ©(RSDL

©

) is cleared by FDA as a device only for spot

decontamination and only for use with CWAs.

• Bleach solutions are not recommended for chemical decontamination in a civilian mass-exposure

incident; the contact time required for effectiveness is too long to be practical and is associated with

potential irritation to the skin which may increase chemical penetration.

• Chemical neutralization of acids or alkalis on skin or eyes with acidic or basic decontamination

mixtures (e.g., 1% acetic acid for alkali burns; sodium bicarbonate for acid burns) is not

recommended.

Level of Confidence: IV

1

2 Discussion:

3 When the decision is made to perform decontamination, it should be conducted at the scene (preferably),

4 as expeditiously as possible to reduce chemical “contact (residence) time”, and may involve a tiered

5 approach including self-care, gross patient, and technical patient decontamination. The cornerstone of

6 effective decontamination is the removal of contaminated clothing, followed by decontamination with

7 water, as well as with soap and a cloth or sponge, if available.

8

9 Risks Prompting Consideration of Alternative Practices or Decontaminants

10 Water-based decontamination has the ability to create adverse outcomes itself. These adverse outcomes 

11 include:

12  Extending contamination to clean parts of the body: minimally contaminated patients who

13 undergo

14 gross patient or technical patient decontamination may inadvertently wash contaminant onto an

15 uncontaminated limb, into their eye, or aerosolize and subsequently inhale contaminant during

16 showering;

17  Patients decontaminated in cold weather who risk the development of hypothermia, in addition to

18 their chemical-specific injuries;

19  Patients who sustain mechanical injury (i.e., slips, trips, and falls);

20  Psychological consequences in patients involved in a traumatic mass exposure incident may be

21 compounded in patients for whom a technical patient decontamination process (which may

22 include

23 stripping and showering in view of rescuers and other patients) is necessary and in which

24 responders manage casualties , without sufficient communication (Fetter, 2005; Carter, 2012).

25
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1 Alternatives to Immediate Gross Patient or Technical Patient Decontamination in Cold Weather

2 Decontamination is scalable, and if the risk of wet decontamination in an extremely cold environment is

3 too great, disrobing patients and providing uncontaminated covering in the short term may be sufficient to

4 substantially reduce the risk of chemical-specific health outcomes without inducing hypothermia.

5 Technical patient decontamination may then occur indoors when warm refuge is available. Alternate

6 decontamination practices should be considered when water-based decontamination might be

7 contraindicated. These practices include, but are not limited to:

8  Delaying water-based decontamination due to unfavorable weather conditions;

9  Forgoing water-based decontamination in favor of evacuation and clothing removal for non10 reactive gases;

11  Or use of alternative decontaminants such as polyethylene glycol (PEG) for phenol water12 reactive compounds

13

14 Consideration for adverse outcomes of water-based decontamination, including environmental, and

15 physical and psychological injury to patients, has been previously established in several existing guidance

16 documents (DOD TSWG, 2004; OSHA/Receivers, 2005; ECBC, 2009; OSHA/EMS, 2009).

17

18 Alternative Decontaminants When Water is Contraindicated

19 Unique contamination situations may require consideration of an alternative decontamination solution. For

20 example, RSDL© is considered more efficacious for chemical warfare agents (i.e., nerve and mustard

21 agents) because the solution itself is designed to specifically neutralize nerve agent and partition sulfur

22 mustard away from the skin. In certain niche industries, a particular chemical or mixture may have an

23 especially effective decontaminant; it is not clear how such unique situations might inform general patient

24 decontamination guidelines. Water-reactive chemicals require consideration of alternative removal

25 processes such as dry mechanical removal/brushing (for water-reactive metals) or an alternative solution

26 that has been shown to provide better efficacy (i.e., polyethylene glycol solutions for phenol, [Monteiro27 Riviere et al., 2001; Brown, et al., 1975]).

28

29 Chemical Neutralization of Acids/Alkalis Is Contraindicated

30 Some water-reactive or exothermic chemical reactions (i.e. acid or base) may be an absolute

31 contraindication to water-based decontamination. Early experimental evidence supports the efficacy of

32 immediate water decontamination of acid and alkali chemical burns; the same experiment demonstrated

33 more severe burns if chemical neutralization (5% NaHCO3/acid burns; 1% acetic acid/alkali burns) was

34 attempted in lieu of water decontamination (Davidson, 1927). Sodium hydroxide burns treated with 0.35

35 M sodium citrate in a rat model showed higher (more alkaline) subcutaneous pH at 1 minute over those

36 decontaminated with water alone, suggesting that “neutralization” of the alkaline chemical was(1) slower

37 when an acidic decontamination solution was used, and (2) caused more harm than water washing alone

38 (Yano, 1994). Water decontamination also resulted in less severe burns in a 45% sodium hydroxide39 exposed rat model than did PEG (Brown, 1975). While neutralization (chelation, partitioning, physical

40 removal of a dry contaminant) may be more appropriate than water decontamination in select

41 circumstances, a neutralization reaction (acid burn/alkali solution; alkali burn/acidic solution) can cause

42 more extensive injury.

43

44 Chemical State May be Affected by Environmental Conditions

45 The ambient temperature of the surrounding air and weather conditions may impact the physical state of

46 the released chemical. Freezing points of select chemicals may make the method of decontamination

47 variable, depending on the physical state at the time of release. Conversely, chemicals initially released as 

48 liquids may evaporate, causing an increased inhalational hazard for patients and responders.

49

50 Bleach is No Longer Recommended as an Alternative Decontaminant

51 For the purposes of mass patient decontamination in a civilian population, dilute bleach solutions are not

52 recommended as an alternative decontamination solution. While bleach solutions have proven efficacious
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1 in certain situations and with specific chemical warfare agents (CWAs), notably some nerve agents and

2 sulfur mustard (Wormser, et. al., 2002; Bjarnson et.al. 2008; Braue, et. al., 2011 a/b), their use in civilian

3 population with an unknown chemical contaminant is not recommended. Research on the use of bleach

4 solutions indicates that the concentration and/or contact time required to neutralize chemical warfare

5 agents exceeds the contact time shown to cause skin or eye irritation (Wormser, et.al. 2002).

6

7 Additionally, the following logistical considerations were identified by SMEs demonstrating that a bleach

8 solution is an impractical alternative solution for a civilian mass patient decontamination. They include

9 (but are not limited to): (1) stocking and storage of bleach for mixing, ( 2) ensuring the correct ratio is

10 mixed (0.5%) and maintained throughout the decontamination process, (3) and the time required to ensure

11 the correct concentration of bleach solution.

12
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1 Functional Area 3: Evaluating the Effectiveness of Decontamination

2 Guidance statements 3.1 and 3.2 recommend criteria for determining if a patient has been decontaminated

3 sufficiently. Distinctions between effectiveness of patient decontamination and efficiency of

4 decontamination operations are also presented.

Guidance Statement 3.1

Decisions on whether contamination has been reduced to a level that is safe and/or additional

decontamination is necessary can be guided by the following indicators (and others as appropriate):

• Elimination of visible contamination from the skin and/or clothing;

• Observable improvement in signs and symptoms which prompted the decision to perform 

decontamination;

• Patient perceptions of the effectiveness of decontamination;

• Resultsfromappropriate detection technologies;

• Guidelines in Functional Area 2: Optimized Technical Practices were followed;

• If an effective decontamination method, which is known to be appropriate given the nature of the 

incident and chemical involved, is properly executed, then a sufficient reduction in contamination can

be implied.

Considerations:

• The effectiveness of decontamination may not be objectively measurable with current capabilities.

However, the above can be used as subjective indicators of achievement of the goals of providing first

aid to patients and protecting responders and receivers from secondary contamination.

• Detection technologies must be appropriate to the chemical, properly calibrated, and the user properly

trained

Level of Confidence: III

5

6 Discussion:

7 Within the available literature, there are no widely accepted guidelines for determining the effectiveness of

8 patient decontamination. In order to develop and validate tools for evaluating the effectiveness of a

9 process, objectives must be established. Such objectives for patient decontamination have not been

10 defined nor adopted by the emergency response community. Completely eliminating contamination is not

11 realistic and may not be necessary. Reducing contamination to below a threshold for causing adverse

12 health effects is difficult to implement because for many chemicals, the acceptable human exposure limit

13 is not known. Further, equipment with validated standards for its use in detecting contaminants on a

14 person is not available for making the precise measurements necessary to assess whether such objectives

15 have been met. The challenges of determining “how clean is safe” have been discussed in the literature

16 (IOM, 1999; Raber et al., 2001, 2004; Vogt & Sorensen, 2002). In the absence of established standards,

17 patient decontamination goals have been proposed here (see Desired end points for patient

18 decontamination section). These end points are based on health outcomes: improving patients’ short and

19 long-term health outcomes and protecting the health of responders and receivers. The criteria

20 recommended here for evaluating patient decontamination effectiveness are based on those health

21 outcome-focused goals.

22

23 Due to the lack of established goals and standards up to this time, there is little scientific data or other

24 published evidence to substantiate this or other approaches to evaluating patient decontamination

25 effectiveness. However, the guidance presented here is based on SME opinion and current practice, and

26 complements guidance statements on determining whether a patient needs decontamination (Guidance

27 Statement 1.1) and prioritizing among multiple patients who may need decontamination (Guidance

28 Statement 4.1 and 4.2).

29

30 Looking for elimination of visible contamination on skin and/or clothing is a common sense step toward

31 determining the effectiveness of decontamination. Signs and symptoms of chemical exposure which are
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1 manifest before decontamination may diminish during the course of decontamination. In some cases,

2 however, such as with the absorption of a significant dose of toxic chemical prior to decontamination,

3 effects may progress and become systemic. Signs and symptoms of systemic effects may not improve

4 until antidotes and/or other medical treatments are administered. Given these possibilities, it is

5 recommended that improvement in signs and symptoms be considered in combination with other

6 indicators, rather than by itself.

7

8 Some patients may be quite aware of where they are contaminated and where the levels are greatest. If so, 

9 they might also have a sense of whether the decontamination process reduced that contamination or

10 missed important areas. Many patients can potentially offer feedback on whether or not, in their

11 judgment, the decontamination process was thorough and if they feel any improvement in their condition.

12

13 The guidelines presented in Functional Area 2: Optimized Technical Practices represent the best current

14 thinking, based on available scientific evidence, expert opinion, and common practices in the field.

15 Although the guidance statements do not describe operational step-by-step practices, following the

16 guidelines can help to ensure that desired end points are achieved. Finally, if specific decontamination

17 practices have been demonstrated to be efficacious for known contaminants or certain incident types, then

18 their implementation should contribute to, and can be used as an indicator of the achievement of patient

19 decontamination goals.

20

21 With patient decontamination goals defined, it should be possible to more rigorously analyze the criteria

22 recommended here as indicators of effective decontamination.

23
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Guidance Statement 3.2

Timeliness and efficiency are critical elements of effective patient decontamination: an individual patient

needs to be decontaminated with minimal delay and patients in a mass exposure incident need to be

decontaminated expeditiously in order to do the greatest good for the greatest number. However, a rapid

pace must be balanced with quality and consistency of patient care to achieve the goals of providing first

aid to patients and protecting responders, receivers and health care infrastructure from secondary

contamination.

Considerations:

 Patient throughput or process-based endpoints alone, without consideration of impact on the 

 health of patients, responders and receivers is not a useful measure of effectiveness of patient

decontamination.

 Evaluation of the effectiveness of decontamination must take into account the desired end points,

which are health outcome-based.

Level of Confidence: V

1

2 Discussion:

3 Timeliness and efficiency of a patient decontamination operation are relatively easy to measure. The

4 delay between patient exposure and completion of decontamination should be estimable in most cases, and 

5 patient throughput in a mass exposure incident should be calculable. While minimizing time between

6 exposure and decontamination is critical, the thoroughness of decontamination which does improve patient

7 health outcome(s) should not be compromised for the sake of increasing patient throughput which in-and8 of-itself may not. Protocols need to be carefully executed and the operation should be monitored for

9 quality control. A rapid pace without proper execution will not lead to attainment of health outcome10 based patient decontamination goals. Therefore, a combination of factors need to be included in an

11 evaluation of effectiveness: (1) the indicators listed in Guidance Statement 3.1, which are the best means

12 currently available to determine, directly or indirectly, if and to what extent patient contamination has

13 been reduced; and (2) timeliness and efficiency.

14

15 Rapid decontamination and high patient throughput are often discussed in the literature and best-practice

16 guides as measures of effective patient decontamination (Brennan, 1999; Burgess, 1999; DOD TSWG,

17 2004; Houston & Hendrickson, 2005; ECBC, 2009). Patient throughput is also frequently reported in

18 after-action reports for exercises. However, the SMEs who participated in this project expressed an urgent

19 need to redirect assessments of effectiveness toward indicators that are more closely aligned with health 

20 outcome-based goals, but with timeliness and patient throughput still considered as measures of efficiency.

21 This guidance statement, then, has an LOC of V, since it is based on SME consensus but is not, to our

22 knowledge, current practice and no published supporting evidence is available. With increased acceptance 

23 and analysis of the effect of this guidance on patient, responder and receiver health outcomes, the LOC

24 may improve in the future.

25
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1 Functional Area 4: Patient Prioritization for Decontamination

2 For the case of a mass exposure incident, Guidance Statements 4.1 and 4.2 advise on prioritizing patients

3 for decontamination and coordinating decontamination with medical care.

Guidance Statement 4.1

Immediate, lifesaving medical care and/or antidotal therapy should ideally be a priority, over patient

decontamination.

Considerations:

• Responders must be appropriately trained and have the proper PPE in order to implement medical care

prior to patient decontamination.

• Lifesaving medical care will be defined by the Authority Having Jurisdiction

14

.

• This guidance should be followed as closely as possible within the resource and capability limitations

of the organization.

Level of Confidence: III

4

5 Discussion:

6 The balance between the need for lifesaving medical care and decontamination is tenuous and requires

7 responders and receivers to perform a risk and capabilities assessment to determine whether it is

8 appropriate and feasible to provide medical interventions in the “warm zone” while patients await

9 decontamination. The literature suggests that there is an ongoing debate related to when medical care

10 should be given following a chemical exposure. On the one hand, in the US, medical care following a

11 chemical exposure is typically conducted after patient decontamination (Hick et al., 2003b; Horton et al.,

12 2003; Koenig et al., 2008). Personnel trained to provide life-saving medical care are not always trained to

13 wear and conduct operations in PPE, whereas personnel trained to wear PPE do not always have the skills

14 necessary to render medical care to patients. On the other hand, setting up gross patient or technical

15 patient decontamination operations takes time during which it might be necessary to administer

16 immediate, life-saving care prior to – or in conjunction with – one or more tiers of patient

17 decontamination. However, non-life-saving measures, such as diagnostic and ancillary testing and

18 ongoing vital-sign assessments, are not appropriate until decontamination operations are completed and

19 the victim is in a clean environment (Hall, 1995; Laurent et al., 1999; Jagminas, 2008a; and Ramesh &

20 Kumar, 2010). As one example in which a delay in lifesaving care led to an excess of morbidity and

21 mortality: after the October 2002 Moscow theatre siege, delay in administration of an opioid antidote was

22 felt to be responsible for a majority of the hostage deaths (Wax, Becker, & Curry, 2003). Though

23 decontamination was not performed during the Moscow incident, the result of a delay in lifesaving

24 medical care (administration of a reversal agent) resulted in preventable deaths from respiratory arrest.

25

26 In other countries, for example France, Japan, Israel, and the United Kingdom, some have recommended

27 allowing properly trained medical providers wearing appropriate PPE to provide life-saving medical care

28 in the warm zone (Laurent et al., 1999; Okumura et al., 2003; Markel et al, 2008; Pillin, 2008).

29 Additionally, some U.S. guidance documents contain provisions for the administration of lifesaving

30 medical care in the warm zone or concomitantly with decontamination, in circumstances where the

31 patient’s condition poses a greater risk of death or morbidity than the ongoing exposure itself (ATSDR –

32 ED, 2000; ATSDR – EMS, 2000; DOD TSWG, 2004). OSHA’s Best Practices for First Receivers also

33 describes stabilizing those with life threatening conditions or injuries, such as shock and respiratory

34 failure, prior to entering decontamination (2005) Byers (2008) suggested rapid triage and lifesaving care, 

35 such as antidotes and trauma care, could be administered to patients by fire service personnel wearing

36 Level A PPE and medical providers on scene wearing Level C. An obvious limitation to the model

 

14 The public agency or its delegate that has legal responsibility and authority for responding to an incident, based on political

or geographical (e.g., city, county, Tribal, State, or Federal boundary lines) or functional (e.g., law enforcement, public health)

range or sphere of authority. Defined by the Department of Health and Human Services (HHS) in the Public Readiness and

Emergency Preparedness (PREP) Act, Declaration for Pandemic Flu (2009)
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1 proposed by Byers is that the use of Level C PPE on any scene in which the nature of the chemical hazard 

2 has not been fully characterized may not allow for adequate protection of medical personnel. Laurent et

3 al. (1999) also proposed that medical personnel enter the hot zone in PPE to administer life-saving

4 interventions (the French “Red” Plan). Lifesaving interventions administered before or during

5 decontamination should be limited to those likely to increase the chances of survival (1) through the

6 decontamination process and (2) which increase the likelihood a patient will survive to reach definitive 

7 medical care. For example, it may be possible to administer a nerve agent antidote to prevent respiratory

8 failure and terminate seizures for a non- ambulatory patient as they move through decontamination,

9 thereby allowing them to survive to reach a HCF where a ventilator and ICU level care are available for

10 definitive management. On the other hand, it may not be practical to perform extensive resuscitation

11 (including CPR) through the decontamination process. (The likelihood of surviving out-of-hospital cardiac 

12 arrest is very low, regardless of the cause) (Berdowski et al., 2010).

13

14 In certain situations, administration of life-saving interventions can occur during any of the tiered 

15 decontamination processes. However:

16  There must be adequate PPE for any responders providing immediate life-saving interventions for

17 a potentially contaminated patient, and the intervention must be doable while wearing PPE.

18  Life-saving interventions are resource and capacity dependent, and should only be performed if they 

19 are likely to prolong survival to the next level of care;

20 o For example, a patient who has performed self-care after nerve agent exposure and

21 subsequently developed seizures and respiratory arrest, might receive an antidote autoinjector

22 prior to undergoing non-ambulatory technical patient decontamination

23 o A patient with life-threatening hemorrhage might have bleeding control (direct pressure;

24 dressing) applied prior to decontamination

25 o An unconscious patient whose airway is compromised by position, vomitus, or secretions,

26 might have their airway repositioned, cleared, or an oral airway inserted prior to

27 decontamination

28  The lethality of many chemical warfare agents, even at low levels of exposure, suggests that

29 minimal amounts of contamination may result in mortality irrespective of any lifesaving

30 interventions.

31
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Guidance Statement 4.2

Prioritize patients for decontamination by estimating relative risk and grouping patients into immediate

and delayed decontamination groups. Risk assessment should take into consideration the following

criteria (and others as appropriate) in preferential order:

• Need for immediate lifesaving care or antidotal therapy (see also Guidance Statement 4.1)

• Visible evidence of contamination on patient’s skin or clothing

• Patients displaying signs and symptoms of exposure

• Proximity of patient to the location of release

• Contamination detected on patient using appropriate detection technology

Considerations:

• Priority should be given to those patients who require decontamination in order to receive immediate 

care for life threatening conditions or injury, including antidotal therapy.

• Children should be prioritized before adults within the same decontamination priority group.

• Age, pregnancy and chronic medical conditions should also be considered when estimating relative

risk and prioritizing patients for decontamination.

• Concerned citizens who are at low risk of contamination may request to undergo decontamination.

• In a mass exposure chemical incident, patients needing decontamination most urgently may not be the

first to present; ambulatory patients may reach first responders or first receivers more quickly than

non-ambulatory patients.

• Self-reporting patients arriving at a health care facility should also be prioritized according to these

criteria.

Level of Confidence: III

1

2 Discussion:

3 There is little published evidence, either experimental or empirical, suggesting the best means to triage or

4 prioritize patients according to their need for decontamination. A variety of triage systems are proposed in 

5 the literature, many based on traditional mass casualty incident medical triage protocols (e.g. START,

6 SALT, SIEVE) (Cieslak et al., 2000; Kenar & Karayilanoglu, 2004; Cone & Koenig, 2005; Subbarao et

7 al., 2005; Okumura et al., 2007; Neal et al., 2010; Ramesh & Kumar, 2010). With the exception of

8 assessments of two triage systems, no attempts have been made to evaluate these prioritization schemes

9 empirically or validate them as providing a decrease in overall levels of morbidity or mortality (Bond, 

10 2008 Cone et al., 2008).

11

12 The triage system evaluated by Cone et al. (2008) was developed as a CBRN triage system which includes

13 recommendations for both patient decontamination and medical care (Cone & Koenig, 2005). The

14 evaluation of the system was conducted in conjunction with a disaster drill and was limited to only the 

15 chemical and trauma algorithm. Despite recent training, the study found a high rate of under-triage (or

16 placing casualties in a triage category that was lower than where they should have been placed) as well as

17 a failure to recognize toxidromes. The results indicate that the system needs further refinement and 

18 testing.

19

20 Subbarao et.al. (2005) developed a set of symptom-based triage algorithms for CBRN incidents based on

21 situational characteristics (e.g. type of attack or release) and patient presentation. While patient

22 decontamination is identified in some of the algorithms, others focus on providing medical care or other

23 protective measures. Bond et.al. (2008) conducted a usability assessment of this system with first

24 receivers (attending physicians, emergency medicine residents, and nurses) using 26 paragraph length

25 written scenarios. Aggregate scores for all scenarios and all testing groups yielded a correct triage rate of

26 45%, indicating that additional revision and simplification of the algorithms is needed.

27

28 It has also been noted that there is no commonly accepted evaluation method. Before an applicable triage

29 system can be examined, a standard evaluation method needs to be established (Ramesh & Kumar, 2010).
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1 The use of triage protocols or other methods to prioritize patients is also well represented in best-practice

2 guides – seven of the eight documents examined mention prioritizing patients for decontamination. The

3 assertions in this guidance statement would be difficult to evaluate in a controlled human trial but could be 

4 analyzed through retrospective study of actual incidents.

5

6 The list of criteria proposed in this guidance statement is an extension of the criteria listed in guidance

7 statement 1.1 used to determine if a patient requires decontamination in the first place. In this guidance 

8 statement, these criteria are used to prioritize patients who require decontamination according to a resource 

9 and/or time-constrained response, where some patients may require decontamination sooner than others. 

10 Upon evaluation, patients should be categorized into immediate or delayed categories based on the 

11 criteria listed; this evaluation is in addition to, and should take into account, traditional medical triage.

12

13 Need for medical care or antidotal therapy

14 Patient decontamination should not be delayed when lifesaving medical care or antidotal therapy are

15 needed and available. Alternatively, if resources are available, lifesaving medical care or antidotal therapy

16 should not be delayed while waiting for decontamination. Providing medical care and antidotal therapy in 

17 the warm zone while patients are awaiting decontamination requires properly trained personnel in 

18 appropriate PPE (Laurent et al., 1999; Okumura et al., 2003; Markel et al., 2008).

19

20 Visible

21 Visible indications of chemical contamination on the patient or the patient’s clothing are another factor

22 that can be used to determine the need for decontamination (Ramesh & Kumar, 2010). Visible evidence

23 of contamination indicates an ongoing exposure with increased contact time (Kirk & Deaton, 2007).

24

25 Symptoms

26 Toxidromes, or clusters of symptoms, could be utilized to help distinguish between affected and

27 unaffected individuals (Kirk et al., 1994; Markel et al., 2008) and between priority levels (immediate and

28 delayed). However, there is some research to suggest that individuals who have a low probability of being

29 contaminated can still exhibit symptoms that do not have an organic origin (Kirk & Deaton, 2007),

30 indicating that additional information is required to determine their appropriate priority level for

31 decontamination.

32

33 Proximity

34 Patients who were in closer proximity to a release are suspected of having received a higher dose of

35 contamination and therefore have a higher need for decontamination than a patient who was further from

36 the release (Kirk & Deaton, 2007). Proximity to the release is cited in various articles as one of the main

37 factors to consider when determining decontamination needs (Ramesh & Kumar, 2010).

38

39 Detection

40 Historically, there is a lack of discussion in the literature regarding the use of detection and diagnostic

41 technologies that can be used to determine decontamination requirements. Although there are

42 environmental detection technologies available and are used by first responders to characterize hazardous

43 environments, there is little mention of the use of these devices in determining decontamination

44 prioritization. Ancillary testing, such as laboratory confirmation of contaminants in biological samples,

45 has no role in the immediate decision to decontaminate or prioritize decontamination. While subsequent

46 confirmation of exposure through laboratory testing may inform some aspects of attribution (who was

47 exposed versus who was not), medical management (ongoing antidotal therapy), or prognosis, no
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1 laboratory result could reasonably be expected to be available, on scene, to prioritize decontamination

2 decisions.

3

4 Age extremes, pregnancy, and chronic medical conditions, should also be factored in to the prioritization

5 framework, with the assumption that patients in these categories may have a higher risk of injury due to

6 the chemical contamination. Historical examples indicate that in a mass patient incident, those needing a

7 higher level of care are not the ones to reach responders and receivers first (Okumura et al., 1996; Scanlon, 

8 2010). In these cases, decontamination should still be conducted until patients of a higher risk category

9 arrive for decontamination and treatment.

10
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1 Functional Area 5: System-wide Coordination of Patient Decontamination

2 The purpose of Functional Area 5 is to promote planning that is coordinated throughout the entire

3 community and addresses the needs of all community members. Guidance particularly emphasizes the

4 importance of communication and coordination between responders at the incident scene and at health

5 care facilities.

Guidance Statement 5.1

If decontamination is indicated, it should be performed as soon as possible, preferably at the scene if not

contraindicated by safety considerations.

Considerations:

• The location for on-scene patient decontamination should be at the perimeter of the warm zone 

upwind, uphill and far enough away from the chemical release location to prevent re-contamination and 

serve as the egress point to the cold zone.

Level of Confidence: II

6

7 Discussion:

8 Once the decision is made to decontaminate patients, the best location for decontamination is at the scene

9 or at another suitable location that can be accessed with minimal delay if there are contraindications to on10 scene decontamination such as extreme weather, safety concerns, or a risk of additional release. The

11 preference for decontamination at the scene is based on several observations:

12

13  Decontamination at a facility introduces a delay and ongoing absorption of contaminants;

14  Only one decontamination set up is required. This depends on health care facilities accepting that

15 decontamination at the scene is sufficient, which in turn, depends on coordinated pre-incident

16 planning and trust building.

17  Decontamination at all potential receiving facilities requires more resources and introduces

18 considerable variability in the thoroughness of decontamination;

19  Decontamination at a facility risks contamination of transport assets;

20  Decontamination at a facility increases the risk of secondary contamination of medical 

21 infrastructure and personnel;

22  First responders are for the most part more proficient in decontamination than first receivers,

23 based on their training and frequency of equipment use (Keim et al., 2003; Moffett, 2010):

24 o They are more skilled in the use of PPE,

25 o They are more familiar with decontamination equipment,

26 o They exercise and re-train frequently.

27

28 Kirk and Deaton (2007) contended that decontamination is a first aid procedure and that any delay in its

29 execution increases the contact time patients have with a chemical. Considerable concern exists with

30 regard to secondary contamination. Okumura et al. (2005) noted that 10% of fire service personnel and

31 23% of the staff at St. Luke’s hospital had exposure to Sarin vapor following the 1995 Tokyo subway

32 attack; however, it should be emphasized that no decontamination – either on-scene or at the hospital –

33 was performed. Burgess (1999) examined 11 ED secondary contamination events and found that the

34 resulting ED evacuations lasted from 1-10 hours during which between 0 and 50 ED patients had to be

35 moved. In addition, up to 15 medical personnel were treated for exposure.

36

37 Several existing guidance documents describe decontamination on-scene as the preferred approach (DOD

38 TSWG, 2004; ECBC, 2009) when not precluded by contraindications such as weather or safety concerns.

39 Subject matter experts asserted that decontamination at the scene, if possible, is the preferred approach.

40 First, rapid removal of contaminant and prevention of secondary contamination are obvious advantages.

41 Second, estimation of resources and personnel needed is easier when based on the number of patients

42 marshaled at the scene, than when decontamination is performed at multiple alternative sites or receiving
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1 facilities. Third, triage of patients to appropriate medical facilities is easier from one location than among

2 several different sites. Fourth, uniformity of assessment of the need for decontamination, quality of that

3 decontamination, and determination of the need for medical evaluation is easier from the scene. It is

4 possible that medical resources may be more readily available for those patients most in need if

5 decontamination is performed at the scene; effective decontamination at the scene could eliminate the

6 need to transport a proportion of patients to a health care facility, thereby preserving transport and hospital

7 access for those who more urgently require it. In such instances, some patients may not require

8 decontamination and thus, released, and some patients may undergo decontamination and be released 

9 following a period of asymptomatic observation.

10

11 Provision of follow-up instructions is easier on-scene where patients are all in one place. Additionally,

12 providing limited special resources for patient care (e.g., translation, behavioral health/psychological

13 support, special access equipment) is easier at the scene (one location) than providing the same resources

14 at multiple receiving facilities. Management of decontamination wastewater (containment and disposal) is 

15 also easier at the one location.

16

17 Subject matter experts recognize several limitations to the guidance provided in this statement: many

18 patients may self-evacuate and decontamination at facilities may be still required (Okumura et al, 1998a/b;

19 Vogt & Sorensen, 2002; US Chemical Safety and Hazard Investigation Board [CSB], 2008). At the same 

20 time, some patients will still insist on medical evaluation even if the possibility of exposure has been ruled 

21 out; they too may be required to first undergo decontamination at the facility at which they seek such

22 evaluation. Finally, some facilities may perform a second decontamination despite assurances that

23 patients have already been decontaminated at the scene.

24

25 The health outcome benefits of reducing contact time sooner rather than later – if weather or safety

26 concerns do not require consideration of an alternative approach – are apparent. Decontamination at the

27 scene, or as soon as possible thereafter, is optimal, even if not completely achievable.

28
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Guidance Statement 5.2

Anticipate self-evacuation from the scene prior to decontamination and develop a coordinated whole

community response plan to manage the entire spectrum of patients, which include:

• At scene: Ambulatory and non-ambulatory patients who remain at the scene; individuals other than

responders who arrive at the scene after the release and become exposed (e.g., news reporters,

bystanders).

• Self-evacuated: Patients who travel without the assistance of responders to a health care facility (e.g.,

hospital, physician’s office, or urgent care center).

• Left scene: Patients who leave the scene and do not seek care (e.g. return home or to work, travel

elsewhere), or seek care later due to delayed onset of signs and symptoms.

Considerations:

• The response community should be prepared for a spectrum of patients who may seek delayed care,

including:

o those who remain without symptoms but who present out of concern based on media 

reports;

o those who may be especially susceptible to low levels of secondary contamination

introduced to the home by an asymptomatic patient who left the scene.

• Patients should remain at the scene or medical facility for observation and/or treatment as long as

suggested by responders and/or receivers.

Level of Confidence: III

1

2 Discussion:

3 During an incident, patients will use various routes to reach medical care. Scanlon (2010) described the

4 means by which patients self-evacuated and self-transported to reach medical care after the 1943 Bari,

5 Italy bombing with mustard gas and after the 1995 subway Sarin attack in Tokyo, Japan. In Bari, patients 

6 self-evacuated the seaside and reported to the hospital to seek treatment for burns and respiratory injuries.

7 In Tokyo, Japan, many patients walked or used a taxi to get to the closest hospital. Tokuda, et al. (2006)

8 described the self-transport of patients after the 1995 subway attack: 35% of the injured walked to the

9 hospital, 24% were transported by taxi, and only 7% were transported by ambulances. Wenck et al. (2007)

10 reviewed the January 2005 liquid tanker car derailment that caused the release of chlorine in Graniteville, 

11 SC and interviewed the patient population which sought medical treatment. Transportation data was 

12 collected for the 57% of patients that were treated within the first 24 hours: 63% self-transported in a 

13 privately owned vehicle to a medical center; only 35% were transported by EMS and 2% were transported 

14 by the police (Wenck et al., 2007). These results indicate that many patients will not wait for EMS and 

15 will leave the scene, possibly delaying decontamination. These patients may still be contaminated and 

16 could potentially spread the contamination to others. Many may travel across a city to their preferred

17 source of medical center for treatment. Because of the tendency to self-evacuate and self-transport to 

18 reach medical care, Scislowski (1997) and Auf der Heide (1989, 2006) describe that in nearly all mass 

19 casualty incidents ambulatory patients arrive first while the most seriously injured arrive last for medical

20 treatment.

21

22 Medical personnel should be prepared and able to manage contaminated patients. In both the Bari, Italy

23 and Tokyo, Japan incidents, the medical staff did not initially decontaminate the patients. In the Tokyo

24 attack, 39% of nursing assistants, 27% of nurses, 26% of volunteers, 22% of physicians and 18% of clerks

25 became ill with symptoms (Okamura et al., 1998; Scanlon, 2010). By being prepared, the patients will

26 receive the best care and first responders/first receivers will be protected.

27

28 Since some patients may leave the scene and return home prior to seeking and/or receiving medical care, 

29 information should be available to advise them on proper self-decontamination procedures. This includes 
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1 recommendations that clothing be removed, sealed in a bag and then sealed into another bag (i.e., double

2 bagged). Showering with the use of soap and washcloth should be advised. These individuals should be

3 further instructed to seek medical care if exhibiting any of the signs and symptoms as described by local

4 authorities responding to the chemical incident.

5
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Guidance Statement 5.3

Responding and receiving organizations should plan for both ambulatory and non-ambulatory patients

simultaneously.

• Ambulatory patients should be able to follow verbal, written or posted directions with no physical

assistance from first responders or first receivers.

o May be helped by “buddy” or family member.

• Non-ambulatory patients will need additional personnel to assist them through the process.

o Specialized equipment will be needed (e.g., backboards, raised working surface/roller

tables).

Considerations:

• Planning for ambulatory and non-ambulatory patients should occur for all tiers of decontamination

(non-ambulatory patients may not be able to conduct self-care).

• A significant number of ambulatory patients are expected to leave the scene prior to decontamination

and may self-present at a health care facility.

Level of Confidence: IV

1

2 Discussion:

3 The need to prepare for both ambulatory and non-ambulatory patients is highlighted in existing guidance

4 documents and is typically based on incident reports following real-world events. The most notable

5 example of this planning need is the 1995 sarin attack in Tokyo. In reviewing a report from St. Luke’s

6 Hospital (in Tokyo), Tokuda, et al. determined that 35% of the injured walked to the hospital. In addition

7 24% were transported by taxi, and only 7% were transported by ambulances which may have included

8 both ambulatory and non-ambulatory patients (Tokuda et al., 2006). Thus, given any incident, the

9 expected ratio of ambulatory to non-ambulatory is difficult to predict and contingencies are needed to

10 prepare for both sets of patients.

11

12 Non-ambulatory patients will consume the most resources in terms of personnel management (e.g., triage,

13 maintain observation, supportive care, medicinal dispensing) over ambulatory patients. Therefore,

14 contingency plans for ambulatory patient surge is to reduce pressure on the healthcare facility to allow

15 concentration of resources towards non-ambulatory patients (Hick et al., 2004). Deductively,

16 decontamination of non-ambulatory patients will require additional resources well above requirements for

17 ambulatory patients.

18

19 Tiered decontamination (i.e., self-care, gross patient and technical patient decontamination) must,

20 therefore, account for resource-intensive requirements to care for non-ambulatory patients. In fact, self21 care is assumed as not appropriate and instead, skipped to gross and/or technical tiered approaches.

22 Ambulatory patients, on the other hand, should be able to follow commands and should be self-sufficient

23 in conducting decontamination, including, self-care; following instructions for alternative decontamination

24 (i.e., evacuation/marshaling to an alternative site, disrobing, and spot decontamination). Ambulatory

25 patients should also be able to assist other ambulatory and non-ambulatory patients, if necessary. The

26 utilization of a buddy system, such as a parent or caretaker assisting a child or the elderly through the 

27 decontamination process, may facilitate those who require minimal assistance to utilize the ambulatory

28 route. In fact, in a healthcare facility-based surge capacity, the use of solicited volunteers (e.g., former

29 employees and retirees) and unsolicited volunteers (e.g., bystanders and possibly ambulatory patients who 

30 are “well enough”) are recommended considerations (Hick et al., 2004).
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Guidance Statement 5.4

At-risk populations

15 require additional assistance. Responder and receiver organizations should

implement planning and training to assist at-risk populations through the decontamination process.

• At-risk individuals have needs in one or more of the following functional areas: communication,

medical care, maintaining independence, supervision, and transportation.

• At-risk populations may include infants, children, the elderly, and pregnant women, as well as people

who have functional or mobility impairments, live in institutionalized or congregate settings, have

limited English proficiency or are non-English speaking, or have cognitive impairments.

Considerations:

• Planning, training and communication with members of at-risk populations should be practiced prior

to an incident.

• Ensure response plans include integration of additional personnel to assist patients through

decontamination and/or pairing non-ambulatory patients with ambulatory patients to assist.

• Make every effort to keep a child with a parent or trusted adult but if a child is alone, a

responder/receiver should make eye contact and try to explain what is going to happen and, if

possible, assist the child through decontamination.

• A method to hold or carry an infant through decontamination must be in place (e.g., laundry basket,

baby bath).

• Certain individuals may have increased susceptibility to cold or heat injuries (e.g., infants, young

children, senior individuals, patients with history of cold or heat injury) and should be closely

observed by first responders and hospital first receivers.

• Have a plan for service animals; integrate personnel trained in animal triage (as resources allow) and

decontamination into the process; efforts should be made to keep animal with patient.

• Patients with decreased mobility (e.g. in wheelchairs) may need to be transferred to a backboard or

gurney and treated as a non-ambulatory patient.

• Patients should retain, to the greatest extent possible, all materials required for “normal” functionality

(e.g., prosthetics, hearing aids, eyeglasses).

• Provide written and pictographic instructions for the decontamination process; translate to the most

commonly used languages within the population (see also Functional Area 6: Crisis and Emergency

Risk Communication).

• Integrate interpreters into a response plan or have pre-recorded messages in the most frequently used

languages within the population, as resources allow.

• Integrate behavioral health professionals early in the response to address potential severe reactions of

patients, as resources allow.

• Every effort should be made to keep at-risk patients with a trusted person/caretaker.

• During the planning process, identify at-risk groups within the community and include members of

these groups as advisors to the decontamination planning team and as participants in decontamination

exercises.

Level of Confidence: IV

1

2 Discussion:

3 Scientific studies are lacking for specifics of how to assist at-risk populations through the decontamination 

4 process. Several existing guidance documents cite the need for additional planning for at-risk populations.

5 The DOD TSWG (2004) also recommends an escort be provided for unaccompanied children and, if

6 possible, to keep children with an adult family member. Another recommendation from recent events is to

 

15 Note that this term is used throughout 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 definition in the Pandemic

and All-Hazards Preparedness Act of 2006 (PAHPA), Pub. L. No. 109-417 (Dec 19, 2006). This definition can be found in

the glossary and on the HHS/ASPR website at: http://www.phe.gov/Preparedness/planning/abc/Pages/atrisk.aspx.
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1 group unaccompanied children together under the supervision of two or more adults who can account for

2 the children’s well-being throughout the incident and decontamination process (Wiley, 2006; Centers for

3 Bioterrorism Preparedness, 2008).

4

5 Taylor et.al., (2009) describes the results of a decontamination exercise utilizing people with disabilities as 

6 both advisors to the planning process and as exercise participants. This particular exercise involved: (1)

7 deaf participants who used American Sign Language (ASL) to communicate; (2) Spanish-speaking

8 participants with limited English proficiency; and (3) participants with physical disabilities (e.g. requiring

9 a wheelchair or other device for functional mobility). In an effort to meet the needs of these groups, the

10 planning team added the following personnel to the decontamination team: interpreters for Spanish11 speaking and ASL patients, and physical therapists to assist in transferring patients. Different equipment

12 was also utilized, including accessible shower tents (low wall stalls) and shower chairs, which were used

13 in lieu of transferring wheelchair participants to backboards or gurneys.

14

15 Three main themes emerged from the interview and focus group data: (1) communications; (2) disability

16 awareness; and (3) differing expectations. For communication, deaf participants indicated that more

17 direction was needed to instruct participants how to move through decontamination. Other suggestions

18 included: making eye contact, use of body language or gestures, and posting signs to tell and show what

19 participants should do. It is interesting to note that the comparison group (fluent English speaking

20 participants without a disability) was also confused about where to go and how to conduct

21 decontamination. With regards to disability awareness, it was noted that decontamination team members

22 should ask participants if they have a disability rather than just assuming and whether the participant

23 actually needs assistance, particularly when transferring from a wheelchair to the shower chair.

24 Participants with disabilities indicated a fear that their auxiliary devices (wheelchairs, canes, walkers, etc)

25 would be taken from them, with one participant stating “When they take away your way of moving, they

26 strip you of everything!” (Taylor et al., 2009). Actions that allow at-risk populations to maintain self27 control should be taken into consideration (e.g. maintaining eyeglasses, reduce anxiety by stating the

28 process before the patient enters).

29

30 Taylor et al., (2009) asserted that by “addressing the needs of people with disabilities, the needs of other

31 individuals are often met, providing a universal benefit”. Incorporating people from at-risk populations in

32 the planning process for decontamination operations, as well as including them as participants in

33 exercises, permits planners an opportunity to identify new issues and as opportunity to improve the

34 decontamination operations.

35

36 In addition, this guidance recommends additional preparation take into account the expected population

37 characteristics likely encountered – their demographics, ethnic make-up, language barriers, and

38 socioeconomic status and resources/resiliency – within a jurisdictional area. Subject matter experts

39 indicated that their experience shows that owners will bring their animals (including household pets and

40 service animals) with them. Therefore, it is beneficial for a community to build this component into their

41 plans and to identify capabilities prior to an incident.

42

43 Additional information on specifics for communication with the at-risk populations can be found in

44 Guidance Statements in Functional Area 6: Crisis and Emergency Risk Communication. State and local

45 public health emergency, medical countermeasure distribution, disaster evacuation, and other disaster

46 response and recovery plans may provide additional recommendations for accommodating at-risk

47 populations unique to your specific locations.

48
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Guidance Statement 5.5

A formal rapid communication procedure should be utilized to provide advance notice to area health care

facilities of a hazardous chemical incident and to specifically alert facilities to the possibility of selfevacuated patients needing assessment of contamination and arriving unannounced to health care

facilities.

Considerations:

• First responders and first receivers should have ongoing communications throughout the incident.

• Communication systems should be redundant, interoperable, multi-directional and include

notifications to all emergency response partners.

• A pre-scripted template indicating critical information requirements should be produced during

planning between first responders and first receivers (see Functional Area 6: Crisis and Risk 

Communication).

o Initial communications should include the following: initial scene assessment; identity of 

the involved chemical(s) (and their toxicity if known), commonly observed signs and 

symptoms; patient decontamination efforts underway at the scene.

o Updates from the scene to health care facilities should include the confirmed identity of

hazardous chemical(s); estimated patient numbers requiring transport; their triage 

categories; estimated times of arrival; and the status of patient decontamination.

o Updates from receiving health care facilities to the scene should include: the status of

facility- based patient decontamination efforts (if any); effectiveness of decontamination 

and medical treatment from the scene; expected hospital capacity; re-routing of traffic 

around hospitals or ambulance diversions; information on chemical identification and 

toxicity (e.g., through hospital laboratory testing); delayed symptoms observed

o Regional poison centers can serve as an authoritative information resource for both 

responders and receivers regarding the human health effects of toxic chemical exposure. A

central point of information will prevent conflicting recommendations.

• All communication pathways should be pre-established, frequently rehearsed, and include written

protocols for the most effective use of resources. Clearly establish expectations and critical

information needs among all response stakeholders regarding information sharing.

• The volume of information to be expected on communication systems in mass casualty events is often

underestimated. It is important that response plans include provisions to rapidly augment 

communications capacity and personnel.

Level of Confidence: III

1

2 Discussion:

3 While there is a large amount of anecdotal literature concerning this topic (Okumura, 1998a/b; Auf der

4 Heide, 1989, 2006), Hood et al. (2011) described an exercise where a team provided both decontamination 

5 and medical care during a simulated mass casualty event. One of the study’s findings was that first

6 receivers took 40minutes to set up the decontamination facility and equipment as well as don appropriate 

7 PPE before handling the first patient. Therefore, any warning given to first receivers prior to receiving the

8 first patients will aid in reducing setup time and allow for immediate care.

9

10 In addition, Tokuda and colleagues asserted that the ability of the ED to provide timely and effective

11 treatment is enhanced by the information coming from HAZMAT teams at the scene (2006). This

12 emphasizes the need for rapid and early communication from the field to the medical care centers. Such

13 early communication will allow receiving health care facilities to prepare for the self-evacuating patients

14 who, many times, show up before first responder-transported patients. Additionally, this communication

15 allows health care facilities to coordinate transport of non-critical patients to neighboring hospitals;

16 increase staffing levels; identify and collect materials; identify medication and references needed to treat

17 incoming patients; and possibly coordinate patient load based on availability of resources at a given 
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1 institute, as well as coordinate in the event a hospital must be evacuated due to secondary contamination.

2 In mass casualty incidents of all types, coordination of patient distribution is often lacking (Kirk and

3 Deaton, 2007). In fact, Kirk and Deaton (2007), describe the period where first receivers are left in

4 uncertainty as the “silent gap” or where there is little information that has been shared on the nature of the 

5 event from the scene. At least in large part, this is because patients self-transport (Auf der Heide, 1989, 

6 2006; Zoraster et al., 2007). Okumura et al. (1996) suggested that if large numbers of patients requiring

7 mechanical ventilation exceeds the number of ventilators available at a particular hospital, then there is a

8 need for pre-hospital coordination to determine patient distribution.

9

10 Many communities require first responders to notify first receivers of any transport to their facility. The

11 communication between on-scene first responders and first receivers is a critical ongoing requirement

12 (Auf der Heide, 1989). Despite this requirement, many subject matter experts believe that this

13 coordination does not occur most of the time because of ineffective communication networks between first

14 responders, first receivers, poison centers, and other emergency response entities. For example, cellular

15 and telephone systems are unreliable in disasters because if they are not damaged, they quickly become 

16 overloaded and non-functional (Auf der Heide, 2007). Cell phones may play a vital role in

17 communicating to both first responders and potential patients through newly implemented emergency text

18 messages systems such as FEMA's Integrated Public Alert Warning System (IPAWS) and the Commercial

19 Mobile Alert System (CMAS). A potential approach to the issue of communication needs in a chemical

20 incident is to begin to adapt these communication procedures and networks for more routine emergencies

21 to increase responders’ familiarity with them and to identify problems with the communication system

22 itself (lack of interoperability; lack of redundancy). Another issue to consider is the accuracy of

23 information being conveyed between on-scene responders and receiving medical facilities. However,

24 literature suggests that most secondary contamination occurs because the health care facility is not ready

25 to receive patients (Okumura et al, 1998a/b). Thus, it is better for any available information regarding

26 chemical identity, route/duration/severity of contamination, toxidrome or symptom complex, and extent of

27 decontamination efforts to be communicated without delay. For planning purposes, other suggestions

28 include establishing a fill-in-the-blank form that would help first responders notify health care facilities of

29 pertinent information (e.g., chemical substance, if known; state of chemical; sign and symptoms patients

30 are presenting; patient’s response to antidotes, if given; number of patients; and what type of

31 decontamination, if any, is being performed at the scene).

32
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Guidance Statement 5.6

Notification, by visible, written, or verbal means, and ideally a combination of all three, should be used

to record scene decontamination practices for clear communication and coordination with health care

facilities.

Considerations:

• If a physical documentation system is used, it should be durable and tamper proof.

• Notification systems should be redundant, interoperable, and multi-directional and include 

notifications to all emergency response partners.

• If a physical notification system is used, the amount of time the notification tool is valid after the

incident is over should be determined.

Level of Confidence: III

1

2 Discussion:

3 Triage categories are largely discussed throughout the literature with many of the crosswalked documents

4 recommending the utilization of such tools to help organize patients. Given this, clear guidelines need to

5 be set for language used in correlation with the triage tools. These guidelines can standardize

6 communication between responders and receivers, making the decontamination conducted by receiving

7 hospitals more efficient and avoiding duplication of efforts. When large numbers of patients arrive at the 

8 ED in a short amount of time, difficulty arises in the ability of ED staff to differentiate between those that

9 are contaminated and those who have been decontaminated in the field (Clarke et al., 2008). The market

10 place has developed numerous triage tags that convey similar information including baseline vital signs, 

11 medical counter measure or antidotes given, if and how much decontamination has occurred, location of

12 injury, etc. However, others such as Okumura et al. (2007) are developing a system for the initial triage 

13 and decontamination of patients of a chemical release. This system will use colored clothes pegs where

14 red indicates the need for emergency care, yellow for semi-emergency care, green for non- emergency

15 care, black for expectant, white for dry decontamination, and blue for wet decontamination. Okumura et

16 al. (2007) determined that two clothes pegs would be used per person. Once the patient had completed

17 wet decontamination, the patients were switched back to conventional paper triage tags.

18

Many EMS and HAZMAT personnel utilize the START (Simple Triage & Rapid Treatment/Transport)

16 19

20 model for categorizing patients’ injuries at the scene. First responders and receivers can utilize toolssuch 

21 as the HHS Chemical Emergency Medical Management Intelligence Support Tool (CHEMM-IST) or the 

22 National Library of Medicine’s Wireless Information System for Emergency Responders (WISER)to 

23 recognize toxidromes and identify the general class of chemical agent to which the patients were exposed.

24 This additional information will aid in START, particularly in prioritizing patients forresuscitation, 

25 antidotal therapy, decontamination, and then transport or release from the scene.

26

27 However, Zoraster et al. (2007) found that the current triage system (START) has challenges. In

28 particular, there is the potential for the misdistribution of patients to health care facilities. This poses

29 communication challenges in relaying decontamination practices occurring at the scene with the various

30 health care facilities. For example, if some patients (with varying exposures) were adequately

31 decontaminated with self-care or gross patient decontamination processes while others were technically

32 decontaminated, communicating what has (or has not) occurred in terms of decontamination may be

 

16 Defined as a trauma-based system utilized for the triage of adult and pediatric medical patients resulting in a

reproducible triage process so that different Emergency Medical Service (EMS) providers come to the same triage

category conclusion when assessing patients based on severity. (Gonzalez, D. (2011), Triage Overview: Modified

S.T.A.R.T., Continuing Medical Education – News & Information, FDNY Office of Health Affairs, Nov 2011,

Vol 17, Issue 11, Retrieved from http://www.nysvara.org/news/2011/nov/111122b.pdf on 3 January 2013.
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1 difficult if not almost impossible in a mass casualty event. The communication challenges are further

2 compounded by patients evacuating the scene quickly and showing up at the health care facility on their

3 own, or possibly assisted by good Samaritans (not knowing that the patients were possibly contaminated

4 further exacerbating the medical problems) (Okumura, 2007).

5

6 Two-way communication should occur between the healthcare facilities and first responders on-scene.

7 Ideally, first responders should relay to supporting health care facilities of the decontamination process

8 used on the patients (i.e., self-care, gross patient and technical patient). In turn, health care facility

9 based first receivers should send feedback to field first responders on decontamination effectiveness and

10 effectiveness of initial emergency medical treatment. This will allow responders to alter practices in

11 real- time, identify the need for specific intervention/antidote (if the health care facility is first to

12 identify the poison), or alert responders of adverse effects (e.g., patients are arriving hypothermic). In 

13 addition, first responders should communicate to hospital first receivers the suspected or field

14 confirmed identity (using field chemical detection methods and/or devices) of the agent released in 

15 order for appropriate definitive care to occur. Furthermore, if decontamination is not or cannot (due to

16 environmental conditions) be performed, this must also be communicated to health care facilities and 

17 may result in routing contaminated patients to facilities with decontamination capabilities.

18

19 The Laboratory Response Network - Clinical (LRN-C) may also provide communication to first receivers

20 on the likely chemical identity. LRN-C is a nationwide network of local and state public health accredited

21 clinical laboratories. These laboratories receive blood and urine specimens from hospitals in order to

22 analyze for the biological indices indicative of a particular chemical exposure. From the clinical

23 laboratory results, LRN-C facilities can communicate the likely chemical identity (or at least class of

24 chemical agents) involved with patient exposure. The process, however, may take several hours

25 depending upon the number of clinical samples received and the analytical methods used.

26

27 Defining the endpoint of when decontamination and field emergency medical treatment have ceased also

28 requires communication to servicing health care facilities. This information proves valuable for tracking

29 patients arriving to a hospital at a later time (but who may have left the scene earlier in the response).

30 These patients, then, would require decontamination at the hospital (which requires a state of readiness in

31 anticipation that patients will show up after the incident response transitions to recovery).

32
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Guidance Statement 5.7

PPE selection, training and use should be based on applicable regulations (OSHA

17), standards

(NIOSH

18), and/or guidance (NFPA19), subject matter expertise, and manufacturers’ specifications, in

conjunction with scene evaluation and risk assessment and Authority Having Jurisdiction standard

operating procedures or standard operating guidelines.

Considerations:

• PPE selection should incorporate the contingency that responders may conduct life-saving medical

interventions, supportive care, and/or antidote administration for contaminated patients prior to or

during the conduct of patient technical decontamination.

• All respirators used by civilian responders and receivers should be NIOSH-approved.

Level of Confidence: III

1

2 Discussion:

3 Studies on personal protective equipment (PPE) efficacy against a variety of chemical agents and among

4 first responder and receiver communities are well founded (Myers, 2000; Ziskin et al, 2003). PPE is the

5 last in the line of defense to protect personnel; typically PPE follows after engineering controls, workplace 

6 practices and administrative controls (OSHA, 2006). In a chemical event, however, the use of these 

7 higher hierarchy forms of protection is not immediately available or practical, particularly within the first

8 few hours of a dynamic incident. Personal protective equipment (PPE), therefore, remains the most viable 

9 and readily accessible form of protection against chemical agent exposures. In addition, PPE will limit

10 cross contamination from patient to responder.

11

12 The OSHA, NIOSH and, NFPA advise a risk-based approach when determining the type and use of PPE.

13 Horton et.al (2008) found that the level of PPE and respiratory protection needed by HAZMAT personnel

14 varies greatly and depends on their anticipated work activities. The factors to consider in the selection of

15 PPE include the anticipated substance, toxicity of the substance, potential routes of exposure, degree of

16 contact, and the specific task assigned to HAZMAT personnel. Personnel must be provided with

17 appropriate respiratory and dermal protection specific to the contaminant. Currently, no PPE can protect

18 the wearer from exposure to all possible hazards (NFPA 472, 2013 Ed). Therefore, responders and

19 receivers must determine the appropriate combination of PPE based on the specific substance and a risk

20 assessment.

21

22 A limitation of PPE is the physical, psychological and communication hindrances to the provider, which 

23 may limit the amount of care due to reduced dexterity while wearing the equipment. Berkenstadt et al.,

24 (2003) describes past studies that show emergency medical technicians wearing increased PPE levels have 

25 decreased dexterity. Koenig (2003) also described the physiological burdens of PPE to the human wearer

26 and concluded the importance tocreate appropriate PPE guidance minimizing responders’ and healthcare

27 workers’ abilities to performtheir primary duties. Furthermore, Clarke et.al (2008) explained that

28 limitations include the limited life span of the respiration filters and the time it takes to replace these

29 filters; rotation of staff members to avoid fatigue and heat exhaustion; and the cumbersome nature of the 

 

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: 

http://www.osha.gov/pls/oshaweb/owasrch.search_form?p_doc_type=STANDARDS&p_toc_level=1&p_keyvalue= 1910

18 NIOSH is a federal public health agency that develops technical performance standards and evaluates respirator 

technologies and PPE. For additional information regarding NIOSH-approved respirators and PPE, please see the following:

http://www.cdc.gov/niosh/npptl/

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 http://www.nfpa.org/catalog/
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1 PPE suits that cause decreaseddexterity and interfere with communication between ED staff and patients.

2 In addition, other limitationsfirst responders and first receivers will encounter are limited vision and 

3 hearing, while wearingPPE.

4

5 Therefore, PPE requires extensive pre-event training and regular practice to attain skills, sustain skills, and 

6 achieve familiarity with the physical restrictions. When performing mass human decontamination, PPE

7 wear will significantly affect total patient decontamination numbers over time, and thus, planning and 

8 logistical management (e.g., decontamination personnel rotations, replacement of air purifying filters or

9 swapping out self-contained breathing air tanks) must account for this factor.

10
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Guidance Statement 5.8

Scene response and health care facility emergency planners should work with federal, state, and local

government officials to ensure any guidance, practices, and plans properly address appropriate laws,

regulations and guidance concerning environmental issues such as the management of liquid and solid

wastes, environmental monitoring of decontamination area(s) and other environmental impact issues.

Considerations:

• Environmental concerns need to be subordinate to life-safety concerns.

• Coordination through the Local Emergency Planning Committee (LEPC) or state and local agencies

may be necessary.

• Current EPA guidance suggests decontamination performed for life-saving operations takes precedent

over containing or on-site treatment of water run-off.

Communication and coordination with wastewater treatment facilities of the contaminant identity (if 

known) and approximate quantities discharged can help plan these facilities’ operations including the 

protection of their plant personnel

Level of Confidence: IV

1

2 Discussion:

3 Scientific literature and regulatory guidance points toward the requirements of containing hazardous waste

4 (which includes decontamination run-off). Title III of the Superfund Amendment and Reauthorization Act

5 (SARA) of 1986 requires hospitals to participate in community disaster planning for HAZMAT incidents

6 (Cox, 2009). The Environmental Protection Agency (EPA) is charged with carrying out the

7 responsibilities of SARA, Title III, which states local emergency planning committees (LEPC) must

8 develop a community hazardous substance emergency contingency plan to be followed by facility owners,

9 police, hospitals, local emergency responders, and emergency medical personnel.

10

11 The US Environmental Protection Agency (2000) however has issued the following statement for 

12 CERLCA-related activities and enforcement authorities

13

14 During a hazardous materials incident (including a chemical/biological agent terrorist event), first 

15 responders should undertake any necessary emergency actions to save lives and protect the public and

16 themselves. Once any imminent threats to human health and live [sic] are addressed, first responders

17 should immediately take all reasonable efforts to contain the contamination and avoid or mitigate

18 environmental consequences. EPA will not pursue enforcement actions against state and local responders

19 for the environmental consequences of necessary and appropriate emergency response actions.

20

21 The EPA policy quoted above is based on CERCLA Section 107 (d) (2). However, this protection does

22 not apply in cases where the local government is grossly negligent or intentionally engages in misconduct.

23 Negligence and intentional misconduct are fact-specific determinations (EPA, 2011). Furthermore, this

24 proclamation does not confer immunity from state environmental regulations. Responder and health care

25 organizations should ensure that they comply with all applicable local, state, and federal regulations.

26 Emergency responders should notify the Federal On-Scene Coordinator (FOSC) through the National

27 Response Center. By involving the FOSC when there is the potential for or actual environmental

28 contamination, responders will reduce potential liability concerns as FOSCs can determine which

29 environmental regulations are applicable (or relevant and appropriate) to the response actions being taken.

30 The FOSC can also provide additional technical assistance and support or assume the environmental

31 response action, if needed.

32

33 The LEPC identifies a local health care facility that has agreed to accept and treat patients of emergency

34 incidents. However, evidence is lacking to show that self-transporting patients are aware of this

35 designation or that they will go to the designated hospital even if they were aware (Auf de Heide, 2006).
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1 Dealing with contaminated patients requires ED staff to consider key aspects of readiness, including

2 mitigation, preparedness, response and recovery (Adini et al., 2006). There are numerous historical

3 examples of the low percentages of patients arriving to the hospital via ambulance. They include: 33% of

4 known casualties in the bombing of the Murrah Federal Building, Oklahoma City in 1995; less than 11%

5 of the patients in the sarin attack, Tokyo, Japan, in 1995; and 6.8% of patients injured from the terrorist

6 attack on the World Trade Center, New York City, NY in 2001 (Okumura et al., 1998a/b; Hogan et al.,

7 1999; Guttenburg et al., 112; Pangi, 2002). Therefore, non-LEPC designated health care facilities should

8 also plan and prepare to treat chemically contaminated patients.

9

10 Further, the EPA issued a Chemical Safety Alert to address the possibility of environmental degradation

11 from contaminated runoff (Feldman, 2010). Provisions at the decontamination site must be made to

12 collect wastewater and prevent it from running over lawns and in to sewer drains (Cox, 2009). Ideally,

13 this is accomplished by the use of a portable, outside decontamination unit or a dedicated

14 decontamination facility with appropriate ventilation and water containment (Burgess et al., 1999). This

15 assumes there is either a separate wastewater containment system or sewer system for the health care

16 facility that has the capacity to treat the low concentrations of chemical contaminants (Burgess et al.,

17 1999). Wastewater can be kept in sealed containers for later disposal (Burgess et al., 1999). Portable

18 pools can be used for collection, but provisions must be made to prevent access to these prior to removal

19 (Cox, 2009). Despite these efforts, in a large-scale incident, containment of wastewater may be

20 impossible. This issue should be addressed through comprehensive planning that includes local

21 environmental and water authorities (Macintyre et al., 2000). By working with local environmental and

22 water authorities, plans for the management of contaminated materials and equipment is less subjective

23 and fortified by scientific input (Koenig et al., 2008). Similarly, solids must be collected and properly

24 stored prior to characterization and disposal (Cox, 2009). Contaminated material must be safely stored in

25 approved HAZMAT containers away from the health care workers (Feldman, 2010). Plastic bags (3 or 6

26 ml) are likely to provide adequate protection for transport to storage, but also should be kept in a

27 centralized HAZMAT storage container (Feldman, 2010).

28

29 Pre-planning is highly recommended among first responder and first receiver communities. Although life 

30 saving measures are a priority over requirements for proper decontamination containment, responder and

31 receiver communities, knowing that they are mandated to perform mass human decontamination as part of

32 their mission, should conduct pre-planning.

33
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1 Functional Area 6: Crisis and Emergency Risk Communication

2 Guidance statements in Functional Area 6 address issues related to crisis and emergency risk

3 communications. These guidance statements provide recommendations related to effective messaging to

4 multiple audiences, including appropriate training, planning, public education, and implementation.

Guidance Statement 6.1

Communication is an essential component of effective disaster management. Crisis and emergency risk

Communication

20 should be incorporated into all stages of disaster management, so that planning

addresses communication before, during and after an incident. All personnel expected to respond to a

mass casualty chemical incident should receive job-appropriate training in crisis and emergency risk

communication. Use these principles for effective communication with the public:

• Building trust

• Announcing early

• Transparency

• Listening

• Planning

Considerations:

• Crisis and emergency risk communication training can be incorporated into existing curricula in order

not to increase the training burden on emergency response personnel. However, additional training

focused on crisis and emergency risk communication may be appropriate in some cases, such as for

personnel expected to serve as a public information officer (PIO) during an incident.

• Effective crisis and emergency risk communication is a learned skill. Personnel at all levels who will

be involved in the response to a mass casualty chemical incident (from first responders and first

receivers up through high-level managers) should be trained in effective crisis and emergency risk

communication principles.

Level of Confidence: II

5

6 Discussion:

7 Experimental studies on the subject of the role of communication in shaping outcomes in a mass casualty

8 incident are lacking and not likely to be conducted in the near future. However, a great deal of empirical

9 evidence is available, including results of case studies of actual incidents, upon which an emphasis on the

10 importance of effective communication to successful disaster management is based. Community

11 members’ responses to a disaster can influence morbidity and mortality; in turn, communication with the

12 public can influence their responses. Effective communication enhances the likelihood that at-risk

13 community members will take appropriate protective actions and reassures those at lower risk (Rogers et

14 al., 2007). Many of the cases analyzed in the literature demonstrate the detrimental effects of poor

15 communication on patients and/or community members’ behavior or health. An implication of such

16 findings is that improved communication could have led to better outcomes; though it is perhaps more

17 difficult to demonstrate directly through case studies that effective communication positively influenced

18 health outcomes. Since empirical evidence relevant to this guidance statement has been reviewed in the

19 literature by numerous experts in the fields of communication, risk management, behavioral health and

20 others and is too extensive to cover comprehensively in this discussion, a few example cases are

21 highlighted along with select articles.

22

23  In the Tokyo sarin attack, passengers on the affected subway trains generally acted calmly and

 

20 Crisis and emergency risk communication is defined by the CDC as “the effort by experts to provide

information to allow an individual, stakeholder, or an entire community to make the best possible decisions about

their well- being within nearly impossible time constraints and help people ultimately to accept the imperfect

nature of choices during the crisis” (CDC, 2002).
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1 without panic (Murakami, 2000). However, some passengers reported becoming fearful when

2 their calls to emergency services were not answered in a timely manner (Sheppard et al., 2006;

3 Murakami, 2000). A number of factors may have contributed to the nervousness and unease

4 including: false announcements on trains, news media reports of confusion, chaos and, patients

5 becoming ill, and later, limited information and a lack of openness from officials (Pangi, 2002).

6  The Centers for Disease Control and Prevention (CDC) received angry feedback from postal

7 workers after they learned they would receive a different antibiotic (doxycycline) than 

8 Congressional members, Congressional staff, and television network employees (ciprofloxacin)

9 after the mailing of anthrax in letters in the US in 2001. A message explaining the distribution of

10 doxycycline to at-risk postal workers was distributed by the CDC. These communications failed

11 to adequately explain the reason for the different antibiotic distribution provided to postal

12 workers. As a result, postal workers expressed the perceptions that they were being treated as 

13 second-class citizens and perhaps being discriminated against (Vanderford, 2003; Sheppard et

14 al., 2006).

15  Improved crisis and emergency risk communication potentially could have reduced the intense fear

16 and stress-induced physical effects such as vomiting, diarrhea, blisters, burns and reddening of the 

17 skin, as well as longer term negative consequences including discrimination experienced by residents 

18 of Goiania, Brazil at the time of the radiation accident in 1987 (Becker, 2004).

19  Perhaps one of the most compelling examples of less than optimal communication leading to

20 detrimental behavior is Israeli citizens dying due to improper use of gas masks during the 1991

21 Persian Gulf War (Barach et al., 1998). At least 13 people reportedly died from asphyxiation after

22 failure to follow instructions for and demonstrations of proper use of protective masks and infant

23 carriers in response to a missile attack alarm (Hiss & Arensburg, 1992).

24  In a study of the types of information desired by the public during a hypothetical attack using plague, 

25 subjects predicted that they would be fearful as they learned about the attack and resulting casualties. 

26 However, many reported that their fear would be reduced by communication suggesting that

27 emergency responders were responding to the incident. Most subjects said they would seek out

28 information about the attack and use that information to decide what actions to take for themselves 

29 and their families (Wray & Jupka, 2004).

30

31 These cases help to illustrate the roles of crisis and emergency risk communication in both instructing

32 people to take appropriate protective actions to benefit their health and safety and reassuring people and

33 easing their fears when the risk is low. After the 2001 anthrax attack in the US, effective communication

34 was needed to support the treatment of those determined to be at-risk with antibiotics for post-exposure

35 prophylaxis. In Israel during the Persian Gulf War, precise instructions for the use of respiratory

36 protective devices, a complex activity not without risk itself, was necessary to promote proper use and

37 prevent injury. The cases of the Tokyo sarin attack, the anthrax letters, the radiation accident in Goiania

38 and the hypothetical plague attack illustrate the need to provide complete, accurate and timely

39 information, explanations for official actions, and reassurance when appropriate. Gaps in communication

40 led to intense fear, stress-induced physical effects and large numbers of people seeking potentially

41 unnecessary medical care.

42

43 Motivated by the emergence of severe acute respiratory syndrome (SARS) in 2001, the World Health

44 Organization (WHO) convened a meeting in 2004 to consider the role of public communications in a

45 disease outbreak. Risk communication and public health experts from multiple countries and international

46 organizations reviewed the risk communication literature and their own experiences with outbreak

47 response. Based on the gathered evidence, these experts identified best practices for communicating with 

48 the public during a disease outbreak in order to rapidly contain the outbreak while minimizing the 

49 disruption to economies and society (WHO, 2004). Although this effort was focused on infectious disease 

50 outbreaks, there are no apparent reasons why the best practices or principles would not apply to chemical
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1 incidents or other public health emergencies.

2  Building trust: trust in the people managing and communicating about an emergency enhances

3 the likelihood that community members will comply with recommended protective actions. It

4 also reduces the likelihood of suspicion that information is being concealed or downplayed and 

5 the potential for community members to act on such suspicion. Pre-incident planning presents

6 opportunities to build trust. When emergency managers and community leaders work together, 

7 they can establish trusted relationships that will support effective disaster response. With

8 community leaders involved in emergency planning and perhaps, in emergency response, 

9 individual community members may be more likely to follow the recommendations made by

10 authorities in an emergency (FEMA, 2011).

11  Announcing early: communicating with the public about an emergency as soon as possible

12 allows or protective actions to be taken during the effective time window. It also supports 

13 confidence and trust that authorities are being honest and forthcoming with the information that

14 they hold. The first message about an incident is often the most important and influences all

15 subsequent communications.

16  Transparency: communication that is candid, easily understood, complete and accurate provides

17 transparency, which in turn helps to build and maintain trust.

18  Listening: the concerns of community members should be considered legitimate and addressed in

19 messages. The community will comprise many different audiences, based on how they are

20 affected by or their roles in managing the incident.

21  Planning: as much advanced planning as possible should be done in order to avoid rushed efforts

22 that can cause mistakes.

23
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Guidance Statement 6.2

Develop a strategic communications plan for delivering various types of messages during an incident.

Prepare as much material in advance as possible: identify message topics and their audiences; write prescripted messages; identify appropriate spokespeople or messengers for each type of message.

Communication needs to be coordinated across all organizations so that a single message is spoken with

many voices throughout the community.

Considerations:

• Ensure messages are developed for and disseminated to all stakeholders:

o Those who were exposed and decontaminated

o Those who may have been exposed but left the scene without being decontaminated or

evaluated

o Those who were at the scene and have a low likelihood of having been exposed

o Those with family members or loved ones who were at the scene

o Community members who were not at the scene

o Emergency response organizations

o Health care providers

o Public health community

• Utilize an authoritative source, such as an elected official (e.g., mayor), a public health officer, a

medical association or a well-known local physician, to deliver messages to the public for greater

credibility.

• All elements of crisis communication and instruction during an incident should be redundant and

interoperable, verbal and non-verbal, and be available in all common languages spoken in the

community.

• Communication challenges may include hearing impairment, language barriers, illiteracy, vision

impairment, and impairment caused by the chemical exposure itself.

• Communicating information about why decontamination is necessary and about the process, (e.g.,

segregation of patients by gender, keeping families and caretakers together) how possessions and

functional needs will be handled (e.g., eyeglasses, walkers, prostheses), may increase compliance with

the process.

• Give simple, clear instructions using a calm but authoritative voice broadcast through a public address

or voice amplification device. It is essential to direct people – expect them not to act quickly and not

to panic.

• Patients should be informed of potential health risks to themselves and family members if they neglect

decontamination treatment.

• Evidence suggests that panic is not a common response by people involved in a mass casualty

disaster. However, psychosocial intervention in the first hours to several months 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 safety

o Calming

o A sense of self- and community efficacy

o Connectedness

o Hope

• Integrate behavioral health professionals early in the response to address potential acute stress reaction

in patients, as resources allow.

Level of Confidence: II

1

2 Discussion:

3 As with several other guidance statements, the effects of the recommendations made here on patient
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1 outcomes may be difficult to test in experimental studies. However, the content above is 

2 substantiated by rigorous survey or interview-based research and some by empirical evidence from

3 actual events.

4

5 After the 2001 terrorist attacks in the US, CDC funded a series of studies to aid planning for effective

6 communication in chemical, biological, radiological or nuclear (CBRN) terrorist incidents. Several

7 research teams utilized focus groups and individual interviews to assess the types of information that

8 members of the public wish to receive during such an incident. This was based on the premise that in

9 order to be optimally effective, messages must take into account the recipients’ needs and concerns.

10 Experts in the fields of risk communication, behavioral health, and public health have recommended 

11 that crisis and emergency risk communications include what members of the public want to know in 

12 addition to what government officials want them to know (Rogers et al., 2007; WHO, 2004).

13

14 This Pre-Event Message Development Project worked with a total sample size of 1013 individuals in

15 several different regions of the US. The project gathered data through purposive sampling to provide

16 adequate representation of ethnic groups, urban and rural dwellers, proficiency in the English language,

17 age, socioeconomic status, education level and gender (Wray et al., 2008; Becker, 2004; Glik et al., 2004;

18 Henderson et al., 2004; Wray and Jupka, 2004). Participants in these studies expressed their desires for

19 information about the nature of the threat, how to protect themselves and their families, and the official

20 response to the situation. Specifically regarding protective actions, they wanted to know how to avoid

21 exposure, recognize symptoms and treat effects. In addition, they wanted as much protective information

22 as possible.

23

24 Information needs did not differ among regions of the US or among other sub-groups. Study participants

25 reported that one of the immediate actions they will take is active information seeking, which supports the

26 best practice of announcing early. Study results also suggest that people will seek and compare

27 information from multiple sources, substantiating the recommendation that communication be coordinated

28 across organizations so that a single message is delivered. Inconsistencies will not only cause confusion

29 for the public but can undermine their trust and confidence in the government and other authorities (Wray

30 et al., 2008). Reports on the responses of New York City residents and workers to communications from

31 government officials in the first weeks and months after the September 11 attacks on the World Trade 

32 Center illustrate the potential for poor communication practices to create uncertainty among members of

33 the public and mistrust of authorities. Mixed messages were created by the combination of early

34 reassurances that the local environment was safe with subsequent guidance that citizens should be cautious

35 with dust and ash and reports that the environment was causing people to become ill (Lyman, 2003).

36 Once inconsistencies became apparent, several organizations requested access to data on environmental

37 monitoring for health hazards in the area but were denied. This led some people to conclude that

38 authorities were concealing information about dangers to human health (Lyman, 2003).

39

40 Members of the public want to know that the information they receive about an emergency is credible.

41 Many participants in the Pre-Event Message Development Project studies stated that they wanted to know

42 the source of the information, so that they can judge credibility for themselves. Some offered examples of

43 respected sources, which included both local and national level authorities: local health departments, fire 

44 departments, police departments, the CDC, the American Red Cross, the US President, the

45 military/National Guard, and other organizations having relevant expertise (Wray et al., 2008).

46

47 The influence of non-verbal instructions on the effectiveness of patient decontamination has been assessed

48 in one study. A pictorial aid was provided to subjects in one group in addition to verbal instructions on 

49 what actions a subject should perform for decontamination. The proportion of contaminant removed from

50 these subjects was compared to the proportion removed from subjects who received only verbal

51 instructions. Decontamination effectiveness was not significantly different between the group who had
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1 received verbal plus non-verbal instructions and the group who had received only verbal instructions

2 (Amlôt et al., 2010). This result seems counterintuitive and contradictory to the guidance provided here.

3 However, the investigators have provided additional explanatory information in a subsequent article that

4 suggests that the pictorial instructions were misinterpreted, at least by the adult study subjects (Winfield, 

5 2011). In addition, many circumstances and challenges that could arise during a mass patient

6 decontamination incident would seem to warrant the inclusion of non-verbal instructions in a response 

7 plan. These include verbal instructions not being available in all languages spoken by patients and 

8 difficulty hearing and/or understanding verbal instructions spoken by responders wearing respiratory

9 protection devices. The latter was recently reported in a study of participants in patient decontamination

10 field exercises (Carter et al., 2012).

11

12 The recommendation to expect people not to act quickly and not to panic is based on numerous case

13 studies (Auf der Heide, 1989; DiGiovanni et al., 2003; Sheppard et al., 2006; Murakami, 2000; Sullivan &

14 Bongar, 2007). First, it is important to be clear about the definition of panic and recognize that fear,

15 anxiety and a sense of urgency are often appropriate and necessary responses to an emergency, as they can 

16 facilitate protective actions, such as evacuation and decontamination, in a timely manner. In the context of

17 an emergency affecting a community, panic is characterized by irrational behaviors, hope of receiving

18 apparently scarce resources, a focus on achieving personal safety rather than assisting others, and 

19 contagiousness, in addition to the heightened anxiety and fear of dying associated with panic in other

20 situations (Keating, 1982; Sheppard et al., 2006). DiGiovanni and colleagues (2003) analyzed several

21 natural disasters and concluded that people generally acted with composure and did not exhibit irrational

22 behaviors. The authors added a caveat, however, that people might behave differently in terrorist attacks

23 with CBRN agents than in natural disasters. However, four terrorist attacks (the Tokyo sarin attack, the

24 September 11, 2001 World Trade Center attack, the US anthrax letter mailings and the July 7, 2005

25 London bombings) were analyzed by Sheppard and colleagues (2006) and in all cases it was concluded

26 that the affected community members generally acted calmly and rationally, rather than with panic.

27 Individuals on the train cars involved in the Tokyo sarin attack and the London bombings reported unity

28 and cohesion among those affected (Sheppard et al., 2006). Others have described the composure

29 exhibited by community members in the Tokyo sarin attack (Murakami, 2000) which was disrupted by

30 slow responses by emergency service personnel and images of chaos and severely ill patients in the news

31 media (Pangi, 2002).

32

33 Distinct from the question of how people behave during and in the immediate aftermath of an incident is

34 the issue of relatively longer-term psychological effects of a disaster on the people impacted. Evidence

35 from actual incidents, including many of the cases mentioned above, suggests that the psychological

36 impact of terrorist attacks, CBRN incidents, or other disasters can be significant, both in terms of the

37 numbers of people affected and the severity of effects (Sullivan & Bongar, 2007; Bleich et al., 2003;

38 Murakami, 2000). The types of symptoms experienced can be described by mass psychogenic illness,

39 acute stress reaction, post-traumatic stress disorder and other syndromes or disorders (Sullivan & Bongar,

40 2007; Bleich et al., 2003). In order to support tools for mitigating such psychological effects, a large body

41 of empirical evidence was compiled by a panel of experts on the study and treatment of individuals

42 exposed to disaster and mass violence and used to define by consensus a set of evidence-informed

43 psychosocial intervention principles (Hobfoll et al., 2007). The authors recommend that these elements be 

44 incorporated into intervention efforts during the short and mid-term period (immediate hours to several

45 months) following a disaster or terrorist attack. The principles are: (1) promote sense of safety, (2)

46 promote calming, (3) promote sense of self-efficacy and collective efficacy, (4) promote connectedness

47 and (5) promote hope. Each of these measures can be addressed at least partially through crisis and

48 emergency risk communication. For example, safety includes safety from bad news and sources of

49 additional stress, which are often conveyed through the media in a disaster. Education about behavioral

50 health responses to disaster, techniques for managing anxiety, signs of severe illness and sources of

51 professional evaluation and treatment, all of which help to promote calming, can be provided through
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1 community outreach.

2

3 Self-efficacy and community efficacy, which are directly related to the self-care tier of patient

4 decontamination described in this guidance, can be promoted pre-incident through public education

5 campaigns and during an incident through messages delivered by emergency responders, receivers, public

6 health officials and other trusted community leaders. Resilient communities encourage perceptions of

7 both self-efficacy and collaborative support of one another during times of need. Hobfoll et al. (2007)

8 note that the positive role of social support and connectedness in mitigating stress and trauma is probably

9 the best empirically supported of their five recommended principles, yet there is little evidence suggesting

10 how to apply it for effective intervention in a disaster. This principle is integrated into several parts of the

11 guidance presented here. Keeping families and loved ones together during decontamination and

12 especially keeping children connected (or reconnecting them) with parents or caretakers (Guidance

13 Statements 2.6 and 5.4) will support the connectedness recommended by Hobfoll et al. (2007). Facilitating

14 the reconnection of family members who were in different locations at the time of the incident (Auf der

15 Heide, 1989) as well as reaching out to community members who may be socially isolated or lack strong

16 social support may also allow connectedness to help shape an effective community response to a disaster.

17 Hobfoll et al. (2007) emphasized that a sense of hope can be enhanced by many external factors and is not

18 solely an internal attribute held by an individual. They suggest that a community can foster hope by

19 “helping people focus on more accurate risk assessment, positive goals, building strengths that they have 

20 as individuals and communities, and helping them tell their story” (Hobfoll et al., 2007).
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Guidance Statement 6.3

Public education can be achieved by using naturally occurring opportunities to communicate patient

decontamination goals, potential practices, responsibilities of responders, receivers and patients, and

expected outcomes. A strategic plan for pre-incident communication to enhance community

preparedness should be developed to include information about patient decontamination in community

outreach by fire service and EMS organizations, public service announcements, public venues and other

planned events.

Considerations:

• Prioritize communities that are at-risk (e.g., due to the presence of an industrial site or a transportation 

route) for messaging tailored to the community’s specific hazards.

• Integrate pre-incident communication about patient decontamination into ongoing efforts by the

chemical industry and other organizations (e.g., LEPC, Transportation Community Awareness and

Emergency Response [TRANSCAER]).

• Public interest in learning about and preparing for rare hazardous materials incidents may be low.

Some communities may decide that it would be more efficient to prepare public messages for

dissemination at the time of an incident than to engage in a pre-incident public education

campaign.

Level of Confidence: V

1

2 Discussion:

3 From the perspective of an individual living in the US, hazardous materials incidents are rare; the

4 likelihood that an individual will be involved in or affected by such an incident is relatively low.

5 According to the Pipeline and Hazardous Materials Safety Administration of the Department of

6 Transportation, during the ten years of 2003-2012, there were 159,411 hazardous materials incidents in the 

7 US by all modes of transportation, resulting in 129 deaths and 2,690 injuries, among a population of >280 

8 million people (US DOT Pipeline and Hazardous Materials Safety Administration [PHMSA], 2013).

9 Therefore, it is not surprising that members of the public are generally not well informed about hazardous 

10 materials. CDC’s Pre-Event Message Development Project found that study participants had limited

11 understanding of CBRN agents or the differences between categories of agents (e.g., infectious vs. non12 infectious) (Wray et al., 2008). Pre-incident education could improve the public’s understanding of

13 hazardous materials, what to expect from responders, receivers and officials during a response and what

14 they can do to protect themselves and their families. In turn, the increased knowledge and enhanced

15 understanding among the public can improve the potential for an effective response in an actual incident

16 by promoting appropriate protective actions.

17

18 A study of the impact of public education programs on the public’s preparedness to respond to a chemical

19 terrorist incident in the United Kingdom (UK) and in Israel suggests that the rates of uptake and

20 assimilation of the information were relatively low (Hildebrand & Bleetman, 2007). Thirty-three percent

21 of respondents in the UK and 22% in Israel reported reading the educational booklet provided to all

22 citizens. Large percentages of respondents in both countries (41% in the UK and 33% in Israel) stated that

23 they would not wait for emergency services to arrive at their location; rather, they would travel to or call a 

24 hospital for help. These actions would be contrary to what was recommended in the educational booklet

25 and could undermine the local emergency response. However, as noted in other parts of this guidance 

26 document, if response organizations are prepared for some affected community members to self-evacuate

27 and self-present at a health care facility, then the community’s overall response will not necessarily be 

28 undermined. Furthermore, perhaps improved education and awareness among even a small percentage of

29 a population can be considered a partial success.

30
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1 The influence of a pre-event public education campaign on the effectiveness of a response to a chemical

2 or hazardous materials incident (e.g., using health outcomes or protective actions by the public or some

3 other measure of effectiveness) has not been studied. This would require measuring disaster response

4 effectiveness before and after a public education campaign in the same community or comparing disaster

5 response effectiveness in two similar communities, one of which had conducted a public education

6 campaign and one of which had not. Public health practitioners use public education campaigns regularly

7 to promote healthy behaviors, with demonstrated success in areas of high-prevalence, high-risk behaviors

8 such as smoking cessation and the prevention of HIV transmission. However, the extension of such

9 public health successes to preparedness for low probability events such as a hazardous chemical release is

10 questionable.

11

12 Community resilience depends on informed, empowered and prepared community members. This

13 requires education, two-way communication, and collaborative planning. HHS and FEMA both

14 recommend that significant pre-incident work be conducted on an ongoing basis to engage the whole

15 community in emergency planning. Communities should leverage existing programs and events while

16 also initiating additional activities focused on emergency preparedness (FEMA, 2011; HHS, 2012).

17

18 This guidance statement acknowledges that the available evidence suggests that the time and attention of

19 the public are limited, especially for topics that they perceive as low risk to themselves, and time and other

20 resources of emergency response and public health organizations are limited. Some subject matter experts

21 are skeptical that the cost/benefit ratio for pre-incident public education about chemical incidents is 

22 favorable. The study described above (Hildebrand & Bleetman, 2007) also casts some doubt on the

23 potential for educational material to significantly increase preparedness. These factors are reflected in the

24 low Level of Confidence assigned to this guidance statement (LOC = V). Further, the guidance statement

25 emphasizes efficiency - education about hazardous materials, patient decontamination, and protective

26 actions associated with self- and community efficacy should be incorporated into community outreach

27 efforts and planned events as appropriate.
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Guidance Statement 6.4

To facilitate effective two-way communication during and after an incident:

• Provide patients with pre-scripted and printed follow-up information before they leave the scene or

prior to discharge from the health care facility.

• Obtain patient contact information prior to release from the health care facility to allow for followup by the public health community.

• Establish an easily accessible mechanism for patients to obtain additional information or advice and

for authorities to respond directly to patients’ questions or comments.

• Provide follow-up information for other community members who were either at the scene and not

decontaminated or not at the scene.

Considerations:

• Develop follow-up information in consultation with appropriate medical, technical, behavioral health

and crisis and emergency risk communication experts.

• Include instruction sheets in the most common languages used in the community; confirm that

translations use proper syntax.

• This information should be accessible electronically and through multiple mechanisms or locations.

• Engage the public health community, Poison Control Centers, and other community resources to

help coordinate delivery of patient follow-up information and develop patient registry for further

communication.

• The Agency for Toxic Substances and Disease Registry (ATSDR) Medical Management Guidelines,

available on the internet (at http://www.atsdr.cdc.gov/mmg/Index.asp), include a printable Patient

Information Sheet and Follow-Up Instructions for dozens of specific chemicals as well as guidance for

responders and receivers treating patients exposed to an unknown chemical.

• All medical information disseminated to patients and community members must have a consistent

message and be coordinated across the entire response.

Level of Confidence: III

1

2 Discussion:

3 Providing written, in addition to verbal, follow-up or discharge instructions to patients is common medical

4 practice and has been shown to increase patient compliance with medical recommendations compared to 

5 verbal instructions alone. Preparation of patient follow-up information in advance of an incident allows

6 for thorough review and input by medical experts and enhances preparedness. The printable Patient

7 Information Sheets and Follow-Up Instructions available on ATSDR’s website (at

8 http://www.atsdr.cdc.gov/mmg/Index.asp) have been developed by experts in medicine and toxicology

9 and are regularly reviewed and updated.

10

11 The CDC’s Pre-Event Message Development Project which conducted over 1000 focus group and

12 individual interviews, found that study participants would actively seek information about how to protect

13 their health and that of their families in a CBRN terrorism incident (Wray et al., 2008). In the study of a

14 hypothetical plague attack, participants reported that after initially seeking information from local and

15 national authorities, over time, they would use the internet and newspapers to find more in-depth

16 information (Wray & Jupka, 2004). Therefore, the internet and newspapers could be used to disseminate

17 follow-up and provide additional information to patients and other community members as the incident,

18 response and recovery proceed. The same mechanisms could provide means for collecting and responding

19 to patients’ and community members’ questions and comments.

20

21 Obtaining patient contact information allows for additional medical or other information related to the 

22 incident to be communicated to patients later, if necessary. Most importantly, such communication
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1 should address patients’ physical, behavioral and mental health needs. Additionally, data on the impacts

2 of the incident and the effectiveness of countermeasures can be collected through post-event

3 communication. Assessment of patients exposed to sarin vapors in the 1994 Matsumoto and the 1995

4 Tokyo, Japan attacks has led to documentation of acute and long-term health effects as well as data on the

5 efficacy of medical interventions (Yanagisawa et al., 2006). This type of analysis provides information on 

6 the effects of hazardous materials on human health that is difficult to obtain, helps to fill in significant

7 knowledge gaps, and can be used to improve emergency preparedness and response.

8
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1 Appendix A: Working Group Charter and Membership

2

3 Mass Human Chemical Decontamination Working Group

4 Subcommittee on Standards-CBRNE

5 Committee on Homeland and National Security

6 National Science and Technology Council

7

8 Background

9 Chemical attacks perpetrated by terrorists and accidental releases of toxic industrial chemicals are

10 recognized as current threats to public health in the United States. Both types of events can

11 potentially expose significant numbers of people to dangerous chemicals that would overwhelm

12 local response capabilities. Patient decontamination, when performed using appropriate techniques 

13 and during the appropriate time frame, limits patient exposure and the toxicity that follows as well

14 as protects responders in the field and in the hospital setting from secondary contamination.

15 Therefore, patient decontamination is an integral component of the medical response to a chemical

16 event. Patient decontamination also impacts the flow of casualties at many levels of a mass

17 casualty chemical event, meaning that decisions about decontamination will impact the entire 

18 emergency response. Thus various aspects of patient decontamination are of interest to multiple 

19 responder agencies, such as fire/HAZMAT, emergency medical services, hospitals, public health 

20 officials and emergency preparedness planners.

21

22 Patient decontamination plans and procedures have evolved over time with only limited guidance based on 

23 scientific evidence; many basic questions about decontamination have not yet been addressed by research.

24 Evidence-based planning and best practices are thus limited. For example, attempting to fully

25 decontaminate every person in the vicinity of a chemical release will slow the transport of seriously ill

26 patients from the scene to hospitals. In this case, inappropriate decontamination protocols might hamper,

27 rather than contribute to, medical mitigation of morbidity and mortality. In addition, past chemical

28 incidents demonstrate that scene perimeters will not be established quickly enough after the release to

29 prevent a large number of people from leaving the scene. These potentially exposed people will show up

30 at hospitals or other facilities without being decontaminated. Health care facility chemical incident

31 response plans should address such scenarios. The recent closure of two St. Louis hospital emergency

32 departments due to suspected secondary contamination of the facility from exposed patients illustrates the

33 need for scrutinizing the patient decontamination process.

34

35 Homeland Security Presidential Directive-22, Domestic Chemical Defense, calls for the Federal

36 government to support the development of State and local plans and protocols for the decontamination of

37 persons. In order to best accomplish this task, the Federal government, through the Mass Human

38 Chemical Decontamination Working Group (WG), will attempt to ensure that those State and local plans

39 and protocols reflect current best practices. The working group will also identify decontamination issues

40 in need of research and draft a strategic plan for addressing such research gaps.

41

42 Purpose

43 The WG will assess the current state of capabilities and the current knowledge base regarding patient

44 decontamination practices and technologies. Recommendations will then be made as to how the Federal

45 government could facilitate improvements in these areas.

46

47 Scope

48 The WG will address a variety of issues including operational analysis and research, technology research
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1 and development, emergency preparedness planning, education, training, exercises and assessments.

2

3 Objectives

• Prepare a strategy that addresses the following (estimated timeline: 1 year from 1

st 4 meeting):

5 • Review national standards of care for mass casualty human decontamination, compare and contrast

6 differing standards and assemble a gap analysis

7 • Provide an assessment of current human decontamination education, training, exercises, and

8 assessments for fire, EMS, and hospital systems

9 • Perform a literature review of patient decontamination research, identify current research activities, and

10 describe research questions that need to be addressed.

11 •Assessdecontaminationsolutions

o Evaluate current decontamination solutions (e.g., soap & water, dilute bleach, RSDL

©

12 ) for

13 effectiveness/feasibility/cost/barriers and safety (e.g., intact skin, eyes, open wounds, prolonged

14 contact, environmental run-off)

15 o Define role of each solution in Concept of Operations (CONOPS)

16 • Develop optimizing strategies for decontamination that may be employed recognizing constraints in

17 equipment, training, time, and capability at local response levels and provide proposals for evaluation

18 and validation. Proposed strategies will consider current capabilities and time constraints for mass

19 casualty decontamination.

20 • Establish CONOPS for mass decontamination after chemical exposure

21 • Define metrics for mass patient decontamination after a chemical exposure (e.g., the % patients or

22 number that must be decontaminated per hour by “system”)

23 • Provide Working Group recommendations to Target Capabilities Working Group

24 • Implement plans to address highest priority areas (estimated timeline: year 2 and beyond)

25

26 Mass Human Chemical Decontamination Working Group Membership

27

28 Co-Chairs

29

30 Susan Cibulsky

31 Department of Health and Human Services

32 Office of the Assistant Secretary for Preparedness and Response

33

34 Mark Kirk

35 Department of Homeland Security

36 Office of Health Affairs

37

38 Participants

39

40 Bill Anderson

41 Department of Homeland Security

42 Plum Island Fire Department

43

44

45 James Area

46 US Marine Corps

47 Chemical Biological Incident Response Force

48
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1 William C. Ashby

2 US Marine Corps

3 Chemical Biological Incident Response Force

4

5 Erik Auf der Heide

6 Department of Health and Human Services

7 Centers for Disease Control and Prevention

8 Agency for Toxic Substances and Disease Registry

9

10 Christina Baxter

11 Department of Defense

12 Combating Terrorism Technical Support Office

13 Technical Support Working Group

14

15 Grant Bissey

16 Department of Homeland Security

17 Federal Emergency Management Agency

18

19 Ernest H. Braue Jr.

20 Department of Defense

21 US Army Medical Research Institute of Chemical Defense

22

23 Michael Carringer

24 Contract Support

25 Department of Homeland Security

26 Office of Health Affairs

27

28 Jennifer Hornsby-Myers

29 Department of Health and Human Services

30 Centers for Disease Control and Prevention

31 National Institute for Occupational Safety and Health

32

33 Charles G. Hurst

34 Department of Defense

35 US Army Medical Research Institute of Chemical Defense

36

37 Joselito Ignacio

38 Department of Homeland Security

39 Office of Health Affairs

40

41 John Koerner

42 US Department of Health & Human Services

43 Office of the Assistant Secretary for Preparedness and Response

44 John Kulifay

45 Department of Defense

46 Office of the Secretary of Defense

47

48
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1 William A. Lake

2 Department of Defense

3 US Army Material Command

4

5 Adam D. Leary

6 Department of Health & Human Services

7 Office of the Assistant Secretary for Preparedness and Response

8

9 James Madsen

10 Department of Defense

11 US Army Medical Research Institute of Chemical Defense

12

13 Joe Morris

14 Department of Homeland Security

15 Office of Health Affairs

16

17 Richard Patrick

18 Department of Homeland Security

19 Office of Health Affairs

20

21 Hillary Sadoff

22 Contract Support

23 Department of Homeland Security

24 Office of Health Affairs

25

26 Peter G. Schulze

27 Department of Defense

28 US Army Training and Doctrine Command

29

30 Michael Schwartz

31 Department of Health and Human Services

32 Centers for Disease Control and Prevention

33 National Center for Environmental Health

34

35 Bettina Stopford (Former)

36 Contract Support

37 Department of Health & Human Services

38 Office of Assistant Secretary for Preparedness and Response

39

40 Jerry Thomas

41 Centers for Disease Control and Prevention

42 National Center for Environmental Health

43

44 Additional subject matter experts are invited as necessary. The working group may interact with and

45 receive ad hoc advice from various non-Federal persons and entities, provided such interactions occur in a

46 manner that maintains the working group’s status as compliant with the Federal Advisory Committee Act.

47

48
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1 2010 Mass Human Chemical Decontamination Symposium Participants

2

3 Ryan Adam

4 Arlington County Fire Department

5 Arlington, VA

6

7 Bill Anderson

8 Department of Homeland Security

9 Science & Technology

10

11 Tom Blackwell

12 Mecklenburg EMS Agency

13

14 Ernest H. Braue Jr.

15 Department of Defense

16 Edgewood Chemical Biological Center

17

18 Justin Brown

19 DC Fire & EMS

20 Washington, DC

21

22 Edward Budnick

23 Department of Defense

24 Aberdeen Proving Grounds

25

26 Robert Chilcott

27 Health Protection Agency

28 United Kingdom

29

30 Susan Cibulsky

31 Department of Health and Human Services

32 Office of the Assistant Secretary for Preparedness and Response

33

34 Tod Companion

35 Department of Homeland Security

36 Science & Technology

37

38 John Delaney

39 Arlington County Fire Department

40 Arlington, VA

41

42 Michael B. DeZearn

43 Department of Defense

44 Edgewood Chemical Biological Center

45

46 John Donnelly

47 DC Fire & EMS

48 Washington, DC
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1

2 Erik Glassman

3 Department of Homeland Security

4 Federal Emergency Management Agency

5

6 Ingrid Hope

7 Department of Homeland Security

8 Office of Health Affairs

9

10 Jennifer Hornsby-Myers

11 Centers for Disease Control and Prevention

12 National Institute for Occupational Safety and Health

13

14 Joselito Ignacio

15 Department of Homeland Security

16 Office of Health Affairs

17

18 Franca R. Jones

19 White House, Office of Science and Technology Policy

20 Chemical and Biological Countermeasures

21

22 Jeffery Keyser

23 Department of Homeland Security

24 US Secret Service

25

26 Mark Kirk

27 Department of Homeland Security

28 Office of Health Affairs

29

30 John Koerner

31 Department of Health and Human Services

32 Office of the Assistant Secretary for Preparedness and Response

33

34 John Kulifay

35 Department of Defense

36 Office of the Secretary of Defense

37

38 William A. Lake

39 Department of Defense

40 US Army Material Command

41

42 Adam D. Leary

43 Contract Support

44 Department of Health and Human Services

45 Office of the Assistant Secretary for Preparedness and Response

46

47 David Marcozzi

48 White House
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1 National Security Staff

2

3 Jennifer Marshall

4 US Department of Commerce

5 National Institute of Standards and Technology

6

7 Phil Mattson

8 Department of Homeland Security

9 Science & Technology

10

11 Janis McCarroll

12 Department of Homeland Security

13 Federal Emergency Management Agency

14

15 Charles McKay

16 American College of Medical Toxicology

17

18 Jonathan Newmark

19 Department of Defense

20 Joint Program Executive Office for Chemical and Biological Defense

21

22 Richard Patrick

23 Department of Homeland Security

24 Office of Health Affairs

25

26 Paul Penn

27 Interstate Chemical Threats Working Group

28 EnMagine

29

30 Gina Piazza

31 Department of Health and Human Services

32 Office of the Assistant Secretary for Preparedness and Response

33

34 Jeffery Race

35 Fire Department, City of New York

36 New York City, NY

37

38 Gabriel Ramos

39 Department of Defense

40 Technical Support Working Group

41 Peter G. Schulze

42 Department of Defense

43 US Army CBRN School

44

45 Michael Schwartz

46 Centers for Disease Control and Prevention

47 National Center for Environmental Health

48
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1 Bettina Stopford

2 Contract Support

3 Department of Health and Human Services

4 Office of the Assistant Secretary for Preparedness and Response

5

6 Jerry D. Thomas

7 Centers for Disease Control and Prevention

8 National Center for Environmental Health

9

10 Ed Wakayama

11 Department of Health and Human Services

12 Office of the Assistant Secretary for Preparedness and Response

13

14 2012 Mass Human Chemical Decontamination Symposium Participants

15

16 Bill Anderson

17 Department of Homeland Security

18 Science & Technology

19

20 Erik Auf der Heide

21 Centers for Disease Control and Prevention

22 Agency for Toxic Substances and Disease Registry

23

24 Christina Baxter

25 Department of Defense

26 Technical Support Working Group

27

28 Richard A. Brenner

29 Nevada State Emergency Response Commission

30

31 Duane Caneva

32 Department of Defense

33 US Navy Medicine

34

35 Michael Carringer

36 Contract Support

37 Department of Homeland Security

38 Office of Health Affairs

39

40 Michael Castillo

41 Department of Homeland Security

42 Federal Emergency Management Agency

43

44 Christina L. Catlett

45 John Hopkins University

46

47 Susan Cibulsky

48 Department of Health and Human Services
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1 Office of the Assistant Secretary for Preparedness and Response

2

3 Joseph Colliordi

4 Department of Health and Human Services

5 Office of the Assistant Secretary for Preparedness and Response

6

7 Tim Davis

8 Department of Health and Human Services

9 Office of the Assistant Secretary for Preparedness and Response

10

11 Bill Deso

12 Department of Homeland Security

13 Science & Technology

14

15 Carol Evans

16 Contract Support

17 Department of Homeland Security

18 Office of Health Affairs

19

20 Brian Flynn

21 Department of Defense

22 Uniformed Services University of the Health Sciences

23

24 Ed Gabriel

25 Department of Health and Human Services

26 Office of the Assistant Secretary for Preparedness and Response

27

28 Alexander Garza

29 Department of Homeland Security

30 Office of Health Affairs

31

32 Robert Gist

33 Kansas City Fire Department

34 Kansas City, MO

35

36 Robert Gougelet

37 Dartmouth University

38

39 Bill Hall

40 Department of Health and Human Services

41 Office of the Assistant Secretary for Public Affairs

42

43 Dan Hanfling

44 INOVA Health Systems

45

46 Robert Hooks

47 Department of Homeland Security

48 Office of Health Affairs
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1

2 Jennifer Hornsby-Myers

3 Centers for Disease Control and Prevention

4 National Institute for Occupational Safety and Health

5

6 Joselito Ignacio

7 Department of Homeland Security

8 Office of Health Affairs

9

10 Franca R. Jones

11 White House, Office of Science and Technology Policy

12 Chemical and Biological Countermeasures

13

14 Beth Kennedy

15 Department of Defense

16

17 Mark Kirk

18 Department of Homeland Security

19 Office of Health Affairs

20

21 John Koerner

22 Department of Health and Human Services

23 Office of the Assistant Secretary for Preparedness and Response

24

25 Rita Krenz

26 University of Virginia Emergency Department

27

28 John Kulifay

29 Department of Defense

30 Office of the Secretary of Defense

31

32 Judith Wolfe Laney

33 Department of Health and Human Services

34 Office of the Assistant Secretary for Preparedness and Response

35

36 Adam D. Leary

37 Contract Support

38 Department of Health and Human Services

39 Office of the Assistant Secretary for Preparedness and Response

40

41 James Lee

42 Department of Defense

43 National Guard Bureau

44

45 Bill Mayfield

46 Memorial Health Systems

47

48
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113

1 Janis McCarroll

2 Department of Homeland Security

3 Federal Emergency Management Agency

4

5 James McGuyer

6 Department of Defense

7 National Guard Bureau

8

9 Charles McKay

10 American College of Medical Toxicology

11

12 Gretchen Michael

13 Department of Health and Human Services

14 Office of the Assistant Secretary for Preparedness and Response

15

16 Jonathan Newmark

17 Department of Defense

18 Joint Program Executive Office for Chemical and Biological Defense

19

20 Gregory G. Noll

21 South Central Task Force (PA)

22 USAF Fire & Emergency Services

23

24 Ted O. Padgett

25 Dallas Fire-Rescue Department

26 Dallas, TX

27

28 Richard Patrick

29 Department of Homeland Security

30 Office of Health Affairs

31

32 Paul Penn

33 Interstate Chemical Threats Working Group

34 EnMagine 35

36 Sally Phillips

37 Department of Homeland Security

38 Office of Health Affairs

39

40 Linda Pressley

41 Department of Homeland Security

42 Federal Emergency Management Agency

43

44 Jeffery Race

45 Fire Department, City of New York

46 New York City, NY

47

48 Kevin Reilly

49 Department of Homeland Security
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114

1 Science & Technology

2

3 Hillary Sadoff

4 Contract Support

5 Department of Homeland Security

6 Office of Health Affairs

7

8 Peter G. Schulze

9 Department of Defense

10 US Army CBRN School

11

12 Michael Schwartz

13 Centers for Disease Control and Prevention

14 National Center for Environmental Health

15

16 Dave Siegel

17 Department of Health and Human Services

18 National Institute of Health

19

20 T. Michael Self

21 US Department of Veteran Affairs

22 VA Medical Center – West Palm Beach

23

24 Terri Spear

25 Department of Health and Human Services

26 Substance Abuse and Mental Health Services Administration

27

28 Mark St. Marie

29 US Department of Veteran Affairs

30

31 Bettina Stopford

32 Contract Support

33 Department of Health and Human Services

34 Office of the Assistant Secretary for Preparedness and Response

35

36 Jerry D. Thomas

37 Centers for Disease Control and Prevention

38 National Center for Environmental Health

39

40 Frank Walter

41 Centers for Disease Control and Prevention

42 National Center for Environmental Health

43

44 Bernice Zaidel

45 Department of Homeland Security

46 Federal Emergency Management Agency

47

48
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1 Reporting Structure

2 The Mass Human Chemical Decontamination Working Group reports to the Subcommittee on Standards3 CBRNE, under the Committee on Homeland and National Security of the National Science and

4 Technology Council within the Executive Office of the President. The WG also works closely with the

5 White House National Security Staff through the Domestic Chemical Preparedness and Response Sub6 Interagency Policy Committee.
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1 Appendix B: Lexicon

2

3 General Definitions

4

5 Contaminant:

6 Any hazardous chemical (solid, liquid, or gas) that is capable of causing harm to life or health and found

7 in the area around the person, internally, or on the person’s body or clothes.

8

9 Patient Decontamination:

10 Any process, method, or action that leads to a reduction, removal, neutralization or inactivation of

11 contamination on or in the patient in order to: prevent or mitigate adverse health effects to the patient;

12 protect emergency first responders, health care facility first receivers and other patients from secondary

13 contamination; and reduce the potential for secondary contamination of response and health care

14 infrastructure.

15

16 Patient Decontamination Prioritization:

17 Any method used by responders or receivers in an effort to ensure that patients who have a higher relative

18 risk of contamination or are in a higher medical triage category are decontaminated ahead of lower risk

19 patients or those with a lower medical triage category. This may be part of the broader triage effort used

20 to determine medical needs.

21

22 First Responder:

23 An appropriately trained member of a response organization dispatched to the incident scene for purposes

24 of incident management

25 • Examples: Fire and Rescue services; Emergency Medical Services; HAZMAT Technician; Law

26 Enforcement officer

27

28 First Receiver:

29 An appropriately trained member of a hospital or other health care facility who may encounter and work

30 with contaminated or potentially contaminated patients from a hazardous materials incident

31 • Examples: member of hospital decontamination team; emergency department personnel; security

32 officer

33

34 Patient:

35 The WG identified the term patient to represent any individual who may require decontamination. In this 

36 guidance document, a “patient” is defined as:

37

38 Any individual who was at or near the location of a hazardous materials release and who was potentially

39 exposed and therefore potentially contaminated and may require some form of care (e.g., decontamination,

40 supportive medical care, lifesaving interventions, antidotal therapy, communication and reassurance).

41 • Not all patients will require follow-on treatment or evaluation at a health care facility.

42 • Some patients will leave the incident scene prior to responders arriving (i.e., self-evacuation).

43 • Some individuals, who were not at or near the scene, are not likely to have been contaminated, or

44 may not require any medical assistance, may still present for evaluation and treatment up to and

45 including requesting decontamination (See Guidance Statement 1.1).

46

47 This definition does not imply that all decontamination will be conducted by hospital or medical 

48 personnel, and does not imply that by conducting decontamination the patient must be transported to or 

49 evaluated in a healthcare facility.

50
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1

2 Spot decontamination:

3 As opposed to decontamination of the entire body, this decontamination technique involves the removal 

4 of visible contamination from small areas of exposed skin (e.g., hand or portion of the arm or leg). This 

5 technique may be water-based or utilize some of the alternative decontaminants discussed in this guidance

6 document (e.g., RSDL®). Spot decontamination can be performed in all three tiers of decontamination,

7 and can also be used as an alternative method for decontamination.

8

9 Patient Categories

10

11 Ambulatory:

12 Patients who can walk without assistance or with minimal assistance, follow responder or receiver

13 directions, and conduct certain decontamination tasks without assistance from responders or receivers

14 (e.g., remove clothing).

15

16 Some patients in this category may require buddy-help or responder/receiver assistance to complete the

17 decontamination procedure.

18 • These patients may include: minor-to-moderately wounded (e.g., ocular injuries, lacerations, breaks

19 or strains); members of at-risk populations (e.g., pediatrics, sight and/or hearing impaired, elderly);

20 and patients with minor symptoms.

21

22 Non-ambulatory:

23 Mobility impaired (e.g. Stretcher, wheelchair bound) patients. This category of patient may require

24 response personnel to complete decontamination actions with limited, if any, assistance from the patient.

25 • Decontamination of these patients is very resource and time intensive and typically requires

26 specialized equipment (e.g. rollers, chemical resistant backboards).

27 • Additional personnel may be required to decontaminate a single non-ambulatory patient.

28

29 Descriptors of Scale

30

31 Individual Patient Decontamination:

32 Decontamination activities conducted for a single contaminated patient. These activities should almost

33 always fall within the resource and capacity limitations of the properly prepared responding or receiving

34 organization.

35

36 Multi-Patient Decontamination (Resource Sufficient):

37 Decontamination activities conducted for multiple contaminated patients in a situation in which resources

38 are not limiting. Requests for additional resources or assistance should not be required for this level of

39 decontamination. The number of patients that constitutes multi-patient decontamination is dependent on 

40 the jurisdiction, responding agency, and system capacity.

41

42 Mass Patient Decontamination:

43 Decontamination activities conducted for a number of contaminated patients that exceeds the typical

44 response capacity of an organization, which may require additional resources or personnel from

45 surrounding jurisdictions and requires that patients be prioritized for the decontamination process. Mass

46 decontamination generally requires much higher levels of resource coordination than multi-patient or

47 individual decontamination situations. The number of patients that constitutes mass decontamination is

48 dependent on the jurisdiction, responding agency, and capacity.

49
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1 Tiers of Patient Decontamination

2

3 Self-Care:

4 Actions that a patient can perform for him/herself, including distancing him/herself from the site of

5 release, removing clothing, and wiping visible contamination from skin and clothing in order to reduce

6 his/her own contamination level immediately, without waiting for a formal decontamination process to be

7 set up. A perceptive patient or one experiencing acute distress from the chemical contamination may

8 execute self-care even before responders arrive; however, most patients will need instructions.

9

10 Gross patient decontamination:

11 Actions likely to be performed by or with the assistance of first responders or first receivers in order to

12 achieve a gross or hasty reduction in contamination, significantly reducing contamination on skin or

13 clothing, as soon as possible after contamination has occurred.

14

15 Technical patient decontamination:

16 Planned and systematic actions, likely to be performed under the guidance of, or with the assistance of

17 first responders or first receivers, to achieve contamination reduction to a level that is as low as possible.
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1 Appendix C: Glossary

2

Acute Stress Reaction

21 3 :An anxiety disorder precipitated by an experience of intense fear or horror while 

4 exposed to a traumatic (especially life-threatening) event. The disorder is characterized by dissociative 

5 symptoms; vivid recollections of the traumatic event; avoidance of stimuli associated with the traumatic 

6 event; and a constant state of hyper-arousal which lasts at least two days and no longer than four weeks. If 

7 symptoms of Acute Stress Disorder persist for greater than 1 month, a diagnosis of post-traumatic stress 

8 disorder (stress disorders, post-traumatic) is more appropriate. (For more information see Bryant 2011, 

9 and Diagnostics and Statistics Manual V)

10

At-Risk Populations

22 11 :

12 Those who have needs in one or more of the following functional areas: communication, medical care,

13 maintaining independence, supervision, and transportation. At-risk groups may include children, senior

14 citizens, and pregnant women, as well as people who have disabilities, live in institutionalized settings, are

15 from diverse cultures, have limited English proficiency or are non-English speaking, are transportation16 disadvantaged, have chronic medical disorders, or have pharmacological dependency.

17

Authority Having Jurisdiction

23 18 :

19 The public agency or its delegate that has legal responsibility and authority for responding to an incident,

20 based on political or geographical (e.g., city, county, Tribal, State, or Federal boundary lines) or functional

21 (e.g., law enforcement, public health) range or sphere of authority.

22

Crisis and Emergency Risk Communication

24 23 :

24 The effort by experts to provide information to allow an individual, stakeholder, or an entire community to 

25 make the best possible decisions about their well-being within nearly impossible time constraints and help 

26 people ultimately to accept the imperfect nature of choices during the crisis.

27

28 Evidence-based guidance:

29 As applied in this guidance document, evidence-based refers to the conscientious, definitive and judicious

30 use of current scientific evidence and/or sound technical input from subject matter experts in developing

31 patient decontamination recommendations for the care of patients, both individually and in a masscasualty

32 chemical incident, in order to save lives (Sackett et al., 1996).

33

34

 

21 According to the International Classification of Diseases-10 (Effective Date: Oct 1, 2014), Acute Stress Reaction is defined as:

An anxiety disorder precipitated by an experience of intense fear or horror while exposed to a traumatic (especially lifethreatening) 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 Disorder persist for greater than one month, a diagnosis of posttraumatic 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 throughout 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: http://www.phe.gov/Preparedness/planning/abc/Pages/atrisk.aspx.

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: 

http://www.bt.cdc.gov/cerc/.
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1 Appendix D: Toxic Chemical Syndrome Lexicon

2

3 Introduction

4 Military and civilian emergency response communities use a “toxic syndrome” (toxidrome) approach to 

5 quickly assess victims and determine the best immediate treatment when information on chemical 

6 exposures is limited. Toxidromes provide a common language to describe and recognize the clinical 

7 manifestations of toxic chemical exposures which can be defined by a unique group of clinical 

8 observations, such as vital sign abnormalities, mental status, pupil size, mucous membrane irritation, and 

9 lung and skin examinations. Once the toxidrome is recognized, emergency responders and hospital first 

10 receivers can consider a list of chemicals, exposure to which may manifest that toxidrome, as possibly 

11 causing the incident at hand. The USDHHS National Library of Medicine provides a comprehensive, 

12 user-friendly, web-based resources for first responders and hospital first receivers. Chemical Hazard 

13 Emergency Medical Management (CHEMM) and Wireless Information System for Emergency 

14 Responders (WISER) provide lists of potential chemical that align with specific toxidromes.

15

16 The Department of Homeland Security (DHS) Office of Health Affairs (OHA), with the National Library of

17 Medicine (NLM), sponsored a technical workshop on May 8-9, 2012 to discuss and develop a consistent

lexicon to describe toxic chemical syndromes or toxidromes

25 18 . The goal aimed at consensus on a list of

19 syndromes, their definitions, and designated syndrome names to establish a common language for chemical

20 defense planners, policy makers, first responders, first receivers and hazardous materials (HAZMAT)

21 stakeholders. The syndrome list aims to provide this common lexicon to assist key stakeholder

22 communities in quickly and accurately identifying the broad chemical agent category (if not the specific 

23 chemical agent type involved) by which a patient was exposed in order to rapidly determine appropriate 

24 emergency treatment. Comprehensiveness, accuracy, and clear understanding of the lexicon served as the 

25 primary criteria in developing this lexicon.

26

27 Background

28 Tens of thousands of chemicals are harmful to humans and knowing the specific toxic effects of even a

29 large portion of the possible chemical agents would be an impossible task. Toxic chemicals can often be

30 grouped into classes, whereby all the chemicals in a given class cause similar types of adverse health

31 effects. These constellations of toxic effects or syndromes comprise a set of clinical ‘‘fingerprints’’ for

32 groups of toxins. Moreover, all the toxic chemicals associated with a given toxic syndrome are treated

33 similarly. Hence, during the early phases of a toxic chemical emergency, when the exact chemical is often 

34 unknown, identification of the toxic syndromes that are present can be a useful decision making tool that

35 can overcome many of the problems associated with the lack of information on chemical identity.

36

37 Toxic syndromes are easily identified with only a few observations, such as:

38 • Vital signs

39 • Mentalstatus

40 • Pupil size

41 • Mucous membrane irritation

42 • Lung exam for wheezes or rales

43 • Skin for burns, moisture, and color

44

45 Toxic syndrome recognition is important because it provides a tool for rapid detection of the suspected

46 cause and can focus the differential diagnosis to consideration of only a few chemicals with similar toxic

 

25 Workshop attendees agreed that the terms toxic syndrome and toxidrome can be used interchangeably as toxidrome is a

contraction of “toxic syndrome.”
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1 effects. By focusing on certain chemicals, specific diagnostic testing and empiric therapies can be rendered

2 based on objective clinical evidence. Specifically, during a mass exposure, recognition can provide a triage 

3 tool for identifying toxic effects and also provide a common ‘‘language’’ so that all personnel, from

4 emergency responders on the scene to the hospital emergency department, can clearly communicate a 

5 clinical message (Figure 1). With the extraordinary number of chemicals in use, this tool does not apply to 

6 every chemical but to most of the commonly encountered chemicals reported in HAZMAT incidents. The

7 use of toxic syndromes as a diagnostic tool is fundamental to an effective and timely medical response.

8 Figure 1: Toxidrome Names and Descriptions

Toxidrome Name Toxidrome Descriptions

Topical Immediate effects range from minor irritation to severe skin, eye, and mucosal

Irritant/Corrosive membrane effects, which may progress to rapid systemic toxicity.

Inhalation Immediate effects to the respiratory/pulmonary tract presenting as respiratory

Irritant/Corrosive distress, coughing, wheezing, and/or nasal and oral secretions, which may

progress to rapid systemic toxicity.

Oral Ingestion Immediate effects to the oropharynx and gastrointestinal (GI) tract presenting

Irritant/Corrosive as burns, nausea, vomiting, diarrhea, and drooling, which may progress to

rapid systemic toxicity.

Knockdown/ Altered state of consciousness, progressing from fatigue and lightheadedness

Asphyxiants to coma, with possible seizures and cardiac signs, secondary to disrupted

cellular oxygen delivery and/or utilization.

Anticoagulants Alteration of the blood coagulation that results in abnormal bleeding,

indicated by excessive bruising, bleeding from mucous membranes, and

longer bleeding from other soft tissue trauma.

Cholinergic Overstimulation of cholinergic receptors leading to first activation and then 

fatigue of target 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)

Cellular-Asphyxia Inability to use oxygen, leading to acute-onset gasping, convulsions, loss of

(Cyanide-like) consciousness, breathing cessation, and cardiac arrest.

Convulsant CNS disinhibition or excitation (glycine or GABA antagonism, glutamate

agonism) leading to generalized convulsions.

Opioid Opioid agonism leading to pinpoint pupils, and central nervous system (CNS)

and respiratory depression.

Stress-Response/ Stress- or toxicant-induced catecholamine excess or CNS excitation leading to

Sympathomimetic confusion, panic, and increased pulse, respiration, and blood pressure.

Anticholinergic Under-stimulation of cholinergic receptors leading to dilated pupils

(mydriasis), decreased sweating, elevated temperature, and mental status

changes, including characteristic hallucinations.

Acute Exposure to Decreased level of consciousness (progressing to coma in some cases),

Solvents, Anesthetics, depressed respirations, and in some cases ataxia (difficulty balancing and

or Sedatives walking) from acute exposure to solvents, inhalational anesthetics, or

sedative-hypnotic compounds.
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1 Appendix E: Level of Confidence (LOC) Rankings

2

3 Purpose

4 A formal process for evaluating and scoring the quality and quantity of evidence to substantiate each

5 guidance statement was established by the WG.

6

7 Background

8 A Level of Confidence (LOC) score for each guidance statement reflects the WG’s expert judgment of the

9 strength of evidence underpinning the recommendation. The LOC is not a value judgment. The LOC is

10 also not a measure of appropriateness of a given practice: the circumstances of a particular chemical

11 incident and aftermath determine the proper course of action for successful patient decontamination. A

12 recommendation of LOC IV or V may save lives every day even if strong scientific evidence to

13 substantiate it is not available. Rather, the LOC represents the strength, breadth, quality, and quantity of

14 evidence (including literature, current guidance and best practice documents, and subject matter expert

15 input) supporting a particular recommended practice.

16

17 Rating Scale

18 Three main sources of knowledge were used together to establish a rating scale that helps to distinguish

19 guidance statements based on the strength of the supporting evidence: published literature, current

20 practice and SME opinion and experience.

21

22 Definitions

23 Literature Quality - A published article was assigned one of the following quality levels:

24 A = strong clinical (human or trial data) or field research supports study’s conclusions;

25 B = strong basic science (in vitro or in vivo models) research supports study’s conclusions; or an

26 uncontrolled study, field report of an actual response, or findings from an exercise;

27 C = consensus panel recommendations when not based on original research; or review of other studies,

28 editorial, or opinion paper.

29

30 Current practice – A specific principle or operational element is considered current practice if it is

31 supported in two or more of the eight previously published guidance or best-practice documents included

32 in the crosswalk analysis (for more information, see Methodology section).

33

34 SME Consensus - Defined as a group decision-making process that seeks the consent, not necessarily the

35 agreement, of participants and the resolution of objections. For the 2012 Symposium, consensus was

36 achieved through one of the following results:

37 a. Strong consensus – Two-thirds or more of the participating reviewers all vote, in writing, in

38 support of the particular guidance statement;

39 b. Simple consensus - 50% or more of the participating reviewers all vote, in writing, in support of

40 the particular guidance statement.

41

42 LOC Ratings Definitions

43 LOC I - The highest recommendation is supported by strong scientific evidence, including clinical or field

44 research, in addition to current practice and SME consensus.

45 a. Substantiated by strong scientific literature (including at least one Level A article),

46 b. Current practice,

47 c. Strong SME consensus.
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1 LOC II - The second tier recommendation is supported by some scientific evidence which is not definitive

2 or where methodological problems limit the utility of the stated conclusions, but which is current practice

3 and for which there is strong SME consensus.

4 a. Substantiated by adequate scientific literature (>three Level B articles),

5 b. Current practice,

6 c. Strong SME consensus.

7

8 LOC III – The third tier recommendation is one for which very limited scientific literature is informative,

9 but for which there is precedent in current practice and for which there is majority SME consensus.

10 a. Substantiated by limited scientific literature (at least one Level B article),

11 b. Current practice,

12 c. At least majority SME consensus.

13

14 LOC IV- The fourth tier recommendation is supported by at least majority SME consensus and current

15 practice but little or no scientific literature.

16 a. Substantiated by very limited scientific literature (no Level A or Level B evidence support the

17 statement),

18 b. Current practice,

19 c. At least majority SME consensus.

20

21 LOC V - The fifth tier reflects an absence of literature and precedent; SME consensus forms the sole basis

22 for the recommendation.

23 a. No Level A, B, or C articles,

24 b. Not a current practice,

25 c. At least majority SME consensus.

26

27 The WG contends that to varying degrees, additional primary research (basic, epidemiological, clinical

28 trial or observational) is needed for all of the present guidance statements. Additional study could validate 

29 a particular recommendation, and its LOC might therefore rise. Additional research may also lead to the

30 conclusion that a particular practice is not scientifically supported, in which case its LOC would fall and

31 the recommendation would be reconsidered. The LOC score reflects the current state of evidence on 

32 which a guidance statement is based. Any guidance statement in this document may be amended as 

33 science leads to better understanding of the best practices for mass patient chemical decontamination.