PM2ch44.pdf

Public Health Perspectives Related to Technological Disasters and Terrorism

Chapter 44

PUBLIC HEALTH PERSPECTIVES

RELATED TO TECHNOLOGICAL

DISASTERS AND TERRORISM

SCOTT R. LILLIBRIDGE, MD AND RICHARD J. BRENNAN, MBBS, MPH

INTRODUCTION

RISK FACTORS FOR TECHNOLOGICAL DISASTERS

PLANNING FOR TECHNOLOGICAL DISASTERS IN A CIVILIAN

ENVIRONMENT

ASSESSMENTS OF PUBLIC HEALTH AFTER A TECHNOLOGICAL DISASTER

Obtaining an Accurate History

Determining Appropriate Levels of Personal Protective Equipment

Assessing Clinical Presentations

Laboratory Evaluation of the Affected Population

Laboratory Evaluation of the Environment

Analyzing Data

SURVEILLANCE

EPIDEMIOLOGIC STUDIES

PUBLIC HEALTH RESPONSE TO TERRORISM

SUMMARY

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Military Preventive Medicine: Mobilization and Deployment, Volume 2

S.R. Lillibridge , Director, Center for Biosecurity and Public Health Preparedness, University of Texas Health Science Center at Houston

School of Public Health, PO Box 20186, Houston, TX 77225; Formerly, Office of Global Health, Centers for Disease Control and Prevention,

Atlanta, Georgia

R.J. Brennan , Director, Health Unit, International Rescue Committee, 122 East 42nd Street, New York, NY 10168, (212) 551-3019; Formerly,

Visiting Scientist, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia

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Public Health Perspectives Related to Technological Disasters and Terrorism

INTRODUCTION

Disasters are catastrophic events characterized

by urgent requirements for relief resources, techni-

cal expertise, and other vital services to assist the

stricken population. 1 The public health demands as-

sociated with disaster response usually focus on the

emergency needs of large populations. 2 Technologi-

cal disasters are events that result from the unex-

pected release of hazardous materials, including

fuels, chemicals, explosives, nuclear materials, and

biological pathogens, during their manufacture,

storage, transportation, or distribution. Technologi-

cal disasters may be characterized by explosions,

fires, chemical contamination, toxic plumes, radia-

tion exposure, or infectious disease outbreaks. 3,4

(Table 44-1) Many segments of a community’s vital

infrastructure, such as transportation routes, com-

munications, and water systems, can be affected.

The frequency of such disasters is increasing, par-

ticularly as societies with limited experience in oc-

cupational safety and emergency medical systems

rapidly industrialize. 5,6

Adverse health effects associated with techno-

logical disasters include thermal burns, inhalation

injury, blast injury, psychological trauma, and ill-

ness and injury due to contamination with chemi-

cal, radiological, or biological agents. 4,7–9 Long-term

environmental considerations following technologi-

cal disasters may include contamination of surface

water, the water table, the soil, and the food

chain. 4,10,11 The resulting biological effects from such

environmental exposures may not be apparent until

years later, when members of the exposed popula-

tion present with subtle impairments of the nervous

system or immune system. 12–15

Terrorism has been defined as the use or threat

of violence to sow panic in a society, to weaken or

overthrow its leaders, and to bring about political

change. 16 Although the common forms of terrorist

acts, such as bombings, assassinations, and hostage

taking, have important political and security impli-

cations for a nation, the public health impact of

these incidents is usually minimal. They are not

covered in this chapter. Unfortunately, new, more

lethal technologies have made it possible for terror-

ists to target larger segments of the population. 17–19

Some authors have used the term weapons of mass

destruction to convey the public health impact from

chemical, biological, or nuclear weapons designed

specifically for the purpose of attacking populations. 20

From the public health perspective, acts of terrorism

TABLE 44-1

A FEW EXAMPLES OF MAJOR INDUSTRIAL DISASTERS

Date

Place

Event

Result

9/21/1921

Oppau, Germany

Explosion at a nitrate manufacturing plant

561 deaths; > 1,500 persons

destroyed plant and nearby village

injured

4/16/1947

Texas City, Texas

Explosion in freighter being loaded with

561 deaths; much of city

ammonium nitrate

destroyed

7/28/1948

Ludwigshafen, Federal

Vapor explosion from dimethyl ether

209 deaths

Democratic Republic

of Germany

7/10/1976

Seveso, Italy

Chemical reactor explosion released

100,000 animals killed; 760

2,3,7,8-TCDD

people evacuated; 4,450

acres contaminated

2/25/1984

Cubatao, Sao Paulo,

Gasoline leak from a pipeline exploded and > 500 deaths

Brazil

burned nearby shanty town

11/19/1984

San Juan Ixtaheupec,

5,000,000 L of liquefied butane exploded at

> 400 deaths; 7,231 persons

Mexico City, Mexico

a storage facility

injured; 700,000 evacuated

12/03/1984 Bhopal, India

Release of methyl isocyanate from pesticide > 2,000 deaths; 100,000

plant

persons injured

Reprinted from: Centers for Disease Control. The Public Health Consequences of Disasters 1989 . Atlanta, Ga: US Dept of Health and

Human Services, Public Health Service, CDC; 1989.

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Military Preventive Medicine: Mobilization and Deployment, Volume 2

with such agents may be considered “intentional”

technological disasters. But whether a disaster re-

sults from the accidental disruption of an industrial

process or from a calculated terrorist act involving

weapons of mass destruction, many of the same

emergency public health skills will be required for

successful response for the stricken population. 21 A

multidisciplinary approach that includes profes-

sionals such as toxicologists, chemists, microbiolo-

gists, laboratorians, industrial hygienists, health

physicists, physicians, and epidemiologists will

generally be required to mount an effective response

to such hazards. This chapter reviews the public

health management of technological disasters, fo-

cusing on civilian population needs rather than on

those of military personnel, although military per-

sonnel are often involved in addressing public

health and medical contingencies in civilian popu-

lations. Chemical, biological, and radiological war-

fare and the appropriate medical countermeasures

involving military personnel are covered in Chap-

ters 27, Chemical Warfare Agents; 28, Biological

Warfare Defense; and 29, Medical Response to In-

jury from Ionizing Radiation.

RISK FACTORS FOR TECHNOLOGICAL DISASTERS

In civilian populations, people from lower socio-

economic levels may be at greater risk from tech-

nological disasters because of their more limited

access to emergency services and because of the fre-

quency with which hazardous industrial sites are

located near low-income residential areas. 22,23 The

lack of effective urban zoning regulations and en-

forcement policies designed to maintain geographic

separation between residential communities and

industrial sites contributes to this problem. 24 Devel-

oping countries are at particular risk for techno-

logical disasters. This is largely due to industrial

safety problems, including the inability to ensure

the proper use of new technology, the underdevel-

opment of occupational health and the general pub-

lic health infrastructure, the lack of prehospital

emergency medical services, and, in some cases,

civil unrest. 25 Nonmedical occupational groups at

risk during the emergency response to technological

disasters include plant workers, emergency respond-

ers, media representatives, and law enforcement

officials.

PLANNING FOR TECHNOLOGICAL DISASTERS IN A CIVILIAN ENVIRONMENT

One of history’s worst technological disasters

involved a nighttime chemical release in the city of

Bhopal, India, on 3 December 1984. The toxic agent

was methyl isocyanate (MIC) vapor, which was

vented into the atmosphere because of a combina-

tion of operator error and malfunctioning safety

systems within a local chemical plant. 6 MIC is an

intermediate product in the manufacture of carbam-

ate pesticides. The toxic plume of MIC covered an

area of 40 km 2 and extended 8 km beyond the fac-

tory. 26 Because proper warning and evacuation

guidance were delayed, many victims first became

aware of the disaster as they were overcome by

MIC. More than 2,500 people in the adjacent com-

munity may have died, and 200,000 people were

affected by the chemical release. 8,27 Thousands of

victims sought urgent medical assistance, over-

whelming local medical services.

The magnitude of the Bhopal disaster exposed a

number of vulnerabilities associated with the release

of a hazardous agent within a minimally prepared

civilian population. In particular, basic disaster

management strategies, such as informing the com-

munity of the types and quantities of the chemicals

stored on the site and ensuring the emergency no-

tification of the nearby population, were incom-

plete. 8,26 Consequently, many medical personnel and

public health officials were unaware of the appro-

priate treatment options during the initial phase of

the emergency response. In addition, poor initial

documentation of patients’ clinical status, inad-

equate laboratory sampling, and incomplete epide-

miologic studies further limited longer-term relief

initiatives and exposure studies. 27,28 Unfortunately,

such deficiencies in emergency response activities

for technological disasters are widespread in both

developed and less-developed countries. 21

An effective response to disasters such as Bhopal

requires the development of a comprehensive and

effective local strategy to manage the risk of disas-

ters. It is a collaborative process that requires co-

operation between government agencies, private

organizations, and the community. Key objectives

of disaster planning include the clarification of the

capabilities, roles, and responsibilities of the agen-

cies involved and the strengthening of emergency

networks. Public health response considerations

should be incorporated into local, regional, state,

and national disaster plans to ensure the health of

populations at risk. For technological disasters, such

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Public Health Perspectives Related to Technological Disasters and Terrorism

considerations will include rapid assessment, com-

munity notification, mass decontamination, mass

vaccination or other medical management, evacua-

tion procedures, and public health surveillance.

Disaster plans, including the public health compo-

nents, should be tested regularly in exercises to

evaluate their effectiveness, train personnel, and

improve the overall emergency response. Activities

to assess and mitigate local risks should be integrated

into a program of ongoing disaster management.

During domestic disasters, the US military pro-

vides important support as part of the National

Disaster Medical System (see Chapter 46, Domes-

tic Disaster Response: FEMA and Other Govern-

mental Organizations). 29 The United States has a

well-developed Federal Disaster Response Plan, in

which public health professionals play a key role.

This system is supported by the involvement of 26

federal agencies, including the Department of De-

fense, the Department of Veterans Affairs, the Fed-

eral Emergency Management Agency, and the De-

partment of Health and Human Services. Unfortu-

nately, many developing countries lack these re-

sources for national disaster response. Within the

United Nations system, a number of agencies and

organizations may be able to assist such countries

following a technological disaster by providing im-

portant technical information and services. Some

of these agencies are listed in Exhibit 44-1. Military

medical officers may need to coordinate relief op-

erations with these organizations within contin-

gency situations involving civilian populations.

As part of their responsibility to protect popula-

tions from the effects of industrial disasters, public

health professionals should facilitate communica-

tion between local clinical services (eg, hospitals,

EXHIBIT 44-1

UNITED NATIONS ORGANIZATIONS

OR PROGRAMS THAT MAY PROVIDE

ASSISTANCE FOLLOWING

TECHNOLOGICAL DISASTERS

Food and Agricultural Organization

Industrial Development Organization

International Labour Organization

International Programme for Chemical Safety

United Nations Environment Programme

World Health Organization

World Meteorological Organization

ambulance services), occupational health profes-

sionals at the industrial site, and members of the

surrounding community. 30 Other technological di-

saster mitigation activities for public health officials

and preventive medicine officers may include the

following: ( a ) establishing warning systems to alert

nearby communities of a toxic agent release, ( b )

determining minimal threshold concentrations of

toxic chemicals, biological agents, or radiation that

would require the community to evacuate in the

event of a release, ( c ) coordinating evacuation activi-

ties following a hazardous release, ( d ) coordinating

medical care and appropriate referral destinations

for patients exposed to hazardous materials, and

( e ) ensuring the appropriate collection and labora-

tory analysis of specimens. 6,8

ASSESSMENTS OF PUBLIC HEALTH AFTER A TECHNOLOGICAL DISASTER

Following the release of a chemical or radiologi-

cal agent, the adverse health effects associated with

that agent may appear rapidly within the popula-

tion, focusing early attention by health authorities

on the task of identifying the responsible toxin or

toxins. Public health mitigation procedures, such as

evacuation, sheltering in place, and decontamina-

tion, can often be initiated quickly, in some cases

even without precise knowledge of the hazard. The

health effects of other technological disasters, how-

ever, may present more insidiously. For example,

an infectious disease outbreak secondary to the ac-

cidental or deliberate release of a biological agent

may be detected only after an unusual infection or

clinical presentation has been diagnosed by a phy-

sician or identified by routine surveillance activi-

ties or an epidemiologic investigation. 4,31

At other times, it may be unclear if a disease out-

break is due to a chemical or a biological agent. For

example, a 1996 disease outbreak in Haiti charac-

terized by fever and renal failure in children was

initially believed to be caused by an infectious

agent. 32 However, the cause of these deaths was ul-

timately determined to be poisoning by di-ethyl-

ene glycol–contaminated paracetamol, which had

been used to control fever in children. 33 The final

diagnosis and subsequent public health interven-

tions may have been delayed because of the lack of

consideration of a toxic agent. The important lesson

learned was the need to consider from the outset

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