1. Assessing Chemical Exposure: A Lab Perspective Kevin Chao, Ph.D. Department of Public Health State of California

2. Topics Covered  Introduction to All Hazards Terrorism  Chemical Terrorism Specifics  Toxicology/Properties of likely agents  Public Health/Laboratory response  Environmental and clinical sample collection  Environmental and clinical sample testing

3. All Hazards?  Chemical  Biological  Radiological  Nuclear  Explosive

4. Toxic Industrial Chemicals  Chlorine  Hydrogen Cyanide  Ammonia  Phosgene  Methyl Isocyanate

5. Bhopal, India  December 3, 1984  40 Tons of MIC (methyl isocvanate)  500,000 exposed (5-8 miles downwind)  11,000 disabled  3,800 dead

6. Similar Chemical Incident in California?  Metam Sodium  Where did it happen?  Lucky or what?

7. Comparative Toxicity (lethal dose)

8. Highly Toxic Agents Developed to Kill or Disable  Advantages:  Small amounts needed  Surreptitious use  Targeted use  Disadvantages:  “Harder” to obtain  Nations?  Cults?  Lunatics?

10. Some Overt Exposure Scenarios  Blast, leak  Ventilation ducts  Closed spaces: subway cars subway cars planes planes  Vehicular releases: drive-by drive-by crop dusting crop dusting

11. Some Covert Exposure Scenarios  Food, tobacco, alcohol  Medications, blood products  Cosmetics and personal hygiene products products  Surfaces (door knobs, utensils): hand-to-mouth  Fixed distribution systems: water, natural gas natural gas

12. Respiratory Irritant Gases  Chlorine  Phosgene  Oxides of nitrogen  Ammonia  Hydrogen chloride  Formaldehyde  Acrolein

13. Respiratory Irritant Gases  Direct chemical reaction with tissues  pH, redox, addition, substitution reactions  structural lipids and proteins denatured or degraded  Induced inflammatory reaction

14. Metabolic Toxicants  Cyanides  Azides  Sulfides  Carbon monoxide  Fluoroacetates  Dinitrophenol, pentachlorophenol  Many others

15. Cyanide: Toxicological Mode of Action  Blocks electron transport in mitochondria  Binds to Fe+3 in cytochrome oxidase  Prevents electron transfer to oxygen  Oxygen-rich red venous blood

16. Carbon Monoxide  #1 chemical cause of acute toxic death  #2 rank air pollutant after CO2  Vehicular, coal/oil burning, industrial  Invisible, odorless  Affinity for Hgb 220x greater than that of O2  Forms carboxyhemoglobin  Proportionately decreases oxygen carrying capacity  Red venous blood

17. Vesicant Agents (Blister Agents)  Mustard agents Sulfur (military use) Sulfur (military use) Nitrogen (chemotherapy) Nitrogen (chemotherapy)  Lewisite (2-chlorovinyl dichloroarsine)

18. Mustard: Targets

19. Nerve Agents  A family of agents that kill by destroying acetyl cholinesterase, an enzyme essential for proper nerve function

20. Physical Properties  Liquids at room temperature - not gases  Soluble in fat and water  Absorbed through respiratory tract, skin, eyes  Phosphonate esters  Tabun (GA) - most unavailable  Sarin (GB) - most volatile  Soman (GD) - fastest “aging”  VX - most potent and persistent  Other nerve agents

21. Symptoms of Nerve Agents  “DUMBELS”  D - Diarrhea  U - Urination  M - Miosis  B - Bronchoconstriction, Bronchorrhea  E - Emesis  L - Lacrimation  S - Salivation

22. What plant is this?

23. Public Health Aims in a Chemical Event  Identify the agent or cause  Circumstance, intelligence, clinical syndrome  Environmental or biological fluids assay  Determine temporal or geographical distribution of exposure  Determine relative (high/low) exposures

24. Public Health Aims in a Chemical Event (cont.)  Evaluate health implications  Provide medical and public health guidance and support  Provide continued surveillance and prevention

25. After a CT Incident Environmental Samples:  Identify chemical agent on scene  Define contamination zone  Check for effective decontamination  Determine when to allow re-entry

26. Who collects the environmental samples?  Hazmat Team  CST Team, request through State OES  FBI Team  Standard procedures for collecting these samples as described in HAZMAT handbook with proper PPE and precaution

27. What types of samples are needed?  Sample types: solid, liquid, wipes and air

28. Who is going to test them for you?  Agencies may test them for you:  -Cal EPA (DTSC)  -US EPA  -LLNL for warfare agents  -CDHS could also help

29. After a CT Incident Clinical Samples:  Confirm agent ID  Assist in medical treatment  Separate exposed from “Worried Well”  Support health effect studies

30. Continues:  Predicting levels of toxicants in people using environmental monitoring is very difficult and includes many assumptions…

31. Bio-monitoring- Measuring Chemicals in People  California has the funding to start a bio- monitoring program as a tool to assess human exposure to toxic chemicals in California

32. Your Plan for Human Specimens  Local HAZMAT/first responders identify or suspect incident  Jurisdiction or FBI notifies CDHS/CDC

33. Who collects the clinical samples?  Attending physicians at ED to order the collection of clinical specimens (three purple, one green and 25 cc urine for adults; urine only for infants and young children) to be collected  PH Labs as a hub to collect and ship initial samples to CDHS/CDC pending discussion

34. What does CDC do with the first 40 samples?  CDC performs PCR and “Rapid Toxic Screen” on initial samples  CDC provides guidance to LRN for analysis of remaining samples

35. Rapid Toxic Screen  Analysis of 40 samples for 150 agents or metabolites within 36 hrs  CDC has greater “screening” capability than currently available at any city or state public health lab

36. Collecting Clinical Specimens:  Protocols for collecting and shipping blood (3 purple and 1 green) and urine (25 mL) (2 blank tubes and cups are required) posted on CDC’s website: http://www.bt.cdc.gov/labissues/pdf/chemspecimencollection.pdf

37. Collecting Clinical Specimens:  Clinical specimens will be collected at hospitals  Local Public Health Lab should continue train hospital staff (ED nurse managers especially) on what clinical samples should be collected.

38.  Call Kevin Chao for resources may be able to test the samples at 510-377-3435.