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After a chemical fire, an investigation assessed health effects by using syndromic surveillance to monitor emergency department (ED) visits, a general health survey to assess the general public, and a first responders health survey to assess first responders. A total of four separate multivariable logistic regression models were developed to examine associations between reported exposure to smoke, dust, debris, or odor with any reported symptom in the general public. Syndromic surveillance identified areas with increased ED visits. Among general health survey respondents, 45.1% (911 out of 2,020) reported at least one symptom. Respondents reporting exposure to smoke, dust, debris, or odor had 4.5 (95% confidence interval (CI) [3.7, 5.5]), 4.6 (95% CI [3.6, 5.8]), 2.0 (95% CI [1.7, 2.5]), or 5.8 (95% CI [4.7, 7.3]) times the odds of reporting any symptom compared with respondents not reporting exposure to smoke, dust, debris, or odor, respectively. First responders commonly reported contact with material and being within 1 mi of the fire ≥5 hr; 10 out of 31 of first responders reported at least one symptom. There was high symptom burden reported after the fire. Results from our investigation might assist the directing of public health resources to effectively address immediate community needs and prepare for future incidents.

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BACKGROUND: In 2021, a large petroleum leak contaminated a water source that supplied drinking water to military and civilians in Oahu, Hawaii. METHODS: We conducted an Assessment of Chemical Exposures (ACE) survey and supplemented that information with complementary data sources: (1) poison center caller records; (2) emergency department visit data; and (3) a key informant questionnaire. RESULTS: Among 2,289 survey participants, 86% reported ≥1 new or worsening symptom, 75% of which lasted ≥30 days, and 37% sought medical care. Most (n = 1,653, 72%) reported new mental health symptoms. Among equally observable symptoms across age groups, proportions of children ≤2 years experiencing vomiting, runny nose, skin rashes, and coughing (33, 46, 56, and 35%, respectively) were higher than other age groups. Poison center calls increased the first 2 weeks after the contamination, while emergency department visits increased in early December 2021. Key informant interviews revealed themes of lack of support, mental health symptoms, and long-term health impact concerns. DISCUSSION: This event led to widespread exposure to petroleum products and negatively affected thousands of people. Follow-up health surveys or interventions should give special consideration to longer-term physical and mental health, especially children due to their unique sensitivity to environmental exposures.

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OBJECTIVE: The aim of the study was to assess occupational health effects 1 month after responding to a natural gas pipeline explosion. METHODS: First responders to a pipeline explosion in Kentucky were interviewed about pre- and post-response health symptoms, post-response health care, and physical exertion and personal protective equipment (PPE) use during the response. Logistic regression was used to examine associations between several risk factors and development of post-response symptoms. RESULTS: Among 173 first responders involved, 105 (firefighters [58%], emergency medical services [19%], law enforcement [10%], and others [12%]) were interviewed. Half (53%) reported at least 1 new or worsening symptom, including upper respiratory symptoms (39%), headache (18%), eye irritation (17%), and lower respiratory symptoms (16%). The majority (79%) of symptomatic responders did not seek post-response care. Compared with light-exertion responders, hard-exertion responders (48%) had significantly greater odds of upper respiratory symptoms (aOR: 2.99, 95% CI: 1.25-7.50). Forty-four percent of responders and 77% of non-firefighter responders reported not using any PPE. CONCLUSIONS: Upper respiratory symptoms were common among first responders of a natural gas pipeline explosion and associated with hard-exertion activity. Emergency managers should ensure responders are trained in, equipped with, and properly use PPE during these incidents and encourage responders to seek post-response health care when needed.

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PROBLEM/CONDITION: Every year in the United States, thousands of toxic substance incidents harm workers, first responders, and the public with the potential for catastrophic consequences. Surveillance data enable public health and safety professionals to understand the patterns and causes of these incidents, which can improve prevention efforts and preparation for future incidents. PERIOD COVERED: 2010-2014. DESCRIPTION OF SYSTEM: In 2010, the Agency for Toxic Substances and Disease Registry (ATSDR) initiated the National Toxic Substance Incidents Program (NTSIP), and it was retired in 2014. Nine state health departments participated in NTSIP surveillance: California, Louisiana, North Carolina, New York, Missouri, Oregon, Tennessee, Utah, and Wisconsin. The states conducted surveillance on acute toxic substance incidents, defined as an uncontrolled or illegal acute (lasting <72 hours) release of any toxic substance including chemical, biologic, radiologic, and medical materials. Surveillance focused on associated morbidity and mortality and public health actions. This report presents an overview of NTSIP and summarizes incidents and injuries from the nine participating states during 2010-2014. RESULTS: During 2010-2014, participating state health departments reported 22,342 incidents, of which 13,529 (60.6%) met the case definition for acute toxic substance incidents, and included 6,635 injuries among 5,134 injured persons, of whom 190 died. A trend analysis of the three states participating the entire time showed a decrease in the number of incidents with injuries. NTSIP incidents were 1.8 times more likely and injured persons were 10 times more likely to be associated with fixed facilities than transportation. Natural gas, carbon monoxide, ammonia, and chemicals used in illegal methamphetamine production were the most frequent substances in fixed-facility incidents. Sodium and potassium hydroxide, hydrochloric acid, natural gas, and sulfuric acid were the most frequent substances in transportation-related incidents. Carbon monoxide was the most frequent substance in incidents with a large number of injured persons, and chemicals used in illegal methamphetamine production were the most frequent substance in incidents involving decontamination. Incidents most frequently occurred during normal business days (Monday through Friday) and hours (6:00 a.m.-5:59 p.m.) and warmer months (March-August). The transportation and warehousing industry sector had the largest number of incidents (4,476); however, most injured persons were injured in their private residences (1,141) or in the industry sectors of manufacturing (668), educational services (606), and real estate rental and leasing (425). The most frequently injured persons were members of the public (43.6%), including students. Injured first responders, particularly police, frequently were not wearing any chemically protective equipment. Respiratory system problems (23.9%) were the most frequently reported symptoms among injured persons and, in a related finding, volatilization was the most frequent type of release in incidents with injured persons. INTERPRETATION: Industrial and transportation incidents occur frequently and have the potential for catastrophic outcomes. However, exposures to toxic substances occur frequently in other settings. Carbon monoxide, natural gas, and chemicals used in illegal methamphetamine production are commonly found in places where persons live, work, attend school, and recreate and are large contributors to incidents affecting the public. Having active NTSIP state surveillance programs did appear to improve the incidents with morbidity and/or mortality, but these programs have ended. PUBLIC HEALTH ACTION: Archived NTSIP public use data are available to download from the website for analysis. There are also many publications and reports on the website to help understand chemical risks. In addition, jurisdictions might choose to collect surveillance data themselves in a similar manner to what NTSIP states did. Chemical incident surveillance data can be used by public health and safety practitioners, worker representatives, emergency planners, preparedness coordinators, industries, and emergency responders to prepare for and prevent chemical incidents and injuries. As noted by the U.S. Chemical Safety Board, more action needs to be taken to prevent large industrial incidents. Although preventing such incidents might not be in the realm of public health, describing the public health implications and preparing for them is. Another important finding of NTSIP is that industrial incidents are only part of the problem. For example, a large number of persons were injured in a private residence or vehicle (22.2%) and an educational facility (11.8%). Public health professionals must resourcefully target prevention and preparedness to protect vulnerable populations in locations where they might spend time (e.g., schools, daycares, nursing homes, recreational areas, jails, prisons, and hospitals). Reducing the threat of chemical incidents and injuries in the United States will require a concerted effort with a variety of stakeholders including industry and labor, responder groups, policymakers, academia, and citizen advocacy groups.

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On April 25, 2019, a farm tractor towing two 2-ton ammonia tanks on a county road in Lake County, Illinois, experienced a mechanical failure that resulted in the release of anhydrous ammonia, a colorless, pungent, irritating gas that can cause severe respiratory and ocular damage (1). Approximately 80% of anhydrous ammonia produced in the United States is used as a fertilizer in agriculture (1). Eighty-three persons, including first responders, motorists, and neighborhood residents, were evaluated at area hospitals because of exposure to the gas. Two weeks after the release, the Agency for Toxic Substances and Disease Registry (ATSDR) and CDC's National Center for Environmental Health (NCEH) collaborated with the Lake County Health Department and the Illinois Department of Public Health on an investigation using ATSDR's Assessment of Chemical Exposures program to describe the release, review the emergency response, and determine health effects associated with the exposure. First responders, community residents, and hospital personnel reported communication challenges related to the nature of the gas release and effective protective measures. Among the 83 persons evaluated at six area hospitals for effects of the chemical release, 14 (17%) were hospitalized, including eight (10%) who were admitted to the intensive care unit (ICU), seven (8%) of whom required endotracheal intubation and mechanical ventilation; no deaths occurred. In addition, ICU health care providers experienced symptoms of secondary exposure. The National Institute for Occupational Safety and Health's Emergency Responder Health Monitoring and Surveillance Program has specific recommendations and tools to protect responders during all phases of a response (2). Hospitals also need to review institutional policies and procedures for chemical mass casualty events, including decontamination (3). Prompt and correct identification of hazardous material (hazmat) events, and clear communication among responding entities, including on-scene and hospital responders, is important to ensure effective response after a chemical release.

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BACKGROUND: Carbon monoxide (CO) is an insidious gas responsible for approximately 21,000 emergency department visits, 2300 hospitalizations, and 500 deaths in the United States annually. We analyzed 10 combined years of data from two Agency for Toxic Substances and Disease Registry acute hazardous substance release surveillance programs to evaluate CO incident-related injuries. METHODS: Seventeen states participated in these programs during 2005-2014. RESULTS: In those 10years, the states identified 1795 CO incidents. Our analysis focused on 897 CO incidents having injured persons. Of the 3414 CO injured people, 61.0% were classified as general public, 27.7% were employees, 7.6% were students, and 2.2% were first responders. More than 78% of CO injured people required hospital or pre-hospital treatment and 4.3% died. The location for most injured people (39.9%) were homes or apartments, followed by educational facilities (10.0%). Educational services had a high number of people injured per incident (16.3%). The three most common sources of CO were heating, ventilation, and air conditioning systems; generators; and motor vehicles. Equipment failure was the primary contributing factor for most CO incidents. CONCLUSIONS: States have used the data to evaluate trends in CO poisoning and develop targeted public health outreach. Surveillance data are useful for setting new policies or supporting existing policy such as making CO poisoning a reportable condition at the state level and requiring CO alarms in all schools and housing. Public health needs to remain vigilant to the sources and causes of CO to help reduce this injury and death.

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IntroductionFirst responders, including firefighters, police officers, emergency medical services, and company emergency response team members, have dangerous jobs that can bring them in contact with hazardous chemicals among other dangers. Limited information is available on responder injuries that occur during hazardous chemical incidents. METHODS: We analyzed 2002-2012 data on acute chemical incidents with injured responders from 2 Agency for Toxic Substances and Disease Registry chemical incident surveillance programs. To learn more about such injuries, we performed descriptive analysis and looked for trends. RESULTS: The percentage of responders among all injured people in chemical incidents has not changed over the years. Firefighters were the most frequently injured group of responders, followed by police officers. Respiratory system problems were the most often reported injury, and the respiratory irritants, ammonia, methamphetamine-related chemicals, and carbon monoxide were the chemicals more often associated with injuries. Most of the incidents with responder injuries were caused by human error or equipment failure. Firefighters wore personal protective equipment (PPE) most frequently and police officers did so rarely. Police officers' injuries were mostly associated with exposure to ammonia and methamphetamine-related chemicals. Most responders did not receive basic awareness-level hazardous material training. CONCLUSION: All responders should have at least basic awareness-level hazardous material training to recognize and avoid exposure. Research on improving firefighter PPE should continue. (Disaster Med Public Health Preparedness. 2018;12:211-221).

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Children are considered to be a vulnerabletion when it comes to exposures to hazardous substances. Schools, where children spend about one third of their day, are expected to be a safe environment. Yet, there are many hazardous substances in schools that can be inadvertently or intentionally released and harm the health of students and teachers alike. The purpose of this analysis is to characterize acute chemical release incidents in school settings and identify prevention practices. The acute chemical incident surveillance programs of the Agency for Toxic Substances and Disease Registry (ATSDR) captured 24,748 acute chemical release incidents from 14 states that participated during 2008-2013. We examined 335 of these incidents that occurred at schools. While only 1.3% (n = 335) of all chemical incidents reported to ATSDR occurred in schools, these incidents represented a larger part of the total impacts, including 8.5% of incidents with persons injured, 5.7% of evacuations ordered, and 31.1% of people evacuated. Natural gas (21.8%) and mercury (18.2%) were the chemicals most frequently released. Collecting and analyzing data on acute school chemical releases allows stakeholders to target prevention initiatives and provide a school environment safe from these chemical exposures.

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When a large chemical incident occurs and people are injured, public health agencies need to be able to provide guidance and respond to questions from the public, the media, and public officials. Because of this urgent need for information to support appropriate public health action, the Agency for Toxic Substances and Disease Registry (ATSDR) of the US Department of Health and Human Services has developed the Assessment of Chemical Exposures (ACE) Toolkit. The ACE Toolkit, available on the ATSDR website, offers materials including surveys, consent forms, databases, and training materials that state and local health personnel can use to rapidly conduct an epidemiologic investigation after a large-scale acute chemical release. All materials are readily adaptable to the many different chemical incident scenarios that may occur and the data needs of the responding agency. An expert ACE team is available to provide technical assistance on site or remotely. (Disaster Med Public Health Preparedness. 2016;10:631-632).

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OBJECTIVE: A chlorine gas release occurred at a poultry processing plant as a result of an accidental mixing of sodium hypochlorite and an acidic antimicrobial treatment. We evaluated the public health and emergency medical services response and developed and disseminated public health recommendations to limit the impact of future incidents. METHODS: We conducted key informant interviews with the state health department; local fire, emergency medical services, and police departments; county emergency management; and representatives from area hospitals to understand the response mechanisms employed for this incident. RESULTS: After being exposed to an estimated 40-pound chlorine gas release, 170 workers were triaged on the scene and sent to 5 area hospitals. Each hospital redistributed staff or called in extra staff (eg, physicians, nurses, and respiratory therapists) in response to the event. Interviews with hospital staff emphasized the need for improved communication with responders at the scene of a chemical incident. CONCLUSIONS: While responding, hospitals handled the patient surge without outside assistance because of effective planning, training, and drilling. The investigation highlighted that greater interagency communication can play an important role in ensuring that chemical incident patients are managed and treated in a timely manner. (Disaster Med Public Health Preparedness. 2016;10:553-556).

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OBJECTIVE: To analyze acute hazardous substance release surveillance data for events involving secondary contamination of hospital emergency departments (EDs). Secondary contamination of EDs may occur when a patient exposed to a hazardous chemical is not decontaminated before arrival at the ED and when ED staff are not wearing appropriate personal protective equipment. This can result in adverse health outcomes among department personnel, other patients, and visitors. Even events without actual secondary contamination risk can be real in their consequences and require the decontamination of the ED or its occupants, evacuation, or temporary shutdown of the ED. METHODS: Events involving secondary contamination were identified by using the Hazardous Substances Emergency Events Surveillance system and the National Toxic Substance Incidents Program from 2007 to 2013. RESULTS: Five incidents involving the threat of secondary contamination (0.02% of all events reported to the surveillance systems [n=33,001]) were detected and are described. Four incidents involved suspected secondary contamination in which the facility was evacuated or shut down. CONCLUSIONS: These results suggest that although rare, incidents involving secondary contamination continue to present a hazard for emergency departments. Suggested best practices to avoid secondary contamination have been described. Hospitals should be made aware of the risks associated with secondary contamination and the need to proactively train and equip staff to perform decontamination.

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Methamphetamine (meth), a highly addictive drug, can be illegally manufactured using easily acquired chemicals; meth production can cause fires, explosions, injuries, and environmental contamination. To analyze injury incidence and trends, data on 1,325 meth-related chemical incidents reported to the Agency for Toxic Substances and Disease Registry's (ATSDR) Hazardous Substances Emergency Events Surveillance (HSEES) system and National Toxic Substance Incidents Program (NTSIP) by the five participating states (Louisiana, Oregon, Utah, New York, and Wisconsin) with complete information during 2001-2012 were examined. The findings suggested that meth-related chemical incidents increased with the drug's popularity (2001-2004), declined with legislation limiting access to precursor chemicals (2005-2007), and increased again as drug makers circumvented precursor restrictions (2008-2012). Seven percent of meth-related chemical incidents resulted in injuries to 162 persons, mostly members of the general public (97 persons, including 26 children) and law enforcement officials (42). Recent trends suggest a need for efforts to protect the general public, particularly children and law enforcement officials. Because individual state legislative actions can result in increased illegal meth production in neighboring states, a regional approach to prevention is recommended.

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On March 22, 2015, the Agency for Toxic Substances and Disease Registry (ATSDR) was notified by the U.S. Environmental Protection Agency (EPA) of four cases of suspected acute methyl bromide toxicity among family members vacationing at a condominium resort in the U.S. Virgin Islands. Methyl bromide is a pesticide that has been banned in the United States for use in homes and other residential settings. An investigation conducted by the U.S. Virgin Islands Department of Health (VIDOH), the U.S. Virgin Islands Department of Planning and Natural Resources (DPNR), and EPA confirmed that methyl bromide had been used as a fumigant on March 18 in the building where the family had been residing, 2 days before they were transported to the hospital; three family members had life-threatening illness. On March 25, 2015, a stop-use order for methyl bromide was issued by DPNR to the pest control company that had performed the fumigation. Subsequent investigation revealed that previous fumigation with methyl bromide had occurred on October 20, 2014, at the same condominium resort. In addition to the four ill family members, 37 persons who might have been exposed to methyl bromide as a result of the October 2014 or March 2015 fumigations were identified by VIDOH and ATSDR. Standardized health questionnaires were administered to 16 of the 20 persons for whom contact information was available; six of 16 had symptoms consistent with methyl bromide exposure, including headache and fatigue. Pest control companies should be aware that use of methyl bromide is banned in homes and other residential settings, and clinicians should be aware of the toxicologic syndrome that exposure to methyl bromide can cause.

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PROBLEM/CONDITION: Although they are infrequent, acute chemical incidents (i.e., uncontrolled or illegal release or threatened release of hazardous substances lasting <72 hours) with mass casualties or extraordinary levels of damage or disruption severely affecting the population, infrastructure, environment, and economy occur, and thousands of less damaging chemical incidents occur annually. Surveillance data enable public health and safety professionals to better understand the patterns and causes of these incidents, which can improve prevention efforts and preparation for future incidents. REPORTING PERIOD: 1999-2008. DESCRIPTION OF SYSTEM: The Hazardous Substances Emergency Events Surveillance (HSEES) system was operated by the Agency for Toxic Substances and Disease Registry (ATSDR) during January 1991-September 2009 to describe the public health consequences of chemical releases and to develop activities aimed at reducing the harm. This report provides a historical overview of HSEES and summarizes incidents from the nine states (Colorado, Iowa, Minnesota, New York, North Carolina, Oregon, Texas, Washington, and Wisconsin) that participated in HSEES during its last 10 full years of data collection (1999-2008). RESULTS: During 1999-2008, a total of 57,975 chemical incidents occurred: 41,993 (72%) occurred at fixed facilities, and 15,981 (28%) were transportation related. Chemical manufacturing (NAICS 325) (23%) was the industry with the most incidents; however, the number of chemical incidents in chemical manufacturing decreased substantially over time (R² = 0.78), whereas the educational services category (R² = 0.65) and crop production category (R² = 0.61) had a consistently increasing trend. The most common contributing factors for an incident were equipment failure (n = 22,535, 48% of incidents) and human error (n = 16,534, 36%). The most frequently released chemical was ammonia 3,366 (6%). Almost 60% of all incidents occurred in two states, Texas and New York. A decreasing trend occurred in the number of incidents in Texas, Wisconsin, and Colorado, and an increasing trend occurred in Minnesota. INTERPRETATION: Although chemical manufacturing accounted for the largest percentage of incidents in HSEES, the number of chemical incidents over time decreased substantially for this industry while heightened awareness and prevention measures were being implemented. However, incidents in educational services and crop production settings increased. Trends in incidents and number of incidents varied by state. Only a certain few chemicals, sectors, and areas were found to be related to the majority of incidents and injured persons. Equipment failure and human error, both common casual factors, are preventable. PUBLIC HEALTH IMPLICATIONS: The findings in this collection of surveillance summaries underscore the need for educational institutions and the general public to receive more focused outreach. In addition, the select few chemicals and industries that result in numerous incidents can be the focus of prevention activities. The data in these surveillance summaries show that equipment maintenance, as well as training to prevent human error, could alleviate many of the incidents; NTSIP has begun work in these areas. State surveillance allows a state to identify its problem areas and industries and chemicals for prevention and preparedness. Beginning in 2010, ATSDR replaced HSEES with the National Toxic Substance Incidents Program (NTSIP) to expand on the work of HSEES. NTSIP helps states to collect surveillance data and to promote cost-effective, proactive measures such as converting to an inherently safer design, developing geographic mapping of chemically vulnerable areas, and adopting the principles of green chemistry (design of chemical products and processes that reduce or eliminate the generation of hazardous substances). Because the more populous states such as New York and Texas had the most incidents, areas with high population density should be carefully assessed for preparedness and prevention measures. NTSIP develops estimated incident numbers for states that do not collect data to help with state and national planning. NTSIP also collects more detailed data on chemical incidents with mass casualties. HSEES and NTSIP data can be used by public and environmental health and safety practitioners, worker representatives, emergency planners, preparedness coordinators, industries, emergency responders, and others to prepare for and prevent chemical incidents and injuries.

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