ETHIOPIAN PUBLIC HEALTH INSTITUTE

CHEMICAL, BIOLOGICAL AND

RADIONUCLEAR /CBRN/ INCIDENT
SURVEILLANCE AND RESPONSE GUIDELINE

NOVEMBER 2021
ADDIS ABABA, ETHIOPIA
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Forward
In the face of growing threats of chemical, biological and radio-nuclear hazards, countries
like Ethiopia need to take timely and standardized caution and responses to avoid any
catastrophic effects. Currently, a threat of biological chemical and radio-nuclear hazards is
observed in different areas of the country even if our surveillance activities in this area are
very low. Fighting high-magnitude disasters should always be integrally addressed as a part
of the country’s emergency preparedness. All stakeholders are in charge of coordinating
public health emergency works related to biological chemical and radio-nuclear hazards.
Prompt and timely response to CBRN incidents in pre, during and post disaster situations is
crucial importance.

The early warning of, response to and recovery from CBRN emergency incidents to minimize
the effects on the health of human being and the environment were done in fragmented and
non-standardized manner. Most of the participant in responding and coordinating of
emergencies is based on their own methodologies and strategies because of absence of CBRN
surveillance and response guideline. Thus it is important to bring all the partners under a
common understanding to develop and follow the same guidelines in managing disasters in
emergency situation. I believe, this CBRN early warning and Response Guideline is jointly
prepared with government sectors and development partners that will be used as guidance for
early warning and response of chemical biological and radio-nuclear incidents. In addition,
the well-coordinated approach for the response of CBRN incidents is boost and synergizes
the individual efforts of the stakeholders. This also helps to ensure efficient utilization of
scarce resources by avoiding duplication of efforts.
Therefore, I believe that proper implementation of this ‘‘National CBRN Surveillance and
Response Guideline’’ will result better and timely management of emergency incidents.

Last but not least, The Ethiopian Public Health Institute/EPHI/ would like to thank all for
adding their valuable contribution in the process of this important guideline development.

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 Table of Content

Forward ............................................................................................................................ i
Table of Content ............................................................................................................... ii
List of Figures and Tables ................................................................................................. iv
Acknowledgments ............................................................................................................ v
Operational Definitions ................................................................................................... vi
Acronyms ....................................................................................................................... vii
SECTION ONE: INTRODUCTION ......................................................................................... 1
1.1. Background ................................................................................................................. 1
1.2. Purpose of the Guideline .............................................................................................. 3
1.3. Objectives .................................................................................................................... 4
1.4. Scope of the Guideline .................................................................................................. 4

SECTION TWO: PREPAREDNESS FOR CBRN INCIDENT ......................................................... 5

2.1. Coordination and collaboration for CBRN incidents ........................................................ 5
2.2. Risk Assessment and Mapping ......................................................................................... 6
2.3. Planning for the Identified Risks .................................................................................... 16
2.4. Logistics.......................................................................................................................... 18
2.5. Capacity Building ........................................................................................................... 18

SECTION 3: EARLY WARNING AND SURVEILLANCE FOR CBRN INCIDENT ........................... 21

3.1. Indicator Based Surveillance (IBS) for CBRN Emergencies ............................................. 21
3.1.1. Facility Based Surveillance ........................................................................................................ 22
3.1.2. Environmental Surveillance ....................................................................................................... 24
3.1.3. Periodic Population Based Survey............................................................................................. 25

3.2. Event Based Surveillance (EBS) for CBRN Incidents ....................................................... 25

3.3. Source of information and Management of CBRN data ............................................. 27
3.3.1. Source of information............................................................................................................... 27
3.3.2. Reporting tools .......................................................................................................................... 27
3.3.3. Analyzing CBRN surveillance data......................................................................................... 29
3.3.4. Interpreting results of analyses ............................................................................................... 31

3.4. Data Quality Dimensions............................................................................................ 31

SECTION FOUR: PUBLIC HEALTH RESPONSE FOR CBRN INCIDENTS .................................. 33

4.1. Introduction to CBRN Response ................................................................................ 33
4.2. Purpose of CBRN Incident Response ......................................................................... 33

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 4.3. Procedures of Incident Investigation .......................................................................... 33
4.3.1. Establish Incident Investigation Team (IIT) .......................................................................... 35
4.3.2. Immediate Action ..................................................................................................................... 36
4.3.3. Data collection: ......................................................................................................................... 37
4.3.4. Data Analysis ............................................................................................................................ 39
4.3.5. Grading the CBRN Incident .................................................................................................... 41
4.3.6. Determine and Implement Corrective Actions ...................................................................... 42
4.3.7. Reporting................................................................................................................................... 44

4.4. Investigation of Intentional CBRN Incidents.............................................................. 45

4.5. Management of CBRN Incidents................................................................................ 47
4.5.1. Management of Chemical Incidents ....................................................................................... 47
4.5.2. Management of Biological Incidents ....................................................................................... 47
4.5.3. Management of Radio-nuclear Incidents ............................................................................... 48

4.6. Public Health Risk Communication ........................................................................... 51

SECTION FIVE: RECOVERY FROM CBRN EMERGENCIES ..................................................... 54

5.1. Coordination and Recovery ....................................................................................... 54
5.2. Objectives of Recovery ............................................................................................... 54
5.3. Components of Recovery............................................................................................ 55

SECTION SIX: MONITORING AND EVALUATION ............................................................... 59

6.1. Monitoring and Evaluation of Preparedness .............................................................. 59
6.2. Monitoring and Evaluation of Surveillance ................................................................ 60
6.3. Monitoring and Evaluation of CBRN Response ......................................................... 60
6.4. Monitoring and Evaluation of Recovery from CBRN incidents.................................. 60

REFERENCES ................................................................................................................... 61
ANNEXES ........................................................................................................................ 62
Annex 1: The case Based Reporting format for the CBRN incidents .......................................... 62
Annex 2: Weekly reporting format (For CBRN Incidents) .................................................... 64
Annex 3: Line list for CBRN Incidents .................................................................................. 65
Annex 4: Incident Investigation Checklist ............................................................................. 66
Annex 5: List of Antidotes ..................................................................................................... 73
Annex 6: List of Essential Medicines for Management of Poisoning ......................................... 75
Annex 7: Selected Biological Hazards in Ethiopia ................................................................. 76
Annex 8: Roles and Responsibilities of Stakeholders ............................................................. 77
Annex 9: Clinical Descriptions of Chemical Poisoning .......................................................... 84

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 List of Figures and Tables

List of Figures

Figure 1: Steps of risk assessment for CBRN hazards .............................................................. 7

Figure 2 Reporting system of CBRN incidents in Ethiopia ..................................................... 28
Figure 3 Incident Investigation procedures.............................................................................. 34
Figure 4 Flow of Information through the Public Health and Law Enforcement Sectors ....... 46
Figure 5 Investigation and management of radiation victim’s protocol .................................. 50
Figure 6 Major areas impacts of an emergency that require recovery .................................... 55

List of Tables

Table 1 Consequences (severity) and Likelihood table for risk analysis 13

Table 2 Risk Matrix of CBRN hazards 15
Table 3 Procedures of life-saving decontamination 37
Table 4 Recommendations for the Administration of Potassium Iodide (KI) 51

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 Acknowledgments

This National Chemical Biological and Radio-nuclear early warning and Response Guideline
is developed by Ethiopian Public Health Institute (EPHI), Minsirt of Health (MOH),
Ethiopian Radiation Protection Authority (ERPA), Ministry of Labour and Social Affairs
(MOLSA), St. Peter Specialized Hospital, Ministry of Agriculture (MOA), Ministry of Trade
and Industry (MOTI), National Disaster Risk Management Commssion (NDRMC), Food and
Drug Administration (FDA), Ethiopian Conformity Assessment Enterprise (ECAE), Addis
Ababa Univesity and Environmental Protection Authority (EEPA). The Ethiopian Public
Health Institute was responsible for the overall coordination of leadership and finance until
the finalization of the guideline. The EPHI would like to acknowledge contributions made by
those organizations listed above and would like to deliver special thanks to all members
participating in this guideline development. The EPHI would like to say thanks the PHE for
their valuable comments and suggestions on the guideline.

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 Operational Definitions

CBRN: Is an acronym for chemical hazards, Intentional biological hazards and radio nuclear
events.

Cluster: Two or more cases associated with the same location, group, or event around the
same time

Hazard: A biological, chemical or radio-nuclear agent with the potential to cause an adverse
health effect.

Incident: Is unintended, unplanned or undesired event due to CBRN hazards that disturbs
normal operations or affect the public health

Incident Investigation Team (IIT): a group of professionals that are being assigned for the
investigation of the hazards and severity of the risk.

Incident Response Team (IRT): A group of experts including the incident investigation
team that work on intervention for CBRN hazards to reduce health impacts.

Intentional: It is delibrate release or adding of a CBRN hazard to the environment or

humanbody to cause a harm

Risk: The probability of an adverse health effect occurring and the severity of that effect
(consequence) to a hazard

Toxicological Center: A specialized unit for the management of exposure to chemical and
radio nuclear agents, including products, pharmaceuticals, substances of abuse, natural
toxins, pesticides and industrial chemicals.

Unintenstional: It is a release of chemical or biological or radionuclear hazards unknowingly

or unable to control the hazard or during man-amade/natural accidents. There is not intended
purpose to harm the people or the environment.

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 Acronyms

CBRN Chemical, Biological, Radiological and Nuclear

EBS Event-Based Surveillance
EPHI Ethiopian Public Health Institute
FMoH Federal Ministry of health
HAZMAT Hazardous Material
IBS Indicator-Based Surveillance
IHR International Health Regulation
IIT Incident Investigation Team
ILO International Labor Organization
IRT Incident Response Team
IPCS International Program on Chemical Safety
JEE Joint External Evaluation
M&E Monitoring and Evaluation
NGO Non-Governmental Organization
PHEM Public Health Emergency Management
POPs Persistent Organic Pollutants
TWG Technical Working Group
WHO World Health Organization

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 SECTION ONE: INTRODUCTION

1.1. Background

Public health emergencies can arise from a wide variety of incidents and circumstances,
however, and the public health system needs to be prepared for all types of emergencies that
have public health impacts, including natural disasters, industrial population and accidents,
and terrorist attacks. The four pillars of public health emergency management including
preparedness, early warning, mitigation, response and recovery have not been examined in-
depth for incidents involving the release of Chemical, Biological, Radiological and Nuclear
(CBRN) hazards.

CBRN primarily indicates materials that could harm the society and environment through
their accidental or deliberate release or dissemination. CBRN materials are produced,
transported and handled under many different circumstances, posing a risk to society; while
so far major incidents involving CBRN materials, including terrorist acts, have been
relatively few because of unreported incidences, the consequences of such an incident could
be devastating effect in developing countries with limited preparedness and response
capacity.

Biological hazards are organisms or substances produced by the organism that pose a threat
to the health of humans and other living organisms. They include pathogenic
microorganisms, viruses, toxins (from biological sources), spores, fungi and bio-active
substances. Biological hazards can also be considered to include biological vectors or
transmitters of disease. Worldwide, it is estimated that around 320 000 workers die each year
from communicable diseases caused by work-related exposures to biological hazards.

In an age of advanced weaponry and tactics, the threat of bioterrorism has never been so real.
This threat, long ignored and denied, poses a significant risk to not only the national security
of all countries but to the health of all citizens. The accidental release of anthrax from a
military testing facility in the former Soviet Union in 1979 and Iraq’s admission in 1995 to
having quantities of anthrax, botulinum toxin, and aflatoxin ready to use as weapons clearly
show that research in the offensive use of biological agents continued despite the 1972
Biological Weapons Convention.

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A chemical incident is the uncontrolled release of a toxic substance, resulting in (potential)
harm to public health and the environment. They can occur in several different situations
where hazardous chemicals are released into the surroundings. Chemical agents are all
chemical elements and compounds in a natural or processed state and their by-products.
Exposure by inhalation, ingestion or skin contact may result in illness or injury to human
health depending on the chemical substance, the amount of the dose and the duration of
exposure. With the increasing exploitation of natural resources and expansion of agriculture
in Africa, a range of toxic effluent is discharged or emitted into the environment, often at
levels well in excess of those that would be allowed in developed countries.

Manual for the public health management of chemical incidents published by WHO in 2009
reported that since the middle of the twentieth century, chemicals have played an increasing
role in the worldwide economy. Currently, more than 15 million chemical substances are
commercially available. Approximately 60,000 to 70,000 chemical substances are in regular
use and between 200 and 1000 chemicals are produced more than one ton annually. In
addition to chemical manufacturing, management of chemical incidents must also take into
consideration transportation, storage, use and waste disposal of chemicals. Fertilizers weed
killers and insecticides are spread in huge quantities on agricultural lands. The overall human
impact between 1970 and 1998 of all reported chemical incidents worldwide ranged between
approximately 13,000 deaths and 100,000 injuries or illnesses to the evacuation of three
million people. The negative impacts of a chemical incident on the local economy can also be
extremely high and may include disruption of agriculture, loss of jobs, long-term evacuation
of the area, rising costs for health care, mitigation and rehabilitation. Chemical incidents can
result in extensive damage to the environment, which might take years to remedy and hence
might continue to pose a significant public health hazard.

Heavy metals such as lead and mercury, persistent organic pollutants (POPs) and highly
hazardous pesticides that are either controlled or banned in developed countries continue to
be used in Africa with major environmental and health impacts. A great deal remains to be
done, therefore, to ensure that the management of toxic chemicals is environmentally sound
and embraces the principles of sustainable development and improvement of the quality of
life for humankind.

A radiological incident is an event that involves the release of potentially dangerous

radioactive materials into the environment. They can be accidental or deliberate, when
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radioactive materials used, stored, transported can greatly impact life and the environment.
The radiological incidents can occur in the nuclear plant, research laboratories, medical
diagnostic procedures, industries, disposal of radioactive wastes and others

The International Health Regulation (IHR) 2005 has made a fundamental change from
notifying certain communicable diseases to all public health emergencies of international
concern including CBRN hazards. The IHR 2005 strongly emphasized the strengthening of
the role of public health institutions/organizations in the management of CBRN incidents.
Based on IHR 2005, which Ethiopia endorsed on June 15, 2007, Ethiopia has completed a
self-assessment using the Joint External Evaluation (JEE) tool for the 19 Action Packages, in
2016.

From the findings of the JEE, the country was found to have a low score on CBRN incidents
for detecting and responding to CBRN emergencies. NAPHS was developed based on the
JEE evaluation which includes improving CBRN incidents/emergencies preparedness and
response capacity (i.e. enabling environment for management of CBRN incidents and
establishing mechanisms for detecting and responding to emergencies).

The numbers of CRBN products are expected to grow year to year for the sake of market
demands; therefore this guideline is prepared to enhance the implementation of public health
emergency preparedness, early warning, and mitigation, response and recovery activities
associated with CBRN incidents.

1.2. Purpose of the Guideline

The purpose of this guideline is to assist the public health sector to plan, prepare for, respond
to, recovery from a range of chemical, biological, nuclear and radiological (CBRN) incidents,
and as a result reduce health, economic, social and environmental impacts

This document will assist public health emergency management actors in their efforts to
address the risks of chemical incidents, biological threats, nuclear and radiological
technologies, to enable the safety and security of staff and volunteers, to assure business
continuity during CBRN incidents, and to fulfill its mandate of providing humanitarian
assistance to those in need. It provides basic background information on CBRN risks and
potential services and assistance that may be needed following such incidents. The Guideline
addresses collaborative and cooperative actions that a public health sector can take with its
government and non-government partners, and guides for CBRN emergencies.
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1.3. Objectives

 To provide clear guidance for preparedness, early warning and surveillance, response
and recovery of potential CBRN incidents.
 To guide the integration of CBRN incidents preparedness, surveillance, response and
recovery into the PHEM system.
 To provide a framework for CBRN hazards monitoring and evaluation within PHEM.
1.4. Scope of the Guideline

This guideline primarily focuses on the prevention and management of public health impacts
associated with Chemicals, biological (Intentional) and radio-nuclear hazards that cover
preparedness, early warning and surveillance, response and recovery activities.

The information and activities in this guideline are intended for use by health managers and
health staff at all levels of the health system (Federal, Regional, Zonal, Woreda and health
facilities) and different institutions/industries. These include;-
 PHEM officers at National, Regional, Zonal, Sub City and Woreda levels
 Surveillance officers/focal points
 Staff at Poison center/s,
 Health professionals at health facilities, toxicology related laboratories, free
hotline/call centers, factories/industrial clinics
 Staff working at emergency services/civil defense (fire, police, transport,
ambulances…)
 Health professional working on occupational health services
 Governmental bodies within relevant ministries and agencies (including ERPA,
NDRMC, MOH, Law enforcement sectors, EPA, MOA, FDA, MOI, etc)
 Partners (PHE, Ohio state university, etc)

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 SECTION TWO: PREPAREDNESS FOR CBRN INCIDENT

CBRN incident preparedness activities and tasks are things that should be done before the
occurrence of the incident. The aim of preparedness is to strengthen capacity in recognizing
and responding to public health CBRN incidents. Establishing partnership and collaboration,
Conduct regular risk assessment and mapping, planning for identified risks and hazards,
providing capacity building, development of procedures and protocols, monitoring and
rehearsal or simulation exercise are the main preparedness activities to strengthen CBRN
capacity in hazard identification and incident management.

2.1. Coordination and collaboration for CBRN incidents

Implementation of international conventions related to CBRN incidents requires strong

institutional mechanisms that allow effective inter-sectoral coordination and collaboration.
Because CBRN incidents present special circumstances, such as unfamiliar health hazards,
special medical treatment and supply needs, and environmental health concerns. They may
require coordination among organizations that are not normally covered under the general
coordination practices. Thus, CBRN incidents may require special practices to coordinate
specific kinds of information or among specific organizations.

In the absence of such mechanisms, the formulation of a strategic approach and the
implementation of treaties on CBRN management into action at the national/ regional level
will not be effective.

Activities and steps required for effective CBRN incidents coordination and collaboration
are:

 Identify all sectors, collaborators and partners, their areas of intervention and
capacity for CBRN incidents;
 Develop a list and keep a register of all experts, institutions and organizations and
update the list yearly;
 Conduct capacity building for those registered and newly identified human
resources;
 Communicate with all stakeholders/partners and establish a
coordination/collaboration mechanism like CBRN TWG;

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  Develop a term of reference (TOR), memorandum of understanding (MOU) for
CBRN;
 Share level of preparedness with all stakeholders as required;
 Organize Incident Investigation Team (IIT), Incident Management Team (IMT) to
initiate activities at the time of CBRN incident response;
 Monitor and evaluate participation and implementation of public health CBRN
incidents/incident activities as per the TOR or MOU;
 Review membership, CBRN TOR or MOU as per the findings.

The following are the list of stakeholders that work on CBRN incident management. Hence
this guideline user can customize/contextualize stakeholders based on their regional, zonal
and woreda context.

 Radiation Protection Authority  Public Health Institute;

 Fire & Emergency Prevention  Disaster Risk Management Commission
and Rescue Agency (DRMC)

 Ministry of Trade and Industry  Police Commission/Ministry of Justice

 Ministry of Agriculture  Ministry of Labor and social affairs

 Ministry of Health (Food and

 Conformity Assessment Enterprise
Drug Administration, St.Peters)

Environmental Protection Authority
 Ministry of Mine and Petroleum
(EPA)
 Ministry of Defense  Red Cross Society
 Universities  Partners
N.B. The CBRN TWG are not limited with the above list.

2.2. Risk Assessment and Mapping

Conducting risk assessment and mapping for CBRN hazards is important for:

 The identification of hazards and risk factors that have the potential to cause harm
(hazard identification)
 The identification of possible incident scenarios and their exposure pathways
 The identification of vulnerable populations, facilities and environments
 Estimation of the health impact of potential CBRN incidents and the requirements for
healthcare facilities
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  The analysis and evaluation of the risk associated with that hazard
 The determination of health system capacity

Hazard Identfication

Hazard characterization

Risk Identification

Exposure Assessment • Vulnerability Assessment

• Adapative Capacity

Risk Characterization • Likelihood/Probablity

& Risk Analysis • Impact/Consequences

Risk Evaluation

Risk Reduction
(Risk Management
strategies)

Figure 1: Steps of risk assessment for CBRN hazards

Step1: Hazard Identification

Hazard identification is part of the process used to evaluate if any particular situation, item,
thing, etc. may have the potential to cause harm. The main objective of CBRN hazard
identification is to find and record possible hazards that may be present in your workplace.
The identification of CBRN hazards should be done before the occurrence of incidents.
However, identification should be continued after the occurrence of near-misses or incidents
or injuries. Each level of the health system should identify those CBRN hazards.

To identify hazards, the following are recommended:

A. Examine past incidents to see what happened and whether the incidents could occur
again.
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 B. Consult employees/communities to find out what they consider are safety issues
C. Review worker’s medical records
D. Inspect the work environment, tools and equipment well as tasks and procedures
should be examined for risks.
E. Review information about equipment (e.g. plant, operating instructions) and
Material Safety Data Sheets (MSDS) to determine relevant safety precautions.
F. Think what hazardous event could take place here

As an example for chemicals hazards (industrial chemicals, medical chemicals…), biological

hazards (intentionally used pathogens or toxin…) and radiological hazards (radio therapy,
Secondary Standard Dosimeter Laboratory radiator (SSDL), Industrial radiography, industrial
gauge, linear accelerator.

The identification of hazardous sites in the local community is an important means of

recognizing possible emergencies. Once they are identified, it is possible to check the
availability of appropriate expertise, site emergency plans and evacuation, procedures,
materials, decontamination equipment and antidotes.

Step 2: Hazard characterization

Hazard characterization is a stand-alone process in a risk assessment that consists of a

qualitative or quantitative description of the inherent properties of an agent having the
potential to cause adverse health effects. During any CBRN hazard characterization, we need
to see the following important points:

 Dose of the hazards  Timing of exposure

 Inherent properties of the hazards
 Route of exposure
 Dose-response assessment
 Duration of exposure
For example, biological hazards can be classified into four groups based on the inherent
properties of the organism.

 Group 1 – Unlikely to cause human disease

 Group 2 – Can cause human disease and might be a hazard to workers; unlikely to
spread to the community; there is usually effective prophylaxis or treatment available;

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  Group 3 – Can cause severe human disease and present a serious hazard to workers;
it may present a risk of spreading to the community, but there is usually effective
prophylaxis or treatment available;
 Group 4 – Causes severe human disease and is a serious hazard to workers; it may
present a high risk of spreading to the community; there is usually no effective
prophylaxis or treatment available.

Step 3. Risk Identification

Risk identification is the process of finding, recognizing and describing risks. It is a screening
exercise and serves as a preliminary step for the subsequent risk assessment stage. It is the
process of identifying but not yet quantifying the consequences (positive or negative) and
likelihoods and how they will be expressed. This process should result in a narrative
description of the risks or significant uncertainties of concern to the risk management activity
and a decision on whether or not to pursue a risk assessment.

Early risk identification helps decision-makers to prevent risks from developing into issues
that are likely to threaten the public and it provides them with sufficient time to take the
appropriate measures for tackling risks before result in health and environmental impacts.

Risk identification should be based on quantitative data (historical, statistical) and/or also
qualitative methods, such as expert opinions, intelligence information, checklists, systematic
team approaches, inductive reasoning techniques, or others. Techniques to improve the
completeness of the risk identification process may also include brainstorming and interactive
forecasting method relying on a panel of experts.

Step 4: Exposure Assessment

Exposure assessment is the qualitative and/or quantitative evaluation of the likely exposure of
CBRN hazards in which the extent of human exposure to the CBRN hazards (actual or
anticipated) is determined. Concentration, ways and dose of exposure should be considered in
exposure assessment.
Generally, the purpose of conducting an exposure assessment is to answer the questions such
as

 In what ways the people come into contact with the CBRN hazards?
 How much exposure is likely to occur?
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  For how long is the exposure likely to occur?
 What metric of exposure is appropriate for characterizing health risks?

During exposure assessment, it is important to assess both vulnerability and adaptive capacity
of individuals, peoples or an organization.

 Vulnerability Assessment: It is the process of estimating the susceptibility of

different elements at risk to various hazards and of analyzing the causes behind
their vulnerability. There are many aspects of vulnerability (physical, social,
economic, and environmental factors) and the vulnerability varies significantly
within a community and over time.
 Adaptive Capacity Assessment: This analysis will enhance to develop
preparedness level and coping capacities of the individuals and the communities,
and the organizations to develop resiliency from any type of hazard taking into
account the longer trends produced.

Step 5: Risk Characterization and analysis

When all the risks have been identified, you then have to ascertain the level of risk associated
with each one. To do this you have to determine the potential consequence (Severity) of the
risk, if it were to occur, and the potential likelihood of this happening. Hence it is the
qualitative and/or quantitative estimation, including attendant uncertainties, of the probability
of occurrence and severity of known or potential adverse health effects in a given population
based on hazard identification, hazard characterization and exposure assessment. The
consequence and likelihood for each risk need to be combined to produce an estimated level
of risk.

Tasks expected in Risk characterization and Analysis

There are two processes within Risk Analysis:

a. Likelihood/probability analysis
b. Impacts/consequences analysis

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 a. Likelihood Analysis

Likelihood is an estimate of the chance of an event or an incident happening, whether

defined, measured or determined objectively or subjectively. It can be described using
general terms or mathematical variables, such as a probability or a frequency over a time
period. The likelihood of CBRN hazards should be done by considering All Hazards Risk
Assessment (AHRA) process.

Likelihood can be estimated using either quantitative or qualitative techniques, or by using

approaches that combine the two methods. The list below provides the type of information
required in order to estimate the likelihood of a risk scenario:

 Historical data on past incidents

 Historical data on the frequency of contributing incidents (e.g. weather conditions).
 Simulation models of sequences of incidents, protective system failures, and the
associated consequences.
 For malicious acts, intelligence judgements regarding intent, technical feasibility,
including access to target, and enabling capabilities such as funding and logistics of
adversaries.

In addition, quantitative data extracted from past risk incidents or extrapolated from experiments or
qualitative information derived from experts' judgement may support the estimation of the impacts for
each of the following primary impact category:

 People
 Economy
 Environment
 Territorial Security
 Ethiopia's Reputation and Influence
 Society and Psycho-Social

b. Impact/Consequence Analysis

Risks can have many potential impacts/consequences which, by definition, can potentially
affect the public health or institutional objectives. Impacts/consequences can be expressed
quantitatively through physical event modeling or extrapolation from experiments, studies or
11
past data; or qualitatively as a descriptive representation of the likely potential outcome for
each risk. For instance, a pre-determined set of impact questions can be used to better assess
risk consequences, such as:

 Does the risk have the potential to impact a large geographic area?
 Does the risk have the potential to impact the health of the population?
 Does the risk have the potential to impact on the country border?
 Does the risk have the potential to impact the environment in the long term?

Impacts can be expressed in terms of monetary, technical, operational, social or human

criteria. They can be evaluated against predetermined segments of interest to institutions
(e.g., impacts on people, the economy, the environment, national security and law
enforcement).

Impact analysis generally comprises the following steps:

i. Identification of all individual impacts from CBRN hazards and threats associated with the
risk event.
ii. Quantification of the impacts from CBRN hazards and threats associated with the risk event,
based on the six impact categories and their respective rating schemes as described in detail
below.
iii. Consolidation of all impacts into high-level impact dimensions.
iv. Aggregation of the high-level impacts into an overall impact for the risk event, together with
an expression of the level of confidence in the estimates.

In the context of the all hazards risk assessment (AHRA), the primary impact categories are:

 People: It includes fatalities and injuries, including physical injuries, displacement,

chronic diseases and mental illnesses.
 Economy: It encompasses direct and indirect losses on the Ethiopian economy.
 Environment: It captures the type of response, the geographical extent, magnitude
and duration of damage.
 Territorial Security: It includes the disruption in the effective functioning of an area
or a border, including the area affected, combined with duration and population
density.

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  Ethiopia's Reputation and Influence: They are situations that would result in a shift
in views towards the reputation and influence of Ethiopia and actions taken by
citizens and/or stakeholders as a consequence.

 Society and Psycho-Social: It captures the impact of widespread public anxiety and
outrage.

Table 1 Consequences (severity) and Likelihood table for risk analysis

Grade/Rating Criteria

Insignificant • Minor Injury, No or basic first aid required

Minor • Medical or paramedical treatment

• Up to four days lost time from work

Moderate  Need more than 4 days treatment/admission at hospital

 Short term disruption of the main activities of the organization
Consequences (Severity)

(in days)
 Uncontrolled non-hazardous chemical spill/release

Major  Permanent impairment/disability (unable to return to work)

 Medium term disruption to core activities (weeks)
 Any notifable incident requiring medical attention
 Uncontrolled hazardous chemical spill/release

Catastrophic • Fatality/s
• Significant damage to reputation
• Long term cessation of core activities
• Criminal charges, civil suits

Rare (Very
unlikely) • May only occur in exceptional circumstances

Unlikely • The risk event could occur at some time(during a specified

period), but it is unlikely
Likelihood

Possible • Might happen at some time; occurrence would not be unusual

Likely • Will probably occur in most circumstances

Almost
certain (Very • Is expected to occur in most circumstances
Likely)

13
For CBRN hazards, risk analysis should be done using a ranking technique that is based on
quantity of use, mobility in the environment, acute (lethal effects) and chronic health risks
(teratogenicity, mutagenicity, carcinogenic and neurotoxicity).

The output of risk analysis process is:

 An assessment of the likelihood of the realisation of the hazards with an associated

confidence level
 An assessment of the impact for the risk event in terms of each of the primary impact
categories with associated confidence levels
 An assessment of the overall impact for the risk event, with an associated confidence
level
 Other information generated during the risk analysis Process such as assumptions and
justifications

Step 6: Risk Evaluation

Once you have determined both the consequence and the likelihood, you combine them using
the risk matrix to determine the risk rating which is called risk evaluation. Risk evaluation is
the process of comparing the results of risk analysis with risk criteria to determine whether
the risk and/or its magnitude are acceptable or tolerable. Due to resources limitation, which is
unavoidable, addressing all identified risks becomes a non-realistic approach. So risk matrix
is a preferred approach to prioritize those identified risks for the appropriate application of
resources. A risk matrix is a risk assessment tool that has severity (consequences) and
likelihood (Probability) categories for the assessment.

The activities in risk evaluation generally comprise the following steps:

i. Determination of the risk magnitude (i.e. likelihood and impact) for the risk.
ii. Aggregation and consolidation of risk assessment results for all regions and federal
government risks into a whole-of-government AHRA.
iii. Production of selected AHRA information products and/or graphical representations
of results.

Risks can be ranked by comparing them in terms of their individual likelihood and impact
estimates. The relative ordering of risk incidents based on their ratings can be shown
graphically in a logarithmic risk diagram, risk-rating matrix or other forms of tabular or
14
 visual representations. The one most commonly used is the risk matrix which normally plots
the likelihood and impact on the x- and y-axes (the measured components of risks).

Table 2 Risk Matrix of CBRN hazards

Likelihood (Probability)

Rare/ Very Certain (Very

Unlikely Unlikely Possible Likely Likely)
May only The risk event Might Will Is expected
Consequence/Impact occur in could occur at happen at probably to occur in
exceptional some some time; occur in most
circumstan time(during a occurrence most circumstance
ces specified would not be circumstance s
period), but it is unusual s
unlikely
Insignific Minor Injury, No or basic
Very Low Very Low Low Low Moderate
ant first aid required
Medical or paramedical
treatment
Minor Very Low Low Moderate Moderate Moderate
Up to four days lost time
from work
Need more than 4 days
treatment/admission at
hospital
Short term disruption of the
Moderate main activities of the Low Moderate Moderate Moderate High
organization (in days)
Uncontrolled non-hazardous
chemical spill/release
Permanent
impairment/disability (unable
to return to work)
Medium term disruption to
core activities (weeks)
Major Low Moderate Moderate High Critical
Any notifable incident
requiring medical attention
Uncontrolled hazardous
chemical spill/release
Fatality/s
Significant damage to
Catastrop reputation
Moderate Moderate High Critical Critical
hic Long term cessation of core
activities
Criminal charges, civil suits

Step 7: Risk Reduction

15
Risk Reduction is the process of developing, selecting and implementing risk control
measures. At the risk reduction stage of the process, governmental and non-governmental
organizations including, all levels of concerned health service providing governmental
structure and regulatory bodies should prioritize their own risk reduction measures in
accordance with the size of the risks and the gaps in the capabilities required to respond to
those risks. During the process of risk reduction: assess the type and extent of the capabilities
(equipment, trained staff, facilities, plans) required for managing and responding to the
hazards, identify the capabilities that are already in place, identify the additional resources
needed with a priority order keeping in mind the economic reality of the region, identify what
other organizations may contribute, align actions with what is available at hand and other
organizations’ contributions to minimize or fill gaps should be considered.

Reduction options can include, but are not limited, to:

 Avoiding the risk by deciding not to continue with the activity that gives rise to the
risk.
 Removing the source of the risk.
 Changing the nature or magnitude of the likelihood.
 Changing the consequences.
 Reducing exposures or vulnerabilities.
 Sharing the risk with another party.
 Retaining the risk by choice.

The output of risk reduction options is used to inform risk managers and decision makers in
their formulation of risk treatment options. Risks and risk treatment programs should be
reviewed regularly and the risk assessment should be seen as a living document and should
be referred to regularly and updated when required.

2.3. Planning for the Identified Risks

The preparedness plan for the identified risks and hazards should form the basis of estimation
of required resources for predictable CBRN incidents. It should be exercised periodically to
ensure that stakeholders/partners are familiar with the plan and able to execute their assigned
role. Thus, it is essential that plans reflect the preparedness cycle of plan, train, exercise, and
incorporation of after-action reviews and lessons learned.

16
Planning Considerations:

 Establish cooperative policies, procedures, and networks to operate in a CBRN

environment.
 Recognize the most likely CBRN threats and hazards from capabilities, intentions,
and the environment.
 Conduct assessments (threat, vulnerability, previous-incident/past-use, impact, hazard
prediction modelling).

 Provide recommendations for the critical asset list.

 Coordinate unit protection measures, especially individual protective equipment, all

hazard supply kits and checklists, troop safety criteria, operational exposure guidance,
automatic masking criteria, bypass criteria, decontamination equipment and
procedures.

 Determine CBRN hazards training and readiness requirements.

 Establish the appropriate recovery and mitigation actions to match the threat, hazards,
and locations.

 Coordinate logistics activities, personnel services support, health services (including

vaccinations and medical countermeasures), and reconstitution efforts.

 Coordinate CBRN health surveillance activities (including bio-surveillance) through

the applicable command surgeon channel.

 Coordinate and integrate the CBRN preparedness and response actions of

multinational partners into the plan.

 Synchronize the policies, people, and processes for expedited collection, transport,
and analysis of medical specimens and environmental samples from CBRN incidents.

 Provide guidance for forces and facilities to ensure they are prepared to operate in
CBRN environments.

The activities and steps in the process of planning include:

 Identify and convene preparedness planning experts (CBRN TWG) from different
sectors and partners,
 Coordinate and integrate all response and recovery agencies/organizations in the
planning process,
17
  Identify needs required to early preparedness as well as respond to potential
emergencies,
 Discuss with stakeholders/partners including the CBRN TWG to endorse and agree
on their roles and responsibilities,
 Develop plans, to prevent, protect against, respond to, and recover from CBRN
incidents/emergencies.
 Prepare monitoring mechanisms and tools to ensure preparedness plan is
operationalized,
 Ensure the integration of the plan in the sector of TWG member’s regular plan.

2.4. Logistics
The logistic part focuses on stockpiling drugs, vaccines (buffer stocks), personal protection
equipment (PPE), Test kits, laboratory chemicals and equipment’s, emergency health kits and
medical supplies required for prevention and control of the incident. This has to be
augmented with securing funds for related operational activities.

List of equipment and materials needed for CBRN emergency management such us but not
limited:-

 Questionnaire and Checklists  Vaccine

 Emergency response guide  CBRN respirator
 Antibiotics  PPE
 Chemical antidotes such as  Anti-viral drugs
acetlycysteine, atropine, digoxin  Radiation detectors
immune fab, dimercaprol, flumazenil,  Test kits
vitamin k1, Methylene blue, folic  Laboratory reagents
acid, ethanol, deferoxamine, etc  Dosimeters
 Decontaminants  Software

2.5. Capacity Building

Based on the risk assessment findings, capacity building activities shall be carried out in
order to effectively mitigate, prepare for identified risks, and respond to CBRN
incidents/emergencies.

The capacity building activity could focus on establishing system (i.e. strengthen
organizational structure and infrastructure at all level) and human resource needs related to
18
public health CBRN incidents/incident: surveillance system, communication, laboratory, and
logistics.

Training and education play an important part in preparedness for, and response to, CBRN
incidents. The emergency services, other relevant health professions, etc. need to train their
personnel to properly manage occurrences that might grow to become CBRN incidents to
understand the responsibilities of other professionals, and to minimize the risks to the
workers and members of the public.

It is important that all those with specific responsibilities in a CBRN emergency response
should receive joint theoretical and practical training in the use and implementation of jointly
agreed emergency response plans. This will enable them to become familiar with taking part
in a broad cooperative effort to respond to a CBRN incident.

Core training for the response team is an important mechanism for the various agencies’ staff
to get a good understanding of their own and others’ needs. Public-health elements that
should be included in the core training are:

 Basic Understanding of CBRN Emergency Management

 Chemical Safety and Emergency Management
 Biological Safety and Emergency Management
 Radio-nuclear Safety and Emergency Management
 Decontamination Techniques
 Risk and exposure assessment;
 Epidemiology and toxicology;
 Precautions for first hand responders in CBRN Emergency
 The use of protective equipment;
 Shelter and protective measures and procedures;
 Biological and environmental sampling;
 Safe Transport of Dangerous Goods
 Medical aspects & Psychosocial Impact of CBRN Emergency
 Incident reporting System
Public-health and environmental-health staff require specialist training to a higher level in the
relevant core areas. Countries need to review how to establish access to comprehensive
training for all health professionals concerned. This may be organized through public-health

19
training centers, poisons information centers, national information and advisory centers, or
local response units.

Exercises should be used to maximize the effectiveness of training. There are four main types
of exercise: orientation, table-top, functional and full-scale simulations. Individual agencies
may also consider holding preliminary orientation exercises to introduce participants to their
responsibilities under the CBRN incident plan, and to prepare them for the exercise (For
further information, see PHEM guideline, 2012).

20
 SECTION 3: EARLY WARNING AND SURVEILLANCE FOR CBRN
INCIDENT

Establishing a system to address the immediate and long-term impact of CBRN agents is very
critical to produce comprehensive information for making administrative decisions. The
surveillance system is expected to achieve the following objectives

 To early detect CBRN incident so as to provide prompt response

 To generate information’s about the incident extent / trends for programmatic and
policy level decisions and early prediction and preparedness activities at all health
system levels

To achieve the planned objectives of the CBRN emergency surveillance system, it will
employ both Indicator-based Surveillance (IBS) and Event-Based Surveillance (EBS)
approaches. This can significantly improve the system capacity to detect public health
emergencies due to the indicated hazards. Besides, this approach can help to produce good
quality information on majorly affected population groups, their geographical distribution,
major causes of exposure and event outcome from selected representative sentinel health
facilities and other potential identified institutions including factories and health institutions

Information’s to be produced from this integrated approach can complement each other’s and
supplement decision makings at all levels. However rapid detection of CBRN incidents is not
easily as that of infectious diseases, because most of the world countries including Ethiopia
have no system for the early detection and response of CBRN incidents.

3.1. Indicator Based Surveillance (IBS) for CBRN Emergencies

IBS is a routine and regular reporting of diseases or incidents from health facilities, sentinel
sites, laboratories, and other industries’ clinics. The collection of IBS data for CBRN
emergencies will be integrated with the existing PHEM surveillance system to effectively use
the resources and infrastructure of the PHEM system. It collects individual-based data or
aggregates data in immediately, weekly or monthly basis. IBS consists facility based
surveillance, environmental surveillance and periodic population based survey.

21
 3.1.1. Facility Based Surveillance

Selected health facilities including industry’s clinic for CBRN surveillance are expected to
report on a weekly basis to the next level based on existing weekly reporting format.

To establish effective facility based surveillance system,it needs to provide prior activities
such as:

 Develop standard case definitions

 Trainings and awareness creation activities about the standard case definitions to be
used at health facility level
 Training on reporting mechanism and reporting timeline
 Posting relevant information or availing reference documents including contact
address of the facility or higher-level health system PHEM officers at the appropriate
areas
The case definition indicated in this section is generic and can be considered to be used for all
hazards under this surveillance system. This generic case definition can be used for
identification or detection of cases due to CBRN incidents at health facility level. The
characteristics of specific hazard, its potency, amount/dose, and site and route of exposure
will be considered to categorize the incident.

a. Case definitions for Chemical and Radio-nuclear Incidents

Suspected case: - A case in which a potentially exposed person is being evaluated by health-
care workers or public health officials for poisoning by a particular chemical agent or
radiological hazard but no specific credible threat exists.

OR

A person who have contact or exposure with a particular chemical agent or radiological
hazard (by working, visting, utilizing) and showing any sign and symptoms but no specific
credible threat exists.

Probable case: One in which a person has an illness that is clinically compatible with
poisoning from a particular chemical agent or radiological hazards and in which a credible
threat exists (Example: Clinically compatible illness in an employee of a facility where a
specific threat a chemical release is made or radioactive wastes in the facility)

22
OR

One in which epidemiologic data link the person to a confirmed case (Example: clinically
compatible illness in a person who was at the same location as the subject of case confirmed
by biologic or environmental testing).

Confirmed case: a case in which a suspected or probable case of exposure has been
substantiated with laboratory testing of environmental or biologic specimen.

OR

The case can be confirmed if laboratory testing was not performed because either a
predominant amount of clinical and nonspecific laboratory evidence of a particular agent was
present or a 100% certainty of the etiology of the agent is known.

b. Case definition for Biological agents

The case definition of intentional biological agent is the standard case definition of specific
biological hazards( eg. Anthrax) and any one of the following clinical or public health
indicators.

Clinical indicators  Unusual numbers of presentations of rare or non-endemic diseases

of an intentional  Unusual age, occupational, or geographic distribution
biological agent  Unexpectedly high morbidity or mortality for known disease
release  Unusual seasonal incidence
 Agent-specific clinical clues (e.g. smallpox rash)
 Predominance of respiratory symptoms among usually well individuals
Public health  Incidence demonstrating an epidemic curves with an ‘explosion’ of cases
indicators of an  Simultaneous outbreaks of unusual diseases
intentional  Tight geographical or occupational clustering
biological agent  Unusual resistance patterns or modes of transmission
release  Numerous human and animal casualties
 Absence of a normal disease host or vectors.

Ethiopian selected pathogens (Priority pathogens) are annexed in this document. (Annex 7)

23
 3.1.2. Environmental Surveillance

Environmental surveillance is a new approach for determination of the environment that have
been contaminated, the level of contamination, and the geographical distribution of the
contaminants. It encompasses collecting samples from drinking water, sewage, air, soil, crops
and vegetables, etc for identifying the CBRN hazards particularly chemicals hazards.
Environmental screening can be performed prospectively (before the occurrence of an
incident) and retrospectively (after the occurrence of an incident or disease outbreak).
Prospective environmental surveillance is used to monitor the presence or abundance of
CBRN hazards in the environment whereas retrospective environmental surveillance is help
to identify the cause of an incident or disease outbreak and assess the potential magnitude.

Air: Air pollutants such as nitrogen dioxide, carbon monoxide, sulfur dioxide, and ozone
harm human and environmental health. The sources of these air pollutants mainly from the
industries and factories. Air quality monitoring can be done in collaboration with
Environmental Protection Authority and Environmetal research team of Ethiopian Public
Health Institute.

Water and wastewater: Samples should be collected from water bodies and effluent of
wastewater at the site specified in the permit or downstream from all entering wastewater
prior to discharge into receiving waters. All samples requiring preservation must be preserved
as soon as possible, ideally immediately at the time of sample collection. The amount of
samples needed will depends on the type of test you want to do. Hence prior communication
should be inplace with laboratory center.

Soil: To determine and monitor contamination level at remediation sites, the analysis of soil
is a critically important area of environmental monitoring. Before taking the soil from a
sampling point, first remove surface litter from the surface of a sampling point and take at
least 500g of soil sample with labelled plastic bag.

Environmental surveillance shall be conducted for selected chemicals in every six months
together with trained laboratory professionals. The sampling sites should be selected by
discussing with region PHEM and other concerned organization. Laboratory test of
environmental samples can be done at Ethiopian Public Health Institute (EPHI), Food and
Drug Authority (Based at EPHI), Ethiopian Conformity Assessment Enterprise (ECAE),
Environmental Protection Authority (EPA) and regional laboratories (See annex. Lab
24
Mapped ). All samples should be kept the collection, shipping and transporation requirements
for ensuring the quality of the sample and result.

3.1.3. Periodic Population Based Survey

Surveys are the most appropriate data source for monitoring the long term/chronic/ impact of
CBRN hazards such as exposure to chronic disease risk factors, knowledge about CBRN
hazards and exposure, decontamination of CBRN hazards, prevalence of CBRN incidents,
etc. The survey can also provide indicators disaggregated by background characteristics that
reveal inequalities between geographic areas, socioeconomic groups, and other
subpopulations. Survey data can link respondents’ characteristics to their health outcomes,
offering the potential to estimate independent effects of various determinants on health, ill-
health, and mortality outcomes.

Moratality alone cannot give a complete picture of the CBRN burden. Hence the overall
burden of the CBRN incidents is assessed by a time based measurement called Disability
adjusted life years(DALYS). DALYs is an important parameters that combines years of life
lost due topremature deaths and years of life lost due to disability. So that in each periodical
survey, the value of DALYs of the CBRN hazards will be calculated.

Complementing the CBRN national surveillance system with the findings of population
based survey can potentially help to inform programmatic preparedness and policy level
decision to markedly reduce the health impacts of the hazards. National level representative
population survey can routinely be conducted every three to five years to identify at risk
population groups and their socio demographic characteristics that makes them more prone to
the indicated hazards. Ad hoc base survey might be conducted to triangulate CBRN sites case
based data and weekly aggregated data

3.2. Event Based Surveillance (EBS) for CBRN Incidents

EBS is a type of surveillance that collect, organizing and analysing unstructured and ad-hoc
information from community members, media scanning or rumours or other informal
structures and it should be established alongside with indicator based surveillance. At
community level, simplified case definition will be used to facilitate the detection of CBRN
incidents. Simplified case definitions will be used to receive alerts/ report directly from any
community members, media scanning and any other informal structures. This can facilitate

25
the detection, triaging and verification process of the system at community levels and other
prioritized identified areas (industries, health facilities and other institutions that produce,
transport and store CBRN hazards).

To increase the effectiveness of the EBS and to facilitate the active participation of
community members, providing orientation for community members including leaders about
case definitions, notification mechanism, and the need of notifying incidents immediately is
very important for the detection, reporting, responding to and monitoring health incidents.

The following are important indicators to community and event based surveillance of CBRN
incidents.

 An unusual temporal or geographic clustering of illness

 An unusual age distribution for common diseases
 An unexplained increase in the number of cases, morbidity and mortality beyond
expected /occurrence of outbreaks in human and animal populations
 Evidences of environmental changes such as air pollution, water quality changes and
visible contamination
 Noticing important industrial accidents (chemical spills…), radio nuclear accidents
etc.
 An exposure to chemicals or radiological source and consequently patient developing
acute symptoms (nausea, vomiting, weakness, fatigue, fainting, and confusion,
bleeding from the nose, mouth, gums, and rectum; bruising, skin burns, open sores on
the skin, sloughing of skin, eye irritation, difficult of breathing, dehydration, diarrhea,
bloody stool, fever, inflammation of exposed areas (redness, tenderness, swelling,
bleeding), can be reported as rumor for local health facility

Community Case Definition

For chemical hazards For Radiological hazards

Any person who have contact/exposure to Any person who work on radiation releasing
chemicals and show any sign and symptoms environment and show any sign and symptoms
ከኬሚካል ጋር ግንኙነት ወይም ንክኪ ያላቸው እና ጨረር አመንጪ ከሆነ ቁሶች ጋር ንክኪ ያለው እና
ማንኛውንም የበሽታ ምልክት የሚያሳይ ሰው ማንኛውንም የበሽታ ምልክት የሚያሳይ ሰው

26
 3.3. Source of information and Management of CBRN data
3.3.1. Source of information

Any member of the community, women development army and 1 to 5 networks, health
extension workers, any health professionals, media, key informants, government and non-
governmental organizations, private institutions, schools, investment sites/industries, refuge
camps, local civic associations, religious institutions, traditional healers, traditional
communication methods (e.g Dagu), hotline, Law enforcement and intelligence reports and
any interesting parties can be the source of information to detect a cluster of cases.

Identification of suspected and confirmed CBRN cases should be done routinely from the
health facility registration books at OPD, emergency departments and inpatient departments
and reported to next higher level by the facility level surveillance focal person. The
surveillance focal person will always check the registrations for any missed (unreported)
CBRN case.

Following detection of incidents, assigned focal persons in the member organizations are
responsible for immediately communicating the information to the assigned personnel for all
relevant stakeholders horizontally and to the TWG chair vertically by telephone. This helps
the early investigation of an incident and activation of response activities.

3.3.2. Reporting tools

Case Based Reporting: This will be collected from the selected CBRN sites and the case-
based report is expected to be sent to the national within 14 days after the time of detection.
And Lower level health facilities are expected to report to the next level within 48 hr. The
case Based Reporting format for the CBRN incidents is annexed (Annex 1).

Line list: If the cases exceed to five cases, it is needed to use the line list and filled all cases
and kept at health facility and woreda levels (The line list template is annexed at annex 3).

Weekly reporting format: This normally aligned with the existing weekly reporting format.
Hence the number of cases (Suspected and confirimed) and deaths wil be incorporated in the
weekly reporting format and the pilot surveillance sites should expect to report the chemical
poisoning.

27
Rumour logbook: The rumour logbook should contain at least what type of incident, where
is occurred,extent of the incident, number of people affected (if possible), and who is
reporting the incident.

Incident verification should start immediately within 24 hours to minimize CBRN morbidity
and mortality. The verification can be done by telephone or site visit and can include the
collection of information about

 Place of residence at onset of illness, Where cases are occurring (community-level

data),
 Symptoms and signs
 Date of onset of symptoms of the first and the most recently detected cases,
 Number of person affected and death by age and sex
 Place and date seen or admitted at the health facility

Figure 2 Reporting system of CBRN incidents in Ethiopia

28
 3.3.3. Analyzing CBRN surveillance data

CBRN Surveillance data analysis is a crucial part to provide key information for taking
prompt public health actions and emergency responses at all level. Data analysis should be
done on regular basis depending on the conditions (daily, weekly or monthly) starting from
the health facility to the national level. PHEM officer and focal persons at all level are
responsible to organize and analyse the CBRN data routinely.

Before starting data analysis, it needs to check the completeness of the data received from the
reporting facility/institutions. The completeness of the data can be computed by dividing the
number of health facility/institutions reported in the week to the number of reporting
institutions expected to report. The timeliness of a reporting unit can be calculated by
assessing how many of its expected reports have come on time (For more information, see
PHEM Guideline, 2012).

Analysis of CBRN surveillance data can provide:

 Frequency count by reporting units help in identifying CBRN emergencies or

potential incidents
 Analysis of routine data provides information for predicting changes of CBRN
incident rates over time and enables appropriate action
 CBRN incident rates change over time. Some of these changes occur regularly and
can be predicted. Analysis and use of the trends in summary data over time provides
information for improving prevention activities
 Identifies problems in the health system; so that gaps can be effectively implemented
 During CBRN incidence, analysis of the data identifies the most appropriate and
timely control measures. Analysis in terms of person, time, and place will be help
focus the intervention
 During an acute phase of the incident the information that is generated from data
analysis leads to the identification of the most appropriate and timely control actions.
The actions are taken immediately to limit the CBRN emergencies and prevent further
cases from occurring.
Analysing CBRN data about a health outcome should address the description of cases by
time, place, and person.

a. Analyzing CBRN data by time variables

29
Analysis of CBRN surveillance data by time is usually conducted to characterize trends and
detect changes in disease incidence or emergencies. Time includes the variables such as day
of exposure, date of facility visit, number of hospitalizations and number of cases per week,
month, and year.

The importance of time analysis is to detect changes in the number of morbidity and
mortalities due to CBRN emergencies over time. It also helps to compare the current CBRN
incidents trend with previous trends. It enables you to see if thresholds are reached or not.

These data can be organized into a table, a graph, or both and additional statistical methods
can be used to detect changes in CBRN incident occurrence.

b. Analyzing CBRN data by place

Analysing CBRN data according to place gives information about where an incident which
can help to identify priority areas for future programmatic responses. The analysis of CBRN
incidents by place is usually displayed in a table or a map. Place variables that are expected
for routine data analysis and information generation regarding CBRN emergencies are place
(site) of exposure like industries, place of reporting Health facilities, place of contaminated
water sources and location of specific areas or communities with higher number of case
report.

For those high burden areas, weekly analysis and regularly updating a spot map of CBRN
incidents can give ideas as to where, how, and why the event is spreading. Analysis of place
variables for CBRN reports can potentially provide information on: Clusters of CBRN
incidents occurring in a particular area, spot locations of CBRN incidents and identify
populations at highest risk for CBRN incident, common sources of exposure for the CBRN
incidents, the population distribution and population density of the area, the variety of
populations in an area (farming area, high-density urban area, refugee settlement, and so on),
environmental factors such as rivers, lakes, pumps, and so on and show distances between
health units and villages (by travel time or distance in kilometers).

c. Analyzing CBRN data by personal variables

Age group, sex, occupation, residence (Urban vs rural) can be considered for personal
variables CBRN data analysis and information generation. However depending on the
characteristics and need of the data, other personal variables may be included in analysis of
CBRN surveillance data.

30
 3.3.4. Interpreting results of analyses

Increasing or decreasing pattern in the incidence of a CBRN event among a specific

population at a particular time and place needs further investigation. For interpreting analysed
data, it needs to compare the current situation with previous week/months/quarter, seasons
and years and observed increases or decreases in incidence or prevalence happened. This may
be the result of an aspect of the way in which surveillance was conducted rather than a true
change in CBRN event occurrence. Common causes of such changes may be due to one of
the following:

 Changes in local reporting procedures or policies (e.g., a change from passive to

active surveillance).
 Changes in case definition
 Increase in diagnosis capacity
 New laboratory test or diagnostic procedure etc
 Industrialization
 Urbanization
It is important to observe the line graphs and look to see whether the number of cases and
deaths for a CBRN emergency/ incident is stable, decreasing or increasing. It also need to
calculate the attack rate and fatality rate of a CBRN event to calculate the resources needed to
respond an emergencies and to measure the quality of case management of toxicological or
treatment centers.

To calculate the attack rate and fatality rate of CBRN event

*100

*100

3.4. Data Quality Dimensions

High-quality data enable the generation of high-quality evidence and therefore lead to better
public health outcomes. CBRN surveillance data can be evaluated for timeliness,
completeness, relevance, accuracy, accessibility, interpretability, and coherence. Among

31
other quality attribute measure of CBRN surveillance data, the six dimensions of data quality
are described below

Timeliness: A report (from a reporting unit) is said to be on time, if it reaches the designated
level within the prescribed time period. If it reaches later, then the report is considered to be
late.

Completeness: At facility level, it is measured by reviewing the forms to check whether all
the data elements that should have been reported are reported. Otherwise, it is measured by
the counting the number of health facilities reported during reporting time from the total
expected reporting health facilities.

Relevance: The relevance of collected information reflects the degree to which it meets the
real needs of Public health experts. It is concerned with whether the available information
really indicates the issues of most importance to the emergency responders.

Accuracy: The accuracy of CBRN information is the degree to which the information
correctly describes the event it was designed to measure.

Accessibility: The accessibility of collected information refers to the ease with which it can
be obtained.

Coherence: The coherence of the collected CBRN information reflects the degree to which
it can be successfully brought together with other collected information within a broad
analytic framework and over time.

32
 SECTION FOUR: PUBLIC HEALTH RESPONSE FOR CBRN
INCIDENTS

4.1. Introduction to CBRN Response

Responses will be provided depending on the severity and magnitude of CBRN incidents and
outbreaks by the responsible bodies at each health system level and designated and
responsible bodies. Individual CBRN cases detected at health facilities should be managed as
per the clinical guideline and the managing health professional is obligated to notify the cases
for the PHEM focal point at the health facility. Then, PHEM focal person will be responsible
to notify the individual or cluster of cases identified to the next higher level by telephone, e-
mail and equivalent available immediately (within 30 minutes). The incident investigation
team is responsible to verify the incident/outbreak and initiate public health responses if it is
a real public health concern. The CBRN TWG members should participate in all processes of
incident management. The public health response for CBRN emergencies should consider
addressing the immediate public health impacts and intermediate level health outcomes for
individual and cluster of cases.

4.2. Purpose of CBRN Incident Response

The public health response for CBRN emergence may have the following goals:

 Save lives of at-risk population from preventable health impacts and gain control
of the event and its impact
 Prevent and mitigate direct and indirect consequences at the incident site
 Prevent and limit the safety risks and health effects to both the impacted
population and emergency responders
 Limit or possibly prevent adverse health impacts from spreading to the general
population. This includes the initiation of focused public health actions such as
prophylactic distributions, public awareness campaigns, warnings, precautions,
counseling and information.
 Protect and limit the damage and destruction to personal property and the general
environment

4.3. Procedures of Incident Investigation

All incidents are to be investigated on time to determine the root cause(s) and contributing
factors involved. The extent of the investigation is dependent upon the severity or potential
33
severity of the incidents. The investigation must identify appropriate recommendations that
address the problems and identify root causes. However, the purpose of the investigation is
not to find fault or blame, rather identify the basic causes of incidents so that controls can be
put in place to manage them and prevent further occurrences.

Rumours
Surveillance data
Self reporting
Information verfication and
anaysis

Close if it doesn't
need incident Initaite incident
investigation investigation

Establish Incident
Investigation Team
(IIT)
Conduct immedaite
action together with local
authorities and health
professionals

Collect data about the Incident

- Interview vvictims
- Gathering evidencce

Data analysis and

Grading

Determine and Implement

corrective action

Figure 3 Incident Investigation procedures

34
 4.3.1. Establish Incident Investigation Team (IIT)

There are two ways by which the establishment of a CBRN incident investigation
team can be triggered. An indicator-based surveillance system such as reporting from
federal health facilities and regional PHEMs, etc.; and an event-based surveillance system
such as rumors health care professionals, Health Extension Workers (HEWs), media,
Community structure, and other key informants. Upon receiving the reports indicating a
CBRN incident, federal PHEM must immediately establish a multi-disciplinary Incident
Investigation Team (IIT) to investigate the incident.

The CBRN TWG members should be one part of the IIT team based on the characteristics of
the rumor received from the incident area. For example, the rumor we received is radiation-
related, the radiation authority and others very concerned stakeholders should be included in
the IIT. Each member of IIT should wear appropriate PPE depending on the type of hazards.
The person responsible for the deployment of experts should give a briefing to the IIT about
the extent of the incidents, geographical location and distribution, their role and
responsibilities, security issues of the areas, report communication, etc.

The incident investigation team might consist of:

 A clinician ( preferred from toxicological center) who will both verify patients’
clinical symptoms and train health care workers in good case management;
 A person who will take and analyze biological and environmental samples for
laboratory confirmation of the incident
 An expert who work on risk communication and behavioral change
 An epidemiologist who will initiate data collection and assess surveillance
procedures;
 An environmental health expert to investigate the possible sources of the incident
and provide appropriate treatment of potentially contaminated sources.
 Any other expert is required based on the incident at hand (CBRN expert).
 Other relevant stakeholders that are directly involved in the hazards/incidents

In any situation, prior to IIT being deployed to the site of a suspected CBRN incident, many
preparatory activities need to be undertaken to make the task ahead effective, as well as,
protect IIT members from any potential hazard and other harmful circumstances. IIT

35
members will attend a pre-deployment briefing that is delivered by the CBRN case team
leader. The briefing will cover two topics:

 General situational briefing: this covers elements such as expected extreme

weather, prevailing communicable diseases, security and safety situation, roads
and communication conditions, etc.
 Specific CBRN related briefing should cover the following
• Roles and responsibilities of team members
• A situational overview of the emergency or event
• Objectives for and expected outcomes from the IIT
• Logistics and human resource coordination
• Reporting mechanism

4.3.2. Immediate Action

On-site, IIT will coordinate with local authorities and experts that it deems necessary to
effectively discharge its responsibility in the shortest time possible. Such a coordination
platform will serve for the timely and accurate exchange of information. The IIT will be
briefed by local authorities regarding the particulars about the CBRN incident, including, the
exact location, time, estimated number of persons affected, measures thus far taken and the
suspected CBRN agent. The IIT can rely on this briefing as a credible source of information
for the probable existence of a specific hazard.

The IIT leader, in turn, will brief local authorities and experts on how the IIT will proceed in
its investigation. IIT will inform local authorities on precautionary measures (such as wearing
PPE) that their staff and first responders must take to protect themselves and the general
public. Further, the IIT may request local authorities to take up certain roles in support of its
investigation. For example, local law enforcement may be requested to secure the CBRN
hazard site, local and surrounding health facilities may be requested to prepare to receive and
treat persons affected by the CBRN hazard, etc.

IIT’s on-site actions should foremost give priority to saving lives and treating the injured. A
case of a biological hazard, for example, may require lifesaving decontamination to be
carried out on scene prior to transport to the health facility.

36
In conjunction, it is important to put in place measures that make the area safe, as well as,
preserve the scene. In most CBRN incidents it is necessary to carry out on-scene lifesaving
decontamination prior to transport to the health facility, if possible. Otherwise, it should be
performed in parallel to medical treatment and antidote administration. The need for life-
saving decontamination, when necessary, can be quickly decided by the IIT. The table below
shows the life-saving decontamination procedures for CBRN hazards.

Table 3 Procedures of life-saving decontamination

Types of Hazard Life-saving decontamination procedures
Chemicals  Remove casualty from the source of exposure.
hazards  Remove clothing without pulling over the head.
 Rinse person with water, when needed.
 Wrap the casualty in blankets to avoid cooling
Biological  Most biological hazards don't need lifesaving decontamination.
hazards Except for Anthrax and botulinum toxin.
 If it is Anthrax or Botulism, follow the procedures of chemical
hazards above
Radio-nuclear  Remove casualty from the source of exposure
 Remove clothing without pulling over the head
 Always wash the casualty’s hands and face to minimize the risk of
internal contamination. When warranted, a full body shower may be
necessary
 Wrap the casualty in blankets to avoid cooling
4.3.3. Data collection:

In addition to accounts of victims and first-hand witnesses to the incident, numerous data
from other physical sources may be available. The scene of the incident can be visually
observed as well as examined using measuring equipment. Further, a paper trail of documents
(for example, chemical store records) can also serve as a secondary source of data.

Interview of victims and first-hand witnesses: Gather information as soon as possible after
the incident to understand the basics of what happened without interrupting the medical care.
Each person must be interviewed separately; and the interview must begin with the
reassurance that this is a fact-finding process only to be used to prevent a recurrence of the

37
incident. Where possible, it is best if the victim or witness writes and signs his or her
statement.

It is best to use a structured format to gather information from victims and witnesses, whether
it is completed by the victim or witnesses, or completed by an interviewer to make the data
consistent throughout. In the interview process, the interview form has:

 Personal identifiers of the interviewee

 Identifiers of the interviewer
 Information about the location, time and date of the interview
 Whether the interviewee is a victim or a witness, how far/close s/he was from the
incident, place and position of employment, if s/he experienced any medical
conditions or injuries due to the CBRN hazard, what symptoms s/he exhibited, what
treatments or first-aid care s/he received, and other information that will help the IIT
to definitively determine the CBRN hazard.

If the incident is associated with legal issues, interview the victims with a police officer with
writing the name of the interviewee.

The information gathered from victims and witnesses is important for the formulation of
hypotheses about the cause of the CBRN incident and to formulate an effective response. In
some cases, it may be important to search for additional or related cases in the neighboring
communities.

Gathering evidence/data: Examine the scene of the incident, looking for things that will
help you understand what caused the incident and its impact (human, environment,
infrastructure, livestock & crops, wildlife, etc.). This includes looking for and documenting
factual evidence (pictures, videos, written notes and audio recording) that will lead to
developing a hypothesis on the cause and impact of the incident. Evidence could include
spills, leaks, injuries, damaged equipment, soil samples, etc.

Primary data collected on-site as evidence include the following:

 Environmental samples (example, food, soil, water, wastewater, air, plant

material, landfills, etc.). Before shipping the environmental samples, the one
responsible for sampling should communicate with the laboratory centers. For

38
 Example, for the acute toxicity test, it needs at least 2kg if it is solid, and 2L if it is
liquid.
 Physical evidence (example, cracks/dents on equipment, damaged property, spills,
leaks, industrial discharges, etc.

The primary data needs to be supplemented with secondary data to provide context and an in-
depth understanding of the situation. Secondary data collected as evidence include the
following:

 Demographics (sex, age, occupation, location of residence and/or employment)

 Clinical (sign and symptoms, incubation period, laboratory test)
 Spread and distribution (Geographical distribution, impact clusters, characteristics of
affected and unaffected people, etc.)
 Review records (where appropriate, for example in factory or medical facility, check
training, equipment maintenance, recurrent failure, accident, etc records if it is
available. It is also advisable to see the medical records of the employees/workers if
the incidents happened around the industries or institutions which point to the source
of the hazards.

Data collection activities and evidence gathering is done by use of a standard checklist
purposely developed for the investigation of CBRN incidents (Annexed). All items on the
checklist must be completed before proceeding to the data analysis and evidence examination
stage. The quality and completeness of the collected data and evidence determine how
accurately the cause and impact of the incident are established and described. Incorrect and
incomplete data and evidence reduce the probability of getting to the cause(s) of the incident
and implementing the right actions/interventions.

4.3.4. Data Analysis

The analysis of data and examination of evidence is to reach a clear understanding of the
circumstances that led to the incident. The two main categories that need to be properly and
completely described are:

Identify Contributing Factors: Contributing factors include the environment (noise, light,
heat, and vapors, fumes, and dust), design (workplace layout, design of tools and equipment,
and maintenance), systems and procedures (lack of systems and procedures, inappropriate

39
systems and procedures, training in procedures, and housekeeping), and the human factor
(negligence, stress, fatigue, and so on).

Find Root and Direct Causes: Typically, an incident is not just a single event, but a chain of
events. The sequence of events needs to be understood before identifying why the incident
happened. When asking how and why, we need to identify the underlying root causes (why?),
as well as the direct causes (how?). For example, a chemical spill may be caused during
transportation. The direct cause may be that the harness broke (how?), while the underlying
root cause could be that there is no proper inspection and maintenance of the vehicle and its
accessories.

For example, if illness/injury occurred within seconds to a few minutes after an incident
without other visible causes, it was probably due to exposure to a chemical, especially in gas
or vapor form. In addition, the following are main indicators of a chemical hazard:

 Dead or distressed people and animals

 Individuals showing unexplained signs of skin, eye or airway irritation, breathing
difficulties, nausea, vomiting, sweating, blurred painful vision, disorientation, fitting,
or unconsciousness
 The obvious presence of hazardous materials (smell, taste or appearance) or unusual
materials/equipment
 Unexplained vapor, mist clouds, oily droplets, or films on surfaces or water

If there are no signs and symptoms within the first few hours after exposure, it was probably
due to a biological hazard. Intentional release of biological hazard's signs and symptoms are
similar to a naturally occurring disease outbreak because the etiological agent is the same.
Hence, it is recommended to use outbreak investigation procedures and implement disease-
specific interventions.

The symptom of radiation exposure is mainly nausea, headache and vomiting within minutes
to hours if the radiation exposure type and/or duration is life-threatening. Otherwise, most
low-level radiation exposures are asymptomatic.

40
 4.3.5. Grading the CBRN Incident

The scale, complexity, urgency, capacity, and reputational risk of the CBRN incidence shall
be used as key criteria’s for the grading purpose. Grading is the means by which the level of
operational response required by the health system and concerned governmental body is
determined. The findings from data analysis and evidence examination are applied to
determine the grading of the CBRN event.

The IIT will assess all the findings and make a considered judgment as to how to grade the
CBRN event. The four CBRN incident grades are:

 Ungraded: CBRN public health event or emergency that is being monitored by EPHI
and/or regional health bureau but that does not require an EPHI response (It can be
handled at the local level).
 Grade 1: Limited national/EPHI response/involvement but the regional health bureau
engagement is required. EPHI and the regional health bureau have to reorganize staff
and functions but have most of the capacity to provide the support required by the
event. In this case, EPHI may deploy a team of experts for minimal support.
 Grade 2: Moderate national level response required. Local and regional health bureau
requires external inputs to organize the response and probably one or more staff to
supplement the IIT.
 Grade 3: Major/maximal national level response required due to CBRN incident with
higher scale, complexity and urgency affecting wider area and population. When the
external support required is such that it mobilizes global organizational-wide assets.
In this case, international support might be considered for effective response.

The CBRN incident grade, along with recommendations for further required action, is
submitted by the IIT in its report. The findings, grade and recommendations of the IIT serve
as inputs for PHEM/EPHI to determine the need to trigger the activation of an Incident
Management System at the regional or national level to manage the organizational response
and the establishment of an Incident Management Team (IMT) under an Emergency
Operation Center (EOC).

During large-scale CBRN emergencies affecting a wide geographic area (multiple districts)
and/or a large population (the national EOC will be activated based on activation criteria and

41
the decision of the responsible official. The organizational structure of the IMS will be based
on the EOC/IMS manual. Equivalent regional EOC will also be activated at the decision of
the responsible regional official.

4.3.6. Determine and Implement Corrective Actions

Once it is determined what happened, how it happened and why it happened, and the CBRN
incident is assigned a grade, a sequence of actions are performed to fix the problem, limit
death and injury and formulate measures to ensure that a repeat of the same incident is
reduced or eliminated.

The implementation of corrective actions may be performed by the IIT, or by an IIT in

conjunction with IMS/EOC, as the case may be. The formulation and implementation of
corrective measures should avoid quick and cheap fixes that do not provide lasting solutions.
If possible, the corrective actions should provide a permanent solution to eliminate a repeat of
the same incident.

The following actions must be taken for any CBRN incident, with specific measures that
should be applied based on the findings of the incident investigation, as quickly as possible.

i. Avoid or minimize exposure

ii. Remove hazard from exposed skin, hair and clothing
iii. Seek medical attention.
i. Avoid or minimize exposure
In order to avoid or minimize exposure to CBRN hazard, the basic principles to keep in mind
are time, distance and shielding:
 Time spent in areas of potential exposure should be minimized
 Distance from areas of potential exposure should be maximized
 Shielding, that is employing a physical barrier against CBRN hazard, should be
used

The ability to implement this principle will depend on an assessment of risks in the particular
situation, which may lead to a decision to evacuate shelter, temporarily relocate or continue
operations using appropriate protective measures. Until the risks have been established,
however, the objective should be to immediately move or stay away from areas of potential
exposure, or to seek shelter if unable to leave the affected area.
42
Evacuation or temporary relocation may be effective if there is a safe location in the
immediate area or if there is safe transit available to a more distant safe location. The
suitability of a safe location will depend on the nature of the event, the type of CBRN hazard
involved and the possible extent of its dispersal.

Seeking shelter in a building or another protective structure will provide a barrier to hazards
dispersed on the ground or in the outside air but even clothing may provide a basic form of
shielding to protect skin from contamination. If sheltering is in place, the location should be
above ground level but not on the roof. Basements or cellars should never be used for some
airborne CBRN hazards that are heavier than air and tend to concentrate in such places.

Where a group of people are at risk of exposure to CBRN agents, and especially when the
event has yet to affect a wider area or region, actions must be taken to scale down operations
and relocate anybody who is not required to remain. This will be effective in reducing the
number of people at risk and enabling those remaining to take maximum advantage of
available protective measures.

Distribution and use of specialized personal protective equipment (PPE) would normally be
limited to those trained in the use of this equipment, such as emergency workers. For
individuals for whom PPE is not available, or who are not trained in the proper use of such
equipment, ordinary clothing may provide a suitable temporary barrier to skin contamination.
The intent is to minimize areas of exposed skin, for example, wearing long-sleeved shirts,
long trousers and a head covering. If available, a simple face mask should be worn to reduce
the risk of inhaling airborne hazards, or an improvised mask made from a moistened cloth
held over the mouth and nose.

ii. Remove agents from exposed skin, hair and clothing

If exposure to CBRN hazard is unavoidable, all possible efforts should be made to remove
hazards from skin, hair and clothing. Simple actions can be effective, such as:
 Removing an agent on exposed areas of skin by scraping, wiping with a damp
cloth or disposable towel, or washing thoroughly. Care should be taken not to rub
the agent further into the skin.
 Showering and washing hair to remove any agent lodged on the body. Start by
leaning forward into the stream of water to remove contamination from the hair
and head first to minimize the spread of contamination further down the body.
43
  Changing into a clean set of clothing (Uncontaminated set) and discarding or
sealing contaminated items in a disposable bag
iii. Seek medical attention

If exposure to CBRN hazard occurs or cannot be excluded with certainty, medical attention
or advice should be sought as soon as possible. Some hazard-specific protective measures and
medical treatments exist but they may not be available for all hazards. Examples include:

 Prophylactic (preventive) use of potassium iodine in a nuclear or radiological event

involving the release of substantial amounts of radioactive iodine to prevent an
increased risk of thyroid cancer in later life (N.B. this is not an effective treatment for
exposure to other radioactive materials)
 Vaccines, antibiotics and antidotes to prevent or to counteract effects of certain viral,
bacterial and toxicological hazards.
 Antidote treatment to counteract the effects of certain toxic chemical hazards. .
If a definitive diagnosis cannot be made of CBRN agent exposure, symptomatic treatment
will be required that is directed by medical assessments based on patient history, physical
examinations and laboratory tests (where available). The clinical management of CBRN
incidents may be individual or cluster cases.

As part of its preparedness regiment, health facilities are expected to periodically provide
training to the staff on mental health and stress management. Because, mass casualty usually
results from fear, psychological problems, distress, and fatigue and sometimes from a sleep
disorder, etc.
4.3.7. Reporting

There are two types of reporting during a response to a CBRN incident. The reporting is done
by the IIT (or any other expanded version it may take if the magnitude and severity of the
incident are deemed large).

i. Periodic activity report: The number and mode of submitting periodic activity
reports is dependent on the duration of the response. Over the phone oral reports (to
a designated phone number) conveyed at shorter intervals, maybe every day. Key
elements of the oral/phone reports are predefined (which also has a section for a
more free-form reporting section where IIT (or another response team) can convey.

44
 The recipient of the oral report can record the information conveyed either on paper
or voice recording.

If the duration of the response extends beyond one week, the daily oral reports must
be complemented with brief weekly written reports as per a pre-set form. The weekly
written reports summarize the actions taken by the IIT (or other response teams)
during the previous seven days and a detailed description of the incident situation and
its impacts.

[*Where warranted, the response team may be required to communicate periodic

reports orally at intervals shorter than 24 hours].

ii. Final report: Once CBRN incident investigation and response are concluded and when
all outstanding issues have been closed out, the IIT will then communicate its
findings, grading and recommendations for further action (lessons learned). The
outline for the final report is predefined. The final report must be communicated
within seven days after the CBRN response is closed (hence, the IIT/response team
will remain active for a week until after the conclusion of the investigation and
response). Communication mechanisms of the final report are both in digital and
analog mode.
4.4. Investigation of Intentional CBRN Incidents

If there is an indication of intentional release of CBRN hazards, the investigation activities

should implement jointly with law enforcement. The objective of the joint investigation is to
determine the nature and source of the threat to implement effective public health and legal
interventions. It also helps to maximize the efficiency and effectiveness of both law
enforcement and human/animal/plant health through collaboration and information exchange.
When a joint investigation is initiated, the law enforcement and health sectors are expected to
share information throughout the joint operations structure.

The law enforcement sectors (the Ministry of Defense and the Federal Police Commission) is
responsible for enforcing public health orders such as quarantines and travel restrictions,
securing the perimeter of contaminated areas and health care facilities, controlling crowds,
criminal and forensic investigation of suspected deliberate misuse of biological materials,
protect national stockpiles of vaccines or other medicines, protect first responders, conduct
threat identification, assessments and analyses of evidence, intelligence collection and
45
analysis, and forensic examination, and identify and interview potential suspects of biological
crimes.

Epidemiological investigation and criminal investigation, if possible, should be done

simultaneously to complement the finding of each investigation. Once the causes of the
hazards are investigated/determined, the response activities are similar to the above-
mentioned. However, the response activities should be conducted along with the engagement
of the law enforcement sectors.

National CBRN Task force

Epidemiologic Investigation Criminal investigation

MOH/EPHI notified/ Technical Federal Law enforcement unit

assistance provided to assess (Federal Police (Forensic
potential threat Investigation directorate),
MOD and/or ENSA)

Regional Health Bureau

notified Regional police office notified

Local health office/ Local police office/ department

Department notified notified

Biological threat or Suspected

Routine Medical Surveillance
biological material found

Community members and other private

or government organizations such as
schools, food and drink establishments

Figure 4 Flow of Information through the Public Health and Law Enforcement Sectors

46
 4.5. Management of CBRN Incidents

4.5.1. Management of Chemical Incidents

If you highly suspect or confirm that the people have been involved in chemical incidents,
clinical and public health responses should be implemented in addition to the above-
mentioned common CBRN management action.

Public health response

 Assess the plausibility/credibility that a chemical agent has been used

 Determine the immediate primary public health countermeasures – especially the need
for shelter or evacuation
 Work with joint command structures to provide advice on the safety of the public,
specific public protection and clinical public health counter-measures that are likely to
be required
 The guideline ‘evaluating rapidly evolving chemical exposure syndromes’ may help
to support your actions
 Determine whether decontamination is needed and advise on urgency and method:
Clinical response
 Use the Initial Operational Response method to coordinate emergency service
actions
 Ensure that you are wearing appropriate personal protective equipment (PPE)
 Decontaminate patient if needed and if this has not already been done (at the
scene, or outside accident and emergency department in designated NHS
decontamination facilities/ decontamination area)
 Breathing (high flow rate oxygen by mask; ventilate if needed)
 Control any hemorrhage, set up IV access and provide fluid resuscitation if
needed
 Assess cause, give specific clinical counter-measures if appropriate, reassess, alert
relevant
4.5.2. Management of Biological Incidents

A biological threat can be controlled by eliminating or reducing the source of infection or

contamination, interrupting transmission and protecting persons/animals at risk. It also

47
demands the identification, control and takes legislative measures on the responsible body for
the threat. This part of the document more focuses on the public health/veterinary response to
biological threats, as the legislative measures can be determined by a court of law. The
health/veterinary sector is responsible to prepare and avail for medical supplies and strength
surge capacities deploying medical teams for an effective response of bio-threats.

In the initial stage of an emergency, the exact nature of the causative agent may not be known
and general control measures may have to be taken for a suspected cause. Once the cause is
confirmed, specific measures such as vaccination can be undertaken according to the hazard-
specific guidelines. Based on the nature of the biological threat, control strategies which
mainly fall into four major categories of activity can be applied.

 Control and prevention measures specific for the disease

 Prevent exposure (e.g. isolation of cases)
 Prevent infection (e.g. vaccination)
 Treat patients with the national or international recommended treatment

Prevention of exposure: the source of hazard is reduced to prevent the disease from
spreading to other members of the community. Depending on the hazard, this may involve
prompt diagnosis and treatment of cases using standard protocols, isolation and barrier
nursing of cases, health education, and improvements in environmental and personal hygiene,
control of the animal, vector or reservoir and proper health facilities infection prevention
measures.

Prevention of infection: susceptible groups are protected by vaccination, safe water,

adequate shelter and good sanitation.

Prevention of disease and death: When scientifically and economically reasonable, high-
risk groups can be offered chemoprophylaxis to prevent disease transmission. Following
hazard-specific guidelines for prompt diagnosis and management of cases, should also be
monitored to reduce the death of patients

4.5.3. Management of Radio-nuclear Incidents

The management of patients following suspected or confirmed radiological incidents
involving mass casualties must be well organized and rehearsed. Patient management
includes determining the signs and symptoms of acute radiation exposure, determining the
extent the patient may be contaminated, providing for decontamination when necessary,

48
treating specific injuries, collecting specimens for laboratory testing, providing care for
special populations (e.g., pregnant women), providing discharge information, follow-up care,
and post-mortem procedures, and addressing the psychological effects of patients and their
mental health concerns. The psychological trauma in a radiological incident may be as varied
in severity and type as physical trauma and will require special skills and training to
adequately meet the needs of those affected.

The facility and staff who had contact with contaminated patients should be decontaminated
to prevent the spread of contamination. Staff should consult their radiation safety officer for
step-by-step procedures

Radiological contamination cannot be detected without specialized equipment. The radiation

authority should take the responsibility to detect the radiological materials using radiation
detection instrumentation and make sure it is understandable to clinical practitioners. If
internal contamination is suspected, bioassays can be conducted by taking body fluids such as
blood, urine, feces, nasal and saliva swabs, sputum, vomitus, and wound secretions.
However, this procedure depends on the capacity of the country and the regions.

Initially, hospitals should obtain as much patient and situation history as possible, noting
circumstances surrounding the patient and the situation that might indicate exposure.
Emergency department staff can measure complete blood counts (CBCs) with differential
initially to serve as a baseline measurement. CBCs taken over the next several days can then
be compared to the baseline measurements and used to assess the radiation dose received.

In a mass casualty incident, hundreds to thousands of patients may attempt to come to a

hospital, putting the hospital in a position where it cannot practically take a blood count on
every patient. Anyone who has or might exhibit prodromal effects would need to be
considered for a CBC with differential to test for acute radiation syndrome. If practicable, this
should be repeated every 6 hours for about 72 hours

Although state and federal assistance may be made available for receiving and analyzing
these samples, hospitals should identify during their emergency planning what agencies or
laboratories the samples should go to for analysis.

In the first 48 hours, the basic premise is that physicians should conduct standard patient
assessment, take care of immediately life-threatening problems, and take care of all other
problems that require immediate attention. Emergency department staff should treat

49
symptoms according to ordinary patient treatment practices and procedures and take care of
wounds by irrigating, debriding, and covering to the best extent possible. Suggested supplies
and medications to keep on hand and have easily accessible in large quantities include IVs,
fluid support, anti-diarrhea, anti-emetic medications, and potassium iodide tablets.

Figure 5 Investigation and management of radiation victim’s protocol

Hospitals should consider keeping a supply of potassium iodide to help reduce the risk of
thyroid cancer from radioactive iodine exposure. The recommended dose of KI is displayed
in Table 4.

50
 Table 4 Recommendations for the Administration of Potassium Iodide (KI)
Predicted KI dose (mg) Number of 130mg Number of 65 mg
radiation dose to tablet tablet
thyroid

Adults over 40 ≥500 130 1 2

years

Adults (18- ≥10 13 1 2

40years)

Pregnant or ≥5
lactating women
≥5
Adolescents (>12- 65 ½ 1
18 years)
≥5
Children (>3-12 65 ½ 1
years)
≥5
>1 month to 3 32 ¼ ½
years children
≥5
Birth to 1-month 16 1/8 ¼
babies

There is no special pharmaceutical treatment for pregnant women, but they will require
considerable reassurance and communication.

Patient discharge sheets should include basic information about radiation exposure and
accurate information about the long-term health effects of radiation exposure. Hospitals can
customize and relate these possible effects to the specific situation. If the incident is thought
to be of criminal intent, the discharge staff should explain the need for reporting to and
cooperation with law enforcement. Hospitals should avoid generic discussions about
radiation, which could promote unwarranted concern. The more that information is
customized to an individual’s circumstances, the more helpful it will be.

4.6. Public Health Risk Communication

Timely and proper information exchange through the emergency command system is one of
the crucial activities to early identify the source and initiate appropriate intervention. For
situation communication during emergencies, the team lead or a designated IMT member
should send a report summarizing activities to the responsible body in the command system.
There are different types of reporting mechanisms during emergencies which include; rapid
reports (telephone, emails, etc.), regular reports (SITREPs, detail investigation report) and
post-deployment reports (immediate debriefing session and after-action review):
51
 Phone Call or Email: The IIT could share urgent reports or their daily update on daily
basis either via phone call or text message or email, if an internet connection exists, to the
responsible body.

 Situation Reports (SITREPs): It is a type of written report that includes the summary of
the key activities and challenges and usually it is not more than one to two pages. Based
on the situation, SITRE could be produced on daily basis or every other day. If the IIT
lead is sharing their report via phone call or email, they may prepare and share the
SITREP every other day to give a short but complete picture of the situation.

 Detailed Investigation Report: At the end of the investigation and response, a detailed
investigation report should be submitted within three days after completion of the
mission.

 Debriefing Session: In order to identify intervention to be implemented during the post-

emergency period and learn for the response challenges, the national operation center
should arrange a debriefing session within five days of the return of the response team.

 After Action Review: It is a half-day workshop to be arranged within a month of return

the response team this session will aim to present the detailed technical report and
challenges so as to draw lessons of improvement for the future emergency responses.

Effective information management and real-time exchange with horizontal and vertical
response partners is the key to improved coordination and decision-making processes during
CBRN emergencies. It requires an understanding of the audience, the goal, the message, and
the most effective way to achieve the desired outcome. It also requires acceptance and an
understanding of the role of the communicator by the information receiving entity.

During times without emergencies, TWG member's organizations should share routine
surveillance findings, research findings and other relevant information with TWG members
regularly. The CBRN TWG is responsible for monitoring possible emergencies/incidents and
taking appropriate actions as per the findings. It is also responsible for compiling, organizing,
and analysing data to and produce and disseminate a report of findings to all relevant
stakeholders and high-level decision-makers.

Public information during an incident serves many important functions. It can:

 Save lives and reduce injury

 Protect property and the environment

52
  Facilitate the tactical response by calming fears and managing expectations

 Educate, inform, and change behavior and attitudes

 Seek the public’s cooperation

 Install public confidence

 Provide information to help families reunite.

The assigned public relations personnel for emergency communication is mandated to give
media briefings and interviews and is responsible for the design of clear, accessible, specific
and adequate media messages.

During an incident, a wide variety of communication tools are available to provide vital
information to the community. Choosing the right communication tool is a matter of getting
the right information to the right people at the right time so they can make the right decisions.
In a crisis, clarity, specificity, and consistency are vitally important: Tips for effective
communication during an emergency include:

 Present the information in sequence

 Word the message precisely, making every word count
 Avoid jargon, codes, and acronyms
 Use common terminology for all personnel and facilities
 Omit unnecessary details
 Speak in sync with other related authorities
 Keep messages consistent across various media

53
 SECTION FIVE: RECOVERY FROM CBRN EMERGENCIES

5.1. Coordination and Recovery

Recovery is a multidimensional process that requires an integrated and coordinated approach
to gradually turn the public health emergency affected communities into sustainable crisis
recovery, resilience building and development opportunities. It refers to the process of
rebuilding and rehabilitating the population following an emergency. Recovery from a
disaster is often a complicated and lengthy process. Recovery activity comprises well-linked
action to re-establish pre-incident living patterns and to protect and restore livelihoods. These
activities are undertaken in ways that reduce dependency, mitigate impacts of emergencies,
and strive toward meeting longer-term risk reduction objectives.

The recovery process from CBRN emergencies requires a detailed multi-sectoral assessment
of the affected community level to ensure a good understanding of their vulnerabilities,
available capacities and needs. Collaboration and discussions are also needed with
government and other service-providing partners to determine how those needs can be met,
and the areas where the national society can address and provide added value to the overall
recovery effort.

5.2. Objectives of Recovery

Basic objectives of public health recovery activities in regard to managing the post-
emergency phase of CBRN emergencies shall be

 To protect the populations from the dangers of chemical agents, poisons and toxic
agents, ionizing radiation, biological agents

 To provide support to the populations affected by the consequences of the CBRN

emergency

 To restore the affected territories and communities, from an economic and societal
standpoint

In proceeding with recovery planning and programming, and in addressing the key recovery
principles, the public health sector must ensure that the below listed nine strategic issues are
adequately addressed.

 Framing the recovery activities within the Fundamental Principles of the health sector

 Ensuring that programming strengthens resilience

54
  Building on an ongoing and systematic assessment and analysis

 Ensuring integrated or multi-sectoral programming

 Considering cross-cutting issues

 Making use of innovative approaches

 Building strong coordination within and outside the Movement

 Securing a sufficient and realistic level of resources

 Building on and contributing to the public health system development

5.3. Components of Recovery

There are four interlinked categories of the impact that individuals and communities will
need to recover from. The nature of the impacts and whether and at what level action needs to
be taken will depend in large part on the nature, scale, and severity of the emergency itself.

Environment

Humanitarian
Need Recovery Economy
(Including
Health)

Infrastructure

Figure 6 Major areas impacts of an emergency that require recovery

i. Humanitarian Need

It involves anticipating and managing the mental health and psychosocial impacts of the
event. Mental health and psychosocial problems are common among victims of natural
disasters, arising from a range of stressors. Victims may have lost family members, friends,
their property, they may have confronted death and severe injuries, and suffer from social

55
disruption. In the case of CBRN incidents /emergencies, the fear of chemical, radio nuclear
agents and biological agents’ contamination may be an additional stressor. The displacement
of people whose houses have been destroyed by the disaster or are contaminated by
chemicals has an important psychological impact. People may have to live in temporary
housing for many months. The impact on children must also be considered and managed.

Recovery from physical and psychological injuries from any CBRN incidents can take years.
Therefore, the health sector should support the victims by providing further medical care,
including mental health and psychosocial support and follow-up. Health programs should
take into account the specific needs of different age and gender groups.

Provision of information regarding possible long-term health problems is important as it

helps victims to recover. It is helpful to establish an information 'point of contact', who can
provide appropriate and up-to-date advice.

The health sector should also undertake an appropriate evaluation of the CBRN event, as well
as an assessment of public health response, to identify lessons learned, to avoid its recurrence
and to improve the overall response.

ii. Environment

A CBRN event/emergency may result in extensive environmental contamination and the

generation of contaminated waste such as debris, home furnishings and personal belongings.
Typically, clean-up operations start as soon as the natural disaster event has stopped or
abated.

These are often initiated by the local community seeking to restore some order to their
damaged environment and to protect their livelihoods, e.g. by clearing oil spills from shellfish
breeding grounds. In many disaster-prone areas, asbestos cement is widely used as a building
material and when damaged it can release harmful asbestos fibres. There may be a high risk
of chemical exposure in this early clean-up phase and the rapid provision of advice on health
protection is therefore important.

Longer-term decisions on clean-up and restoration will be informed by the results of

environmental sampling and detailed environmental risk assessments. The health sector’s role
here is to assist with risk assessment and the identification and prioritization of the areas to be
remediated, i.e. those that carry the highest risk of human exposure and health impacts. The

56
health sector should also advise on safety measures for the people employed in remediation
and clean-up.

After a CBRN event /emergency, soil, animals, plants and water bodies can be contaminated
by chemicals, affecting food and drinking-water production and supply. Restoration of these
services involves a risk assessment and consideration of possible recovery options.

In addition, Chemical, radioactive and biological contamination will likely not be at a

uniform level throughout the affected landscape. This will prompt different recovery actions
for different areas that must be accurately, clearly and fully explained to the impacted
populations.

Recovery options could involve taking no action if the health risk is judged insignificant,
treating food or water to remove contamination, diverting it to other uses, or disposing of
contaminated food as waste. Depending on the level of contamination it may be necessary to
prohibit the use of areas for growing crops or for animal foraging for a period of time.

iii. Economy

Recovery actions such as the return of displaced populations and the resumed functioning of
community economic enterprises may not be immediate. The incidents affected individuals
and institutions are extremely stigmatized by the rest of the community result in an economic
burden on affected enterprises and people. In addition to providing counseling and mental
health services, these affected individuals should get support from assistant organizations,
partners or the government. Financial assistance should be targeted and concentrate on the
most vulnerable. It would be better if the affected institutions also get support from the
different organizations to cope up with the economic burden.

iv. Infrastructure

After the occurrence of CBRN incidents, the infrastructure affected by the event might be
highly stigmatized and isolated by the communities. Hence rebuilding of the demolished
institution and conducting clean up strategies should be implemented. Moreover, permanent
population relocation may occur due to the nature and level of contamination and projected
prohibitive clean-up costs. Long-term population displacement or permanent relocation
requires arrangement shelter and public infrastructure will require significant livelihood
support, shelter and public infrastructure systems, and may also require dislocated population
integration into new communities.

57
Generally, a recovery plan should be developed immediately after the CBRN emergency in
parallel to the response activities. All the relevant governmental sectors shall plan for
emergency programs and implement them respective to their mandate.

 The public health sector shall plan for restoring of the health service in the affected
area (including psychosocial support);

 The disaster risk management committee shall plan and work in improvement of the
humanitarian issues (like sheltering, food and non-food item, restoring livelihood of
the community through financial support or any other mechanism).

 Environment Protection Authority (EPA) and Radiation Protection Authority (RPA)

shall plan and work on decontamination of the affected geographic area
(environmental aspects etc.)

Note: Guidance for conducting Post Emergency Assessment for CBRN emergencies,
indicators to be used for assessing the building blocks of health system delivery framework,
tools to be used for data collection and roles and responsibilities of each party is indicated in
PHEM guideline.

58
 SECTION SIX: MONITORING AND EVALUATION

Monitoring and Evaluation is used to assess the performance of preparedness, surveillance,

response and recovery activities of CBRN incidents. It is usually carried out on selected
indicators to assess whether the activities being conducted are achieved the overall goal of
CBRN management. The monitoring and evaluation activities of CBRN are listed out by each
pillar (i.e. preparedness, early warning and surveillance, response and recovery).

6.1. Monitoring and Evaluation of Preparedness

Assessing the level of CBRN preparedness at different levels is essential to know the capacity
to effectively manage CBRN incidents.

Some of the monitoring indicators are:

 Presence of CBRN preparedness and response plan in the PHEM preparedness and
response plan
 Availability of decontaminants, antidotes, drugs and vaccines at least for four
incidents
 Presence of trained personnel on CBRN incident management
 Presence of CBRN TWG
 Availability of incident investigation team
 Presence of identified hazards and risk assessment and mapping
 Availability of funds for the management of CBRN hazards or incorporation of
CBRN incidents in Public health emergencies' fund

Some of the evaluation indicators are:

 Number of CBRN TWG meetings conducted

 Number of persons trained on CBRN incident management
 Availability of CBRN focal person in each region, zone and woreda
 List of identified CBRN hazards
 List of mapped hotspot area for CBRN emergencies
 Availability of preparedness plan at each level
 The proportion of training with CBRN incident management (Training included
CBRN/Total training provided)
 Number of woreda/zones with adequate decontaminants, antidotes, vaccine and drugs

59
6.2. Monitoring and Evaluation of Surveillance
The status of early warning and surveillance activities can be monitored and evaluated by the
following indicators. Other additional indicators will be included if the CBRN incident
management system uses the existing PHEM surveillance system.

 The proportion of sentinel sites submitting surveillance reports to the next level
 The proportion of CBRN incidents notified to the next level within 30 minutes
 The proportion of CBRN incidents confirmed with laboratory investigations
 Number of periodic surveys conducted in the region
 Case fatality rate
6.3. Monitoring and Evaluation of CBRN Response

Accurate information is needed during incident management to inform decisions on response

actions, to monitor and evaluate the effectiveness of interventions, to make the right
corrections and to mobilize resources for the response.

 The proportion of incidents investigated with short time

 The proportion of zone/woreda with functional incident investigation and response
team
 Number of incidents confirmed with laboratory
6.4. Monitoring and Evaluation of Recovery from CBRN incidents

Some of the CBRN incidents may result in large-scale social, economic, environmental, and
ecological effects. At this time, rehabilitation and recovery activities should be conducted in a
coordinated manner.

Monitoring indicators for recovery

 Number of action review(AAR) conducted

 Number of the person getting psychosocial support
 Number of rehabilitated institutions

60
 REFERENCES

1. EPHI. Public health emergency management guideline. Addis Ababa, Ethiopia; 2012
2. Federal Democratic Republic of Ethiopia (FRDE). National Action plan for health
security (NAPHS). Addis Ababa, Ethiopia; 2018
3. ICRC. Chemical, biological and radionuclear response: Introductory guidance. ICRC,
Geneva Switzerland; 2014
4. IPCS. Human health rsik assessment toolkit: chemical hzardsManual for the Public
Health Management of Chemical Incidents. World health organization, Geneva; 2009
5. PHE. Chemical, biological, radiological and nuclear incidents: Clinical management
and health protection.London, 2nd edition, 2018
6. US department of homeland security. Guide for the Selection of Biological, Chemical,
Radiological, and Nuclear decontaminatione equipment for emergency first
responders. Washington dc; 2007
7. World Health Organization. Manual for investigating suspected outbreaks of illnesses
of possible chemical etiology: Guidance for investigation and control. Geneva,
Switzerland ; 2021.
8. World Health Organization. Guidelines for establishing a poison centre. Geneva,
Switzerland; 2020.
9. World Health Organization. Manual for the Public Health Management of Chemical
Incidents. Geneva; 2009
10. World Health Organization. International health regulations. Geneva; Switzerland, 3rd
edition; 2005

61
 ANNEXES

Annex 1: The case Based Reporting format for the CBRN incidents

Reporting Region: ______________

Reporting Health care Facility:
__________________________
Zone: _____________ Woreda: _______________

Full Name of Patient: ____________________________________

MRN ____________________________________

Date of Birth (DOB) (DD/MM/YYYY) Year .

Age (If DOB is Unknown)
____/____/_________ Month (If <12) .
Experience (on current occupation)
Sex (Male /Female): ________ Occupation .

Presenting sign and symptom:––––––––––––––––––––––––––––––––––––––––––––

Other associated sign and symptom:
 Vomiting  Respiratory distress
 Diarrhea  Fatigue
 Shortness of breath  Itching
 Unconsciousness  Burning
 Blurring of vision  Rush
 Convulsion  Other specify––––––––––––––––––––––
Biological Chemical
Suspected incident / Event Type
Radio nuclear Uknown
Is the agent known? YES NO
If known, Name of agent: ––––––––––––––––––––––
___________________ Gas Solid
Form of the agent
Liquid Radionuclear
Date of Exposure (dd/mm/yy) Amount of chemical
––––––––––––––––
–––––––––––––––– exposed( If known)

Acquisition of agent (Please Tick one Private Use Workplace

Others (Specify) ––––––––––––––––

Inhalation YES NO
Skine Contact YES NO
Route of Exposure
Ingestion YES NO
Other (Specify) ––––––––––––––––––––––––––––––––––
Is the location of incident known? YES NO
Site–––––––––––––––– Region –––––––––––––––
If known, location of Incident
Zone ––––––––––––––– Woreda –––––––––––––––

62

Circumstances of incident (Please
Patient’s Resident Address
Workplace
Date Seen at Healthcare Facility
(DD/MM/YYYY)
Self-Inflicted/intentional
Accidental
Unknown
Region ––––––––––––––– Zone –––––––––––––––
Woreda ––––––––––––––– Kebele –––––––––––––––
Same with resident address Yes NO
Date of Onset (dd/mm/yyyy)
___/___/______
___/___/______

Date of referal (If refered

Date Healthcare Facility Reported to
___/___/______ from other HF)
woreda (dd/mm/yyyy)
___/___/______
In / Out Patient Oupatient Inpatient
If inpatinet, time of hospitalization ––––––––––––––––
YES NO
Treatment given
If yes, Specify ––––––––––––––––––––––––
Status of the patient Stable Unstable
Outcome of the patient during at the
Alive Dead Uknown
time of the report
Region ––––––––––––––– Zone –––––––––––––––
Name of health professional
Woreda ––––––––––––––– kebele –––––––––––––––
––––––––––––––––––––––––
Date ___/___/______ Signature –––––––––––––––

63
Annex 2: Weekly reporting format (For CBRN Incidents)

Name of Health Facility_____________________________

Address:
o Region ____________________
o Zone ________________
o Woreda ________________
Date of reporting (dd/mm/year) _______/_______/_____________

Number of

Type of Incident
Suspected Confirmed Total cases Death
cases cases
Chemical

Biological

Radio-nuclear

Total

Reported by: ––––––––––––––––––––––––––––

Date: –––––––––––––––––––––––– Signature: ––––––––––––––

64
 Annex 3: Line list for CBRN Incidents
S.No Name age sex Address Occupati Date of Date Date Sign and Sample Type Result Current
on exposure of seen at symptoms taken of (Pos Status
Onset health (See codes (Yes/No) sample /Neg) (Dead/alive)
facility below) (See
code)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Sign and Symptoms

1. Nausea 5. Blurring of vision 9. Respiratory distress 13. Rush

2. Vomiting 6. Convulsion 10. Fatigue 14. Bleeding
3. Diarrhea 7. Unconsciousness 11. Itching 15. Open sores on the skin
4. Shortness of breath 8. Fever 12. Burning 16. Others
Type of Sample

1. Environmental: a. water b. Food c. Soil d. air e. other ________________

2. Human: f. blood g. stool h. sputum i. Other______________
65
 Annex 4: Incident Investigation Checklist

i. Location and Time

1 Place of Incident Occurred?

Region

Zone

Woreda

Kebele

Specific place

Where was the incident occurred? a. Workplace b. Consumer product

Or what sources are suspected?
a. HH chemicals d. Foods
If it was workplace, type of b. Industries
organization c. Research centers
d. Others –––––––––––––––––––––
If it is workplace, in which section
or department?

2 Date and time

Time of an incident occurred

Date of an incident occurred

66
 ii. Characteristics of the Cases
1 Total number of suspected cases?

2 How many deaths have there been?

3 Proprtion of Male to female of suspected cases (Sex characterstics? (M/F)

4 Maximum and minium age (years) of the cases? Max: _______ Min: _______ Average: _______

5 Are the suspected cases distributed in the same geographical areas or Is there a. Yes
cluster of cases? Consider household, workplace, school, public place, water
source, foods, consumer produce, ethnic and religious groups. b. NO

6 Where are cases being cared for (family, community, medical centre, other)? Yes No

iii. Characteristics of the hazards

1 Is the type of hazard known? Yes No

2 If the answer is yes, what is the name of the hazard(s)

3 Has this hazards similarly happened before Yes No

4 If yes, what actions were taken Yes No

5 Is those action taken were effective Yes No

6 Yes: Consider in developing corrective action

No: Don’t repeat again

67
7 If the answer to Q1 is no, are any hazardous substances in use or present? Yes No

8 If yes, What are they

9 Who were using these chemicals before the incidents

10 Are they affected by the incidents yes No

11 What sign and symptoms are being showing of affected person? Codes

12 Were the affected individuals working in the same department or section? Yes No

13 Were the affected individuals the same age group? Yes No

14 Were the affected persons young and healthy? Yes No

15 Were they shared the same geographical area? Yes No

16 Possible contributing factors for the incident (List all the factors)

68
 iv. Environment
1 Was there cracked buildings (Observe) Yes No Take photo
2 Was there chemical spills around the incident area (Observe) Yes No Take Photo
3 Was there unexplained or unusual death of plants, animals or fish? Yes No
4 Was there altered taste or appearance of food or water? Yes No Take photo and sample
5 Was there damping of chemical containers or wastes Yes No Take Photo

6 Was there dust from mining and grinding or particulate emissions from vehicles or Yes No
industry
7 Were there discharge/effluents from the industries? Yes No Take photo

8 If there is discharge of effluent, was the downstream community previously Yes No

complained and history of disease/death?

9 Have any unusual odours been noted in the locality? Yes No

10 Is there a common source of drinking-water or recreational water? Yes No
11 Are any unregulated domestic or industrial materials regularly recycled or sold? Yes No
12 Has there been pesticides or chemical fertilizer application in the area Yes No
13 Have there been any unusual meteorological or extreme weather incidents recently
(flooding, drought)?

69
 v. Victims/Witness
S.no Name Sex Ag Job category Affected Sign and Date of Previous Possible Remark
e by the symptoms onset Health causes of (Victims/witness)
M/F incident status the incident
(Yes/No) (Healthy/
Not
healthy)

Signs and Symptoms (S/S):

1. Nausea 5. Blurring of vision 9. Respiratory distress 13. Rush
2. Vomiting 6. Convulsion 10. Fatigue 14. Bleeding
3. Diarrhea 7. Unconsciousness 11. Itching 15. Open sores on the skin
4. Shortness of breath 8. Fever 12. Burning 16. Others

70
 vi. Findings of the Assessment ( Write the possible causes of the incidents
including the type of hazards)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

vii. Corrective action

S.No Correction action Responsible person time

viii. Sampling

1 Is sample needed Yes No

2 If yes, what type of Biological Environmental Others (Specify)

sample sample sample
––––––––––––––

3 Describe the sample

characteristics, amount,
etc

ix. Grading of the Incident

a. High
b. Medium
c. Low
High: Need of additional response team from national and regional CBRN TWG
Medium: Need only the support of the region or zone
Low: The incident investigation team can manage the incident

71
 x. Contact Information (Incident Site)
Name

Phone number

Address

Responsibility/Position

xi. Investigation Team

S.no Name Signature Position Date

Once you have identified what action is required to prevent a recurrence of the incident in question, you should
record your recommendations in the form of an action plan, making it clear what is required, by when and who
will be responsible for implementing the improvements required. The most important thing is not to apportion
blame, but to learn from our mistakes, so as to continually improve health and safety standards .

72
Annex 5: List of Antidotes

Poisoning Antidotes Remarks

Organophosphates Atropine sulphate Agricultural pesticides

Pralidoxime

Carbamates Atropine sulphate >>

Pralidoxime

Organochlorides Cholestyramine >>

Rodenticides Vitamin K1 >>

Lead Dimercaprol Industrial chemicals

D-Pencillamine

Calcium disodium edetate

Mercury Dimercaprol >>

Dimercaptosuccinic acid

D-Pencillamine

Arsenic Dimercaprol >>

D-Pencillamine

Methyl alcohol Ethanol >>

Folic acid

Ethylene glycol Ethanol >>

Pyridoxine hydrochloride

Folic acid

Thiamine

73
Cyanide Amyl nitrite >>

Sodium nitrite

Sodium thiosulfate

Dicobalt edetate

Nitrites, Nitrates Methylene blue >>

Botulism Botulism antitoxin Environmental toxins

Neurotoxins (Sarin, Tabun, Pralidoxme Nerve agents

Cyclosrin, )
Atropine sulfate

Chemical Asphyxiants Blood agents

(Cyanogen chloride,
hydrogen cyanide, hydrogen
sulphide)

Methylene chloride, carbon Oxygen, Hyperbaric oxygen

monoxide, hydrogen sulfide

Hydrofluoric acid, fluoride Calcium chloride, calcium

salts, oxalic acids gluconate

Bromates, Chlorates Sodium thiosulfate, Methyl

blue

Formaldehyde Folic acid

Contamination of GI tract Activated charcoal(Poweder)

74
Annex 6: List of Essential Medicines for Management of Poisoning
Drug Poisoning
Antipsychotic agents eg. Psychotic sates with severe agitation
Chlorpromazine, haloperidol
β-blockers e,g atenolol, bisoprolol, β adrenergic agonists, hypertension
metoprolol
Biazepam Organophosphates, chloroquine; Convulsions,
excitation, anxiety, muscular hypertonia, etc
Dopamine Myocardial depression, vascular relaxation
Epinephrine (adrenaline) Anaphylactic shock, Cardiac arrest
Ethanol (alternative to fomepizole) Methanol, ethylene glycol
Furosemide Fluid retention, left ventricular failure
Glucagon β-blockers
Glucose Hypoglycaemia
Heparin Hypercoagulability states
Magnesium sulfate Cardiac arrhythmias
Mannitol Cerebral oedema, fluid retention
Midazolam Convulsions, delirium, muscular hypertonia

Neostigmine Neurotoxic snakebite (5), anticholinergic

agents
Oxygen Cyanide, carbon monoxide, hydrogen sulfide
Penicillamine Lead, copper (Wilson disease)
Phytomenadione (vitamin K1) Coumarin derivatives
Protamine sulfate Heparin
Pyridoxine Isoniazid
Salbutamol Bronchoconstriction

75
Annex 7: Selected Biological Hazards in Ethiopia

76
Annex 8: Roles and Responsibilities of Stakeholders
1. Ministry of Agriculture
1.1. Assign members and experts to the National Technical Implementation
Committee, as well as technical leaders, and support the implementation of the
committee's objectives at the institutional level throughout the country.
1.2. Animals Affected by Chemical, Biological, and Radioactive Disasters: Provides
the necessary information and facilitates shared information when asked by
other parties about fish and plant species.
1.3. In animals: Advise and participate in research and control in collaboration with
other parties on chemical, biological and radiological damage to fish and crops.
1.4. Regularly provide information on hazardous areas and areas of risk of
contamination as well as areas prone to such incidents.
1.5. Take precautionary measures against chemical and radiological hazards that
may occur during laboratory sampling, collection and, in general, laboratory
operations.
1.6. To provide an official statement on the current state of animal, fish and plant
health in the light of chemical, biological and radiological hazards at the agency
level or in conjunction with other parties as needed.
1.7. To mobilize and / or allocate resources for the dissemination and / or
dissemination of chemical, biological and radioactive hazards, identification,
prevention, control and elimination and enrichment of communications in the
country.
1.8. Informs the relevant authorities regarding the chemical, biological and
radiological hazards of animals, fish and crops. Coordinates professional
explanation / response;
1.9. Provides guidelines, manuals and formats for the preparation and response to
chemical, biological and radiological hazards of fish and crops;
1.10. Prepares surveys and reports on chemical, biological and radiological hazards to
animals, fish and crops and prepares reporting forms;
1.11. Surveys chemical, biological and radiological hazards; Coordinates disaster
preparedness and emergency response; Provides professional support;

77
 1.12. Identifies hazards and causes in the event of chemical, biological and
radiological disasters; Collaborate with relevant stakeholders and take remedial
action.
1.13. Provide technical support to the CBRN team on agro-chemicals
1.14. Provide technical support for various agro-chemical exploration and
identification activities.
1.15. Establish a monitoring and control system for the use and disposal of various
chemicals used in the sector.
1.16. Provide appropriate support for problem-solving research on agro-chemicals.
1.17. Establish a system in place with relevant stakeholders to prevent and control the
harmful effects of various chemicals on animal and human health.
2. Customs Commission
2.1. In accordance with Article 25 (c) of Proclamation No. 859/2006, it shall be
obliged to ensure that the goods are licensed to the public before they are
released.
2.2. Upon importation of any restricted goods, the Superintendent shall, if he fails to
obtain a permit in accordance with the Proclamation, return to the country of
origin or shall have the representative of the Superintendent's Office removed in
order to remove the restricted goods.
2.3. Pursuant to Article 156 Sub-Article 1 of the Commission Proclamation 859/2006,
any person who enters or exits the country without permission shall be punished
if he fails to submit a permit within one month
3. Food and Drug Authority
3.1. Any person who authorizes the importation, production, distribution, storage
or possession of narcotic drugs or preservatives must obtain a special permit
from the regulatory authority.
3.2. In any case, the concerned person shall keep in mind the use of psychotropic
substances or preservatives in the form of expired narcotic drugs.
3.3. Share information with EPHI/PHEM accordingly and timely.
3.4. Analyse suspected samples if there is a capacity in EFDA Laboratories.
3.5. Provide experts for TWG and also for other purpose regarding CBRN if
necessary

78
4. Ethiopian Radiation Protection Authority
4.1. Use any sealed or unsealed radioactive sources and equipment that emit
radiation; Storing: Transporters: Forwards: Sell, exchange; To remove:
Exporters: Submissions: Etc. individuals; Enforces and regulates institutions or
organizations in accordance with the powers vested in it by Proclamation No.
1025/2009;
4.2. Establish a team of professionals who can respond appropriately and timely in
the event of a radiological or nuclear disaster;
4.3. Develop a plan in line with the Radiological and Nuclear Disaster Preparedness
and Response Plan developed by the Ethiopian Institute of Public Health;
4.4. Performs all disaster risk management activities, including monitoring and
response during radiological and nuclear disasters;
4.5. Establish an institutional structure and capacity to respond appropriately and
timely in the event of a radiological or nuclear disaster.
4.6. Monitors the proper discharge of licenses and the performance of their licenses.
4.7. It serves as a technical lead agency in the event of a radiological or nuclear
accident
4.8. When necessary, consult with licensees, stakeholders, and the community on
possible mitigation measures;
5. Fire and Disaster Risk Management Commission
5.1. Raise awareness among the public who are exposed to chemical, biological and
radioactive hazards.
5.2. Provides professional advice and technical assistance to individuals or
institutions that store, transport, or use chemical, biological, and radioactive
materials and materials to take safety precautions;
5.3. Ensure that those who store and use chemical, biological and radioactive
substances have a disaster safety certification certificate.
5.4. Study the vulnerability of the chemical, biological and radionier and take
corrective action with the relevant bodies;
5.5. Provides chemical, biological and radio-nucler-related information to the
relevant body;
5.6. Respond to chemical, biological, and radioactive materials in the event of an
accident due to hazardous substances and radiation.

79
 5.7. Provides temporary support and rehabilitation services to the affected sections of
the society due to chemical, biological and radioactive substances and materials.
6. Federal Police Commission (Forensic Directorate of the Criminal
Investigation)
6.1. Exchange information with the Institute of Public Health in the event of
chemical, biological, radiological, and nuclear disasters.
6.2. Crime scene investigation
6.3. Crime scene management
6.4. Examine the evidence (send it for investigation)
6.5. Common use of laboratory equipment and facilities
6.6. Expert testimony when asked about the issues we have examined.
6.7. Disaster victim identification based on pre- and post-disaster evidence.
6.8. Protect and escort victims, suspects, evidence and related items through the
Commission's Criminal Prevention Bureau
7. Ministry of Mines and Petroleum
7.1. Prepares, evaluates and evaluates environmental impact assessment data for any
mining and production activity. Fields and supervises the implementation of
environmental and health harm prevention activities through this sector; Adjust
hazards (including chemical and radioactive hazards); He will take action when
necessary.
7.2. Identifies hazards and causes to prevent chemical and radio-nuclear hazards from
being used and produced by mining companies; Prevents protective measures by
miners, ensures and monitors their operation.
7.3. Prohibits the storage and use of chemicals used for exploration and production
that may be harmful to human health and the environment.
7.4. Ensures that waste products or hazardous chemicals and waste from the mining
industry are properly disposed of.
7.5. All miners are required to immediately notify the licensing authority in the event
of an accident or incident involving the environment or human health (including
chemical and radioactive) and to take the necessary steps to minimize the impact
of the situation.

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8. Minister of Defense
8.1. Properly record the chemical, biological, and radioactive materials used by the
institute and their location, time of use and time of control.
8.2. To ensure that chemical, biological and radioactive substitutes and explosives
are stored and used in practice, and that the public be seated and trained in a
place that does not cause temporary or long-term damage and is supported by
research.
8.3. Surveillance and monitoring of possible chemical, biological, and radioactive
attacks by the enemy
8.4. Prioritizes chemical, biological, and radioactive firearms and other chemicals
that may or may not cause harm to the community when used by the facility. A
control system will be set up.
8.5. Have a laboratory certification that can be used to control and monitor the
explosives and chemicals used by the facility.
8.6. Develop a plan for the removal of chemical, biological, and radioactive use and
placement
8.7. Prioritizing information and security work on chemical, biological and
radiological nuclear operations
8.8. Prevention of chemical, biological, and radioactive hazards.
8.9. Build capacity to protect our country from external and internal attacks by
chemical, biological and radio-nuclear.
8.10. Provide the necessary protection of civil society in developing networks and
institutions from chemical, biological and radioactive attacks.
8.11. Establishment of chemical, biological and radioactive vulnerability mitigation
systems
8.12. Carrying out and cleaning the area where chemical, biological and radioactive
ions are found.
8.13. Warn the public of timely, accurate information on possible chemical, biological,
and radioactive attacks from the enemy.
8.14. Provides chemical, biological and radioactive as well as communication
transportation and supply for natural disasters.
8.15. Prevents cross-border chemical, biological, and radioactive hazards that may
pose a threat to public health.

81
 8.16. Practice pretending to prevent chemical, biological and radioactive damage from
relevant bodies
9. Ministry of Trade and Industry
9.1. Monitor the implementation of the Chemical Weapons Convention and submit
the report to the relevant body
9.2. The Ministry of Trade and Industry shall keep a record of the production of
imported and imported chemicals, and shall determine the details to be kept.
9.3. Chemicals administered by the relevant bodies shall be submitted annually to
the Ministry of Trade and Industry.
9.4. Every industrial chemical producer, importer, exporter, distributor or consumer
shall report annually to the Ministry of Trade and Industry the quantity of
chemicals imported, exported, produced, distributed, used or transferred to a
third party.
9.5. No person may engage in industrial chemical trade without reporting the
manufactured or imported industrial chemical to the Ministry of Trade and
Industry.
9.6. Any manufacturer, importer, exporter, distributor or consumer of industrial
chemicals must notify the Ministry of Trade and Industry one year before the
expiration date.
10. Ministry of Environment, Forest and Climate Change
10.1. Manage poisoned patients either accidental or intentional, either single patient
or in mass
10.2. SPSH Poison information center provide 24/7 free hotline(8939, or
0118120023)
10.3. Conduct surveillance, notification and delivering information on cases.
10.4. Develop a clinical toxicology training programme
10.5. Provision of routine health education and promotion related with toxicity and
its public health significance.
10.6. Giving expert advices, recommendation and case management in chemical
incident
10.7. Conduct researches on priority areas and give recommendation for respective
sectors
10.8. Prevention of patients on accidental or intentional exposure to chemicals.

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 10.9. Serving as research and training center for our country and horn of Africa

11. Ethiopian Red Cross Society

11.1. Providing first aid and ambulance services
11.2. Facilitate awareness training for union members and volunteers
11.3. Actively participate in disaster prevention and response activities
11.4. Provide the community with an affordable supply of basic medicines
11.5. Develop a backup plan around the hazards
11.6. Provide personal protective equipment to the volunteers of the association
directly involved in disaster response
11.7. Provide humanitarian assistance to the affected communities as much as
possible
11.8. Practice BDRT-trained activities to prevent the risk of chemical, biological
and radioactive hazards
11.9. Strengthening the Association's Emergency Operation Center (EOC) for
Chemical, Biological, and Radioactive Disasters
11.10. Supporting national immunization campaigns
11.11. Gathering resources on chemical, biological and radiological hazards

12. African Center for Disaster Risk Management- Addis Ababa University
12.1. Develop and deliver tailor made training (we have at our disposal nuclear
physicist , analytical/organic/inorganic chemists)
12.2. Design research projects to address specific issue, implement said project and
produce evidence-base information for decision makers.
12.3. Deliver interactive online trainings and blended learning)
12.4. Design and deploy data/information management system (already, prepared
hierarchical Chemical Information Management System - ChIMS).

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Annex 9: Clinical Descriptions of Chemical Poisoning
a. Adamsite (Diphenylaminechloroarsine or DM)

Clinical Description

The majority of exposures occur by inhalation and typically lead to symptoms of ocular,
nasal, and respiratory tract irritation. Nonspecific gastrointestinal symptoms (e.g., vomiting
or diarrhea) might also occur. The effects of adamsite poisoning take minutes to begin and
might last for hours. If a rapid onset of manifestations of one of the following respiratory
effects occurs, the clinical description for adamsite poisoning has been met: nose or throat
irritation, cough, or dyspnea.

Laboratory Classification for Diagnosis

Biologic: No biologic marker is available for adamsite exposure.

Environmental: No method is available to detect adamsite in environmental samples.

b. Ammonia

Clinical Description

The majority of exposures occur by inhalation and typically lead to symptoms of ocular,
nasal, and respiratory irritation. Signs and symptoms of poisoning might include eye redness
and lacrimation, nose and throat irritation, cough, suffocation or choking sensation, and
dyspnea.

Laboratory Criteria for Diagnosis

Biologic: No biologic marker is available for ammonia exposure.

Environmental: Detection of ammonia in environmental samples, as determined by NIOSH.

c. Arsenic (Inorganic)

Clinical Description

Acute ingestion of toxic amounts of inorganic arsenic typically causes severe gastrointestinal
signs and symptoms (e.g., vomiting, abdominal pain, and diarrhea). These signs and
symptoms might rapidly lead to dehydration and shock. Different clinical manifestations
might follow, including dysrhythmias (prolonged QT, T-wave changes), altered mental
status, and multisystem organ failure that might ultimately result in death.
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Laboratory Criteria for Diagnosis

Biologic. A case in which elevated urinary arsenic levels (>50 µg/L for a spot or >50 µg total
for 24-hour urine) exist, as determined by commercial laboratory tests. Speciation is required
in all cases where total urine arsenic is elevated to differentiate the amount of organic and
inorganic arsenic. Or,

Environmental. Detection of arsenic in environmental samples above typical background

levels, as determined by NIOSH or FDA.

d. Arsine

Clinical Description

Inhalation of arsine gas causes no immediate symptoms. Signs and symptoms occur 2-24
hours after exposure and result from massive hemolysis. These signs and symptoms include
generalized weakness, dark urine, jaundice, and dyspnea. Oliguria and renal failure often
occur 1-3 days after exposure.

Laboratory Criteria for Diagnosis

Biologic. No specific test is available for arsine exposure; however, exposure to arsine might
be indicated by detection of elevated arsenic levels in urine (>50 µg/L for a spot or >50 µg
for 24-hour urine) and signs of hemolysis (e.g., hemoglobinuria, anemia, or low haptoglobin).

Environmental. Detection of arsine in environmental samples, as determined by NIOSH.

e. Barium

Clinical Description

Ingestion of certain forms of barium (e.g., barium carbonate or barium fluoride) in toxic
amounts leads to gastrointestinal symptoms (e.g., vomiting, abdominal pain, and watery
diarrhea). Within 1-4 hours of ingestion, profound hypokalemia develops in certain instances,
and potassium levels <1.0 mmol/L are associated with generalized muscle weakness that
might progress to paralysis of the limbs and respiratory muscles.

Barium sulfate is not absorbed when taken by mouth and is therefore commonly used as a
contrast agent for radiographic procedures.

Laboratory Criteria for Diagnosis

85
Biologic. A case in which an elevated spot urine barium level (>7 µg/L) exists as determined
by commercial laboratory tests. Or,

Environmental. Elevation of barium compounds in environmental samples, as determined

by NIOSH or FDA.

f. Brevetoxin

Clinical Description

After oral ingestion, brevetoxin poisoning is characterized by a combination of

gastrointestinal and neurologic signs and symptoms. The incubation period ranges from 15
minutes to 18 hours. Gastrointestinal symptoms include abdominal pain, vomiting, and
diarrhea. Neurologic symptoms include paresthesias, reversal of hot and cold temperature
sensation, vertigo, and ataxia. Inhalational exposure to brevetoxin results in cough, dyspnea,
and bronchospasm.

Laboratory Classification for Diagnosis

Biologic. Brevetoxin can be detected by an enzyme-linked immunosorbent assay (ELISA)

method in biologic samples; however, ELISA of biologic samples is not a certified method
for the detection of brevetoxin.

Environmental. Any concentration of brevetoxin in environmental samples, as detected by a

commercial laboratory.

g. Bromine

Clinical Description

The majority of exposures to bromine occur by inhalation and typically lead to symptoms of
ocular, nasal, and respiratory irritation. Signs and symptoms of poisoning include eye redness
and lacrimation, nose and throat irritation, cough, and dyspnea. Ingestion of liquid bromine
can cause abdominal pain and hemorrhagic gastroenteritis with secondary shock. Signs and
symptoms might also include brown discoloration of mucous membranes and the tongue.

Laboratory Criteria for Diagnosis

Biologic: No specific test for bromine is available; however, detection of elevated bromide
levels in serum (reference level is 50--100 mg/L) might indicate that an exposure has
occurred.

Environmental: Detection of bromine in environmental samples, as determined by NIOSH.

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 h. 3-Quinuclidinyl Benzilate (BZ)

Clinical Description

BZ toxicity, which might occur by inhalation, ingestion, or skin absorption, is an

anticholinergic syndrome consisting of a combination of signs and symptoms that might
include hallucinations; agitation; mydriasis (dilated pupils); blurred vision; dry, flushed skin;
urinary retention; ileus; tachycardia; hypertension; and elevated temperature (>101ºF). The
onset of incapacitation is dose-dependent. It might occur as early as 1 hour after exposure and
continue up to 48 hours.

Laboratory Criteria for Diagnosis

Biologic: A case in which BZ is detected in urine, as determined by CDC.

Environmental: No method is available for detecting BZ in environmental samples.

i. Carbon Monoxide

Clinical Description

The predominant manifestations of carbon monoxide poisoning are cardiovascular and

neurologic effects. Inhalation of carbon monoxide gas typically leads to headache, dizziness,
and confusion, which might progress to dyspnea, tachypnea, syncope, and metabolic acidosis.

Laboratory Criteria for Diagnosis

Biologic. A case in which carboxyhemoglobin concentration exists >5% in venous or arterial

blood in nonsmokers and >10% in smokers, as determined by hospital or commercial
laboratory tests. The typical range of carboxyhemoglobin concentrations in smokers is 6%--
10%.

Environmental: No confirmatory test is available for carbon monoxide in environmental

samples.

j. Caustic or Corrosive Agents

Clinical Description

Ingestion of caustic or corrosive agents (e.g., phosphoric acid or sulfuric acid) can cause
direct injury to tissue upon exposure, which might lead to the following signs and symptoms:
oral pain, ulcerations, drooling, dysphagia, vomiting, and abdominal pain. Dermal and ocular
exposure might result in local irritation or burn injury. Inhalation of corrosive gases might

87
result in upper and lower respiratory irritation, leading to stridor, dyspnea, wheezing, and
pulmonary edema.

Laboratory Criteria for Diagnosis

Biologic: No biologic marker for exposure to a caustic or corrosive agent is available.

Environmental: Detection of caustic or corrosive agents in environmental samples, as

determined by NIOSH or FDA.

k. Chlorine

Clinical Description

The majority of exposures occur by inhalation and typically lead to symptoms of ocular,
nasal, and respiratory irritation. Signs and symptoms of poisoning might include eye redness
and lacrimation, nose and throat irritation, cough, suffocation or choking sensation, and
dyspnea. For cutaneous exposures, burning, blistering, and frostbite injury to the skin is
possible.

Laboratory Criteria for Diagnosis

Biologic: No biologic marker for chlorine exposure is available.

Environmental: Detection of chlorine in environmental samples, as determined by NIOSH.

j. Colchicine

Clinical Description

Ingestion of colchicine typically leads to profuse vomiting and diarrhea, which can be
bloody, followed by hypovolemic shock and multisystem organ failure within 24-72 hours.
Coma, convulsions, and sudden death might also occur. Subsequent complications include
bone marrow suppression with resultant leukopenia, thrombocytopenia (nadir in 4-7 days),
and possibly sepsis.

Laboratory Criteria for Diagnosis

Biologic. A case in which colchicine is detected in urine, serum, or plasma, as determined by

a commercial laboratory. Or,

Environmental. Detection of colchicine in environmental samples, as determined by FDA.

l. Cyanide

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Clinical Description

Inhalation of cyanide gas or ingestion of cyanide salts typically leads to lethargy or coma
(possibly sudden collapse), dyspnea, tachypnea, tachycardia, and hypotension. Severe
poisoning results in bradypnea, bradycardia, cardiovascular collapse, and death. Nonspecific
laboratory findings include metabolic and lactic acidosis.

Laboratory Criteria for Diagnosis

Biologic. A case in which cyanide concentration is higher than the normal reference range
(0.02--0.05 µg/mL) in whole blood, as determined by a commercial laboratory. Or,

Environmental. Detection of cyanide in environmental samples, as determined by NIOSH or

FDA.

m. Digitalis

Clinical Description

Signs and symptoms of acute digitalis (digoxin or digitoxin) poisoning by ingestion include
primarily gastrointestinal effects (nausea and vomiting), hyperkalemia, and cardiovascular
effects (bradydysrhythmias [heart rate <60 or atrioventricular block] or tachydysrhythmias
[ventricular tachycardia/fibrillation or atrial tachycardia with 2:1 block]).

Laboratory Criteria for Diagnosis

Biologic: A case in which digitalis in serum samples is detected, as determined by a

commercial laboratory.

 Therapeutic levels of digoxin are 0.5-2.0 ng/mL; therapeutic levels of digitoxin are
10-30 ng/mL.

 Because multiple determinants exist for digoxin poisoning and serum digoxin
concentrations overlap between symptomatic and asymptomatic patients, the use of
the therapeutic range for diagnosis might be misleading. The therapeutic range should
be correlated with the clinical findings.

 Serum levels might be low after exposure to plant glycosides, which cross-react
imperfectly. In addition, false positives might be noted for pregnant women and
patients with liver and renal disease. Or,

Environmental. Detection of digitalis in environmental samples, as determined by FDA.

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 n. Elemental White or Yellow Phosphorus

Clinical Description

Ingestion of elemental white or yellow phosphorus typically causes severe vomiting and
diarrhea, which are both described as "smoking," "luminescent," and having a garlic-like
odor. Other signs and symptoms of severe poisoning might include dysrhythmias, coma,
hypotension, and death. Contact with the skin might cause severe burns within minutes to
hours.

Laboratory Criteria for Diagnosis

Biologic. No specific test for elemental white or yellow phosphorus is available; however, an
elevated serum phosphate level might indicate that an exposure has occurred. Although
phosphate production is a by-product of elemental phosphorus metabolism in humans, a
normal phosphate concentration does not rule out elemental phosphorus exposure.

Environmental. Detection of elemental phosphorus in environmental samples, as determined

by NIOSH, and an elevated phosphorus level in food, as determined by FDA, might also
indicate that an exposure has occurred.

o. Hydrofluoric Acid

Clinical Description

Depending on the concentration of dermal exposure, affected skin can initially look
completely normal but often will become painful and appear pale or white, possibly leading
to necrosis. Inhalational poisoning might result in dyspnea, chest pain, stridor, and wheezing.
Oral poisoning can result in vomiting (possibly bloody), abdominal pain, and bloody
diarrhea.

Systemic poisoning might occur after oral, dermal, or inhalational exposure. Systemic signs
and symptoms include hypocalcemia and hyperkalemia, which leads to dysrhythmias,
seizures, and possibly death.

Laboratory Classification for Diagnosis

Biologic. No specific test for hydrofluoric acid is available; however, hypocalcemia,

hyperkalemia, and an elevated concentration of fluoride in the serum might indicate that an
exposure has occurred. Normal serum fluoride levels are <20 mcg/L, but levels vary
substantially based on dietary intake and environmental levels.

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Environmental. Detection of hydrofluoric acid in environmental samples, as determined by
NIOSH.

p. Long-Acting Anticoagulant (Super Warfarin)

Clinical Description

After acute unintentional ingestion of a long-acting anticoagulant, the majority of patients are
entirely asymptomatic. After substantial ingestion of a long-acting anticoagulant, clinical
signs of coagulopathy typically occur within 24-72 hours after postexposure. Coagulopathy
might manifest as epistaxis, gingival bleeding, hematemesis, hematuria, hematochezia,
menometrorrhagia, ecchymosis, petechial hemorrhages, intracranial hemorrhages, or bleeding
that is not in proportion with the level of the injury.

Laboratory Criteria for Diagnosis

Biologic. The criteria for diagnosis of a long-acting anticoagulant is the presence of one of
the following factors:

 Prolonged prothrombin time (PT) and international normalized ratio (INR) 24--72
hours after exposure, persisting for weeks to months, as determined by hospital
laboratory tests.

 Abnormal assays for factors II and VII in patients with unexplained bleeding and a
normal PT, partial thromboplastin time, or INR, as determined by hospital or
commercial laboratory tests.

 Detection of a long-acting anticoagulant (e.g., brodifacoum) in serum, plasma, or

urine, as determined by commercial laboratory tests. Or,

Environmental. Detection of a long-acting anticoagulant in environmental samples, as

determined by FDA.

q. Mercury (Elemental)

Clinical Description

Inhalation exposure is the most typical route of elemental mercury toxicity. Acute toxicity
might result in fever, fatigue, and clinical signs of pneumonitis. Chronic exposure results in
neurologic, dermatologic, and renal manifestations. Signs and symptoms might include
neuropsychiatric disturbances (e.g., memory loss, irritability, or depression), tremor,

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paresthesias, gingivostomatitis, flushing, discoloration and desquamation of the hands and
feet, and hypertension.

Laboratory Criteria for Diagnosis

Biologic. A case in which elevated urinary or whole blood mercury levels (>10 µg/L) (20,58)
exist, as determined by a commercial laboratory. No definitive correlation exists between
either blood or urine mercury levels and mercury toxicity. Or,

Environmental. Detection of mercury in environmental samples, as determined by NIOSH

or FDA.

r. Mercury (Inorganic)

Clinical Description

Ingestion is the most typical route of exposure to cause toxicity from inorganic mercury.
Signs and symptoms might include profuse vomiting and diarrhea that is often bloody,
followed by hypovolemic shock, oliguric renal failure, and possibly death. Survivors of acute
poisoning or persons chronically exposed to inorganic mercury might develop neurologic,
dermatologic, and renal manifestations that might include neuropsychiatric disturbances (e.g.,
memory loss, irritability, or depression), tremor, paresthesias, gingivostomatitis, flushing,
discoloration and desquamation of the hands and feet, and hypertension.

Laboratory Criteria for Diagnosis

Biologic. A case in which elevated urinary or whole blood mercury levels (>10 µg/L) (20,58)
exist, as determined by a commercial laboratory. No definitive correlation exists between
either blood or urine mercury levels and mercury toxicity. Or,

Environmental. Detection of mercury in environmental samples, as determined by NIOSH

or FDA.

s. Mercury (Organic)

Clinical Description

Although ingestion of organic mercury is the most typical route of organic mercury toxicity,
toxicity might also result from inhalation and dermal exposures, particularly with
dimethylmercury. Symptoms of toxicity are typically delayed for >1 month after organic
mercury exposure and usually involve the central nervous system. These symptoms might

92
include paresthesias, headaches, ataxia, dysarthria, visual field constriction, blindness, and
hearing impairment.

Laboratory Criteria for Diagnosis

Biologic. A case in which whole blood mercury levels (>10 µg/L) are detected, as determined
by a commercial laboratory. Urine mercury levels are not useful in evaluating organic
mercury poisoning. Or,

Environmental. Detection of mercury in environmental samples, as determined by NIOSH

or FDA.

t. Methyl Bromide

Clinical Description

Methyl bromide poisoning primarily occurs after inhalational exposure, but concurrent
dermal exposure might also occur. Methyl bromide is an ocular, dermal, and mucous
membrane irritant. The onset of symptoms might be delayed 1-48 hours. Symptoms of
inhalational exposure are typically cough and dyspnea, which can develop into pneumonitis
and pulmonary edema but might be delayed up to 4-5 days. Severe poisoning can result in
seizures, coma, and death.

Laboratory Criteria for Diagnosis

Biologic. No specific test for methyl bromide is available; however, detection of elevated
bromide levels in serum (reference level: 50--100 mg/L) might indicate that an exposure has
occurred. Detection of bromide below toxic levels does not rule out methyl bromide
poisoning. Or,

Environmental. Detection of methyl bromide in environmental samples, as determined by

NIOSH.

u. Methyl Isocyanate

Clinical Description

Exposure to methyl isocyanate typically occurs through inhalation or dermal absorption.

Toxicity might develop over 1--4 hours after exposure. Signs and symptoms of methyl
isocyanate typically include cough, dyspnea, chest pain, lacrimation, eyelid edema, and
unconsciousness. These effects might progress over the next 24--72 hours to include acute
lung injury, cardiac arrest, and death.
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Laboratory Criteria for Diagnosis

Biologic. No biologic marker for methyl isocyanate exposure is available.

Environmental. Detection of methyl isocyanate in environmental samples, as determined by

NIOSH.

v. Nerve Agents or Organophosphates

Clinical Description

Nerve agent or organophosphate toxicity might result from multiple routes of exposure and is
a cholinergic syndrome consisting of excess respiratory and oral secretions, diarrhea and
vomiting, diaphoresis, convulsions, altered mental status, miosis, bradycardia, and
generalized weakness that can progress to paralysis and respiratory arrest.

In certain cases, excessive autonomic activity from stimulation of nicotinic receptors will
offset the cholinergic syndrome and will include mydriasis, fasciculations, tachycardia, and
hypertension.

Laboratory Criteria for Diagnosis

Biologic. A case in which nerve agents in urine are detected, as determined by CDC or one of
five LRN laboratories that have this capacity. Decreased plasma or red blood cell
cholinesterase levels based on a specific commercial laboratory reference range might
indicate a nerve agent or organophosphate exposure; however, the normal range levels for
cholinesterase are wide, which makes interprets levels difficult without a baseline
measurement or repeat measurements over time. Or,

Environmental. Detection of organophosphate pesticides in environmental samples, as

determined by FDA. However, a confirmation test for nerve agents in environmental samples
is not available.

w. Nicotine

Clinical Description

After oral ingestion of nicotine, signs and symptoms of nicotine poisoning mimic those for
nerve agent or organophosphate poisoning and typically include excess oral secretions,
bronchorrhea, diaphoresis, vomiting (common, especially among children), diarrhea,
abdominal cramping, confusion, and convulsions. Although tachycardia and hypertension are
common, bradycardia and hypotension might also occur as a result of severe poisoning.
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Laboratory Criteria for Diagnosis

Biologic. A case in which increased nicotine or cotinine (the nicotine metabolite) is detected
in urine, or increased serum nicotine levels occur, as determined by a commercial laboratory
or CDC. Or,

Environmental. Detection of nicotine in environmental samples, as determined by NIOSH

or FDA.

x. Opioids (Fentanyl, Etorphine, or Others)

Clinical Description

Exposure to opioids typically occurs through ingestion but potentially can result from
inhalation, if opioids are aerosolized. Clinical effects of opioid poisoning result from the
central nervous system and respiratory system depression manifesting as lethargy or coma,
decreased respiratory rate, miosis, and possibly apnea.

Laboratory Criteria for Diagnosis

Biologic. A case in which opioids are detected in urine, as determined by hospital or

commercial laboratory tests. Fentanyl derivatives and certain other synthetic opioids (e.g.,
oxycodone) might not be detected by routine toxicologic screens. Or,

Environmental. Detection of opioids in environmental samples, as determined by FDA.

y. Paraquat

Clinical Description

Ingestion of paraquat typically results in gastrointestinal illness, including oropharyngeal

ulcerations, vomiting, and diarrhea, which might contain blood. Patients might have dyspnea
and hemoptysis as a result of pulmonary edema or hemorrhage, which can progress to
fibrosis over days to weeks.

Laboratory Criteria for Diagnosis

Biologic: A case in which paraquat in urine, plasma, or serum is detected, as determined by a

commercial laboratory. Or,

Environmental. Detection of paraquat in environmental samples, as determined by NIOSH

or FDA.

z. Phosgene

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Clinical Description

The majority of exposures to phosgene occur by inhalation. In high concentrations, exposure

might lead to symptoms of ocular, nasal, and throat irritation. Lower respiratory irritation is
the most consistent finding after phosgene exposure. If one of the following lower respiratory
signs and symptoms is reported, the clinical description for phosgene poisoning has been met:
chest tightness or cough, dyspnea, or pulmonary edema, which might be delayed <48 hours
after exposure.

Laboratory Criteria for Diagnosis

Biologic. No biological marker exists for phosgene exposure.

Environmental. Confirmation of phosgene in environmental samples is not available.

aa. Phosphine

Clinical Description

The majority of exposures to phosphine occur by inhalation. Severe poisoning might result in
multiorgan involvement (e.g., convulsions, cardiac dysrhythmias, and shock). If one of the
following lower respiratory signs and symptoms is reported, the clinical description for
phosphine poisoning has been met: chest tightness or cough, dyspnea, or pulmonary edema,
which might have a delayed onset.

Laboratory Criteria for Diagnosis

Biologic. No biological marker for phosphine exposure is available. Finding measurable

amounts of urinary phosphorus and phosphorus-containing compounds is not a reliable
indicator of exposure.

Environmental. Confirmation of phosphine in environmental samples is not available.

bb. Ricin (Ingestion)

Clinical Description

Ingestion of ricin typically leads to profuse vomiting and diarrhea, which might be bloody,
followed by hypovolemic shock and multisystem organ dysfunction. Weakness and
influenza-like symptoms, fever, myalgia, and arthralgia, might also be reported.

Laboratory Criteria for Diagnosis

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Biologic. CDC can assess selected specimens on a provisional basis for urinary ricinine, an
alkaloid in the castor bean plant. Only urinary ricinine testing is available at CDC for clinical
specimens. Or,

Environmental. Detection of ricin in environmental samples, as determined by CDC or

FDA. Ricin can be detected qualitatively by time-resolved fluoroimmunoassay (TRFIA) and
polymerase chain reaction (PCR) in environmental specimens (e.g., filters, swabs, or wipes).

cc. Ricin (Inhalation)

Clinical Description

Inhalation of ricin typically leads to cough and respiratory distress followed by pulmonary
edema, respiratory failure, and multisystem organ dysfunction. Weakness and influenza-like
symptoms of fever, myalgia, and arthralgia might also be reported.

Laboratory Criteria for Diagnosis

Biologic. CDC can assess selected specimens on a provisional basis for urinary ricinine, an
alkaloid in the castor bean plant. Only urinary ricinine testing is available at CDC for clinical
specimens. Or,

Environmental. Detection of ricin in environmental samples, as determined by CDC or

FDA. Ricin can be detected qualitatively by TRFIA and PCR in environmental specimens
(e.g., filters, swabs, or wipes).

dd. Riot-Control Agents

Clinical Description

Cutaneous exposures of riot-control agents might produce dermal burns and rash (96--101).
However, the majority of exposures to riot-control agents occur by inhalation. If a rapid onset
of the following signs and symptoms occurs, the clinical description for exposure to a riot-
control agent has been met: 1) lacrimation and 2) one respiratory effect (i.e., nose or throat
irritation, cough, or suffocation or choking sensation).

Laboratory Criteria for Diagnosis

Biologic: No biologic marker for exposure to riot-control agents is available.

Environmental: No method is available for detecting riot-control agents in environmental

samples.

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 ee. Saxitoxin

Clinical Description

Exposure to saxitoxin might cause numbness of the oral mucosa within 30 minutes after
ingestion. In severe poisoning, signs and symptoms typically progress rapidly, including
paresthesias, a floating sensation, muscle weakness, vertigo, and cranial nerve dysfunction.
Respiratory failure and death might occur from paralysis.

Laboratory Classification for Diagnosis

Biologic. A case in which saxitoxin in urine is detected, as determined by a commercial

laboratory. Or,

Environmental. Detection of saxitoxin in ingested compounds or seafood, as determined by

a commercial laboratory or FDA.

ff. Sodium Azide

Clinical Description

The majority of exposures to sodium azide occur by inhalation. Signs and symptoms of
sodium azide poisoning include lethargy or coma (possibly sudden collapse), dyspnea,
tachypnea, tachycardia, and hypotension. Nausea and vomiting also might occur, especially
after ingestion. Exposure to dust or gas might produce conjunctivitis and nasal and bronchial
irritation. Nonspecific laboratory findings include metabolic and lactic acidosis.

Laboratory Criteria for Diagnosis

Biologic. A case in which sodium azide in serum is detected, as determined by a commercial

laboratory. Or,

Environmental. Detection of sodium azide in environmental samples, as determined by

FDA.

gg. Sodium Monofluoroacetate (Compound 1080)

Clinical Description

Exposure to sodium monoflouroacetate might cause systemic toxicity by different routes of

exposure. Clinical effects usually develop within 30 minutes to 2.5 hours of exposure but
might be delayed as long as 20 hours. The predominant manifestations of sodium
monoflouroacetate poisoning are metabolic, cardiovascular, and neurologic signs and

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symptoms. Effects of acute exposure might include metabolic acidosis, hypotension,
dysrhythmias, seizures, coma, and respiratory depression.

Laboratory Criteria for Diagnosis

Biologic. No biological marker for sodium monoflouroacetate is available. Or,

Environmental. Detection of sodium monoflouroacetate in environmental samples, as

determined by FDA.

hh. Strychnine

Clinical Description

The major identifying clinical features of strychnine poisoning through ingestion are severe,
painful spasms of the neck, back, and limbs and convulsions with an intact sensorium.
Symptoms might progress to coma. Tachycardia and hypertension are also common effects.

Laboratory Criteria for Diagnosis

Biologic. A case in which strychnine in urine or serum is detected, as determined by a

commercial laboratory. Or,

Environmental. Detection of strychnine in environmental samples, as determined by NIOSH

or FDA.

ii. Sulfuryl Fluoride

Clinical Description

Sulfuryl fluoride poisoning usually occurs after inhalational exposure. The predominant
manifestations of sulfuryl fluoride poisoning are respiratory irritation and neurologic
symptoms. Effects of acute exposure usually include lacrimation, nose or throat irritation,
cough, dyspnea, paresthesias, and seizures.

Laboratory Criteria for Diagnosis

Biologic. No specific test for sulfuryl fluoride exposure is available. However, an elevated
fluoride concentration in the serum, hypocalcemia, and hyperkalemia might indicate that an
exposure has occurred. Normal serum fluoride levels are <20 mcg/L but vary substantially
based on dietary intake and environmental levels.

Environmental. Detection of sulfuryl fluoride in environmental samples, as determined by

NIOSH.

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 jj. Tetrodotoxin

Clinical Description

The consumption of toxic amounts of tetrodotoxin results primarily in neurologic and

gastrointestinal signs and symptoms. In severe poisoning, dysrhythmias, hypotension, and
even death might occur. If a rapid onset of one of the following neurologic and
gastrointestinal signs or symptoms occurs, the clinical description for tetrodotoxin poisoning
has been met: 1) oral paresthesias (might progress to include the arms and legs), 2) cranial
nerve dysfunction, 3) weakness (might progress to paralysis), or 4) nausea or vomiting.

Laboratory Classification for Diagnosis

Biologic. No biologic marker for tetrodotoxin exposure is available.

Environmental. No method for detection of tetrodotoxin in environmental samples is

available commercially.

kk. Thallium

Clinical Description

Ingestion of toxic amounts of thallium might cause gastrointestinal signs and symptoms, most
commonly abdominal pain. Subacute symptoms (onset of days to weeks) after a substantial,
acute exposure or a chronic exposure to limited amounts of thallium might include severely
painful ascending neuropathy, ataxia, seizure, alopecia, and neurocognitive deficits.

Laboratory Criteria for Diagnosis

Biologic. A case in which elevated spot urine thallium levels are detected (reference level:
<0.5 µg/L), as determined by a commercial laboratory.Or,

Environmental. Detection of thallium in environmental samples, as determined by NIOSH

or FDA.

ll. Toxic Alcohols

Clinical Description

Ingestion of toxic alcohols (methanol, ethylene glycol, or other glycols) might result in
symptoms similar to those of ethanol inebriation (vomiting, lethargy, or coma). A high anion
gap metabolic acidosis is common. Renal failure is common after ethylene glycol and

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diethylene glycol toxicity, whereas optic neuritis and visual impairment are unique to
methanol toxicity.

Laboratory Criteria for Diagnosis

Biologic. A case in which glycols or methanol in whole blood is detected, as determined by

hospital or commercial laboratory tests.Or,

Environmental. Detection of glycols or methanol in environmental samples, as determined

by NIOSH or FDA.

mm. Trichothecene Mycotoxins

Clinical Description

Trichothecene mycotoxins might be weaponized and dispersed through the air or mixed in
food or beverages. Initially, route-specific effects are typically prominent. Dermal exposure
leads to burning pain, redness, and blisters, and oral exposure leads to vomiting and diarrhea.
Ocular exposure might result in blurred vision, and inhalational exposure might cause nasal
irritation and cough. Systemic symptoms can develop with all routes of exposure and might
include weakness, ataxia, hypotension, coagulopathy, and death.

Laboratory Criteria for Diagnosis

Biologic. Selected commercial laboratories are offering immunoassays to identify

trichothecenes or trichothecene-specific antibodies in human blood or urine. However, these
procedures have not been analytically validated and are not recommended.

Environmental. Detection of trichothecene mycotoxins in environmental samples, as

determined by FDA.

As a result of indoor air-quality investigations involving mold and potentially mold-related

health effects, mycotoxin analyses of bulk environmental samples are now commercially
available through environmental microbiology laboratories in the United States. Studies have
not been done to determine the background level of trichothecenes in non moldy homes and
office buildings or nonagricultural outdoor environments. Therefore, the simple detection of
trichothecenes in environmental samples does not invariably indicate intentional
contamination.

nn. Vesicant (Mustards, Dimethyl Sulfate, and Lewisite)

Clinical Description
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The most common clinical effects after exposure to vesicants include dermal (skin erythema
and blistering), respiratory (cough, dyspnea, pneumonitis, and acute lung injury), ocular
(conjunctivitis and burns), and gastrointestinal (vomiting) signs and symptoms. The effects of
the majority of vesicants manifest rapidly (within minutes). However, clinical findings might
be delayed for hours after exposure (e.g., sulfur mustard).

Laboratory Criteria for Diagnosis

Biologic. A case in which sulfur mustard in biologic samples is detected, as determined by

CDC or one of five LRN laboratories that have this capacity, and a case in which nitrogen
mustard and lewisite are detected in biologic samples, as determined by CDC.

Environmental. Confirmation of the detection of vesicants in environmental samples is not

available.

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