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Original Article

From investigation of hospital protocols

and guidelines to designing a generic
protocol for responding to chemical,
biological, radiological, and nuclear
incidents
Elham Anbari, Mohammad Hossein Yarmohammadian1, Mehdi Nasr Isfahani2
Department of Health management, School of Health Management and Information Sciences, Isfahan University of Medical
Sciences, Isfahan, Iran, 1Health Management and Economics Research Center, Isfahan University of Medical Sciences,
Isfahan, Iran, 2Department of Emergency Medicine, Isfahan University of Medical Science, Isfahan, Iran

Abstract
Introduction: The awareness of using chemical, biological, and nuclear agents in everyday industrial and nonindustrial incidents has increased
recently; release of these materials can be accidental or intentional. Since hospitals are the forefronts of confronting chemical, biological, radiological,
and nuclear (CBRN) incidents, the goal of the present research was to provide a generic protocol for CBRN incidents through a comparative
review of CBRN protocols and guidelines of different countries and reviewing various books, handbooks, and papers. Methods: The integrative
approach or research synthesis was adopted in this study. First a simple narrative review of programs, books, handbooks, and papers about
response to CBRN incidents in different countries was carried out. Then the most important and functional information was discussed in the form
of a generic protocol in focus group sessions and subsequently confirmed. Results:   Findings indicated that most of the countries had various
protocols, guidelines, and handbooks for hazardous materials or CBRN incidents. The final outcome of the research synthesis was a 50 page
generic protocol whose main topics included introduction, definition and classification of CBRN agents, four major phases of incident and disaster
management cycle, hospital response management plan, equipment, and recommended supplies and antidotes for decontamination (radiological/
nuclear, chemical, biological); each of these also had subtopics. Conclusion: In the majority of international protocols, guidelines, handbooks
and also international and Iranian books and papers, there is an emphasis on the importance of incident command system, determining the
safety degree of decontamination zones, maps of decontamination zones, decontamination process, triage classifications, personal protective
equipment, and supplies and antidotes for decontamination; these are the least requirements for such incidents and also consistent with the
provided generic protocol.
Key words: Biological incidents, chemical incidents, decontamination, generic protocol, hospital protocols, nuclear incidents, radiological incidents

Address for correspondence: Introduction

Ms. Elham Anbari,
Department of Health Management, School of Health Management and The awareness of using chemical, biological, and nuclear
Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran. agents in everyday industrial and nonindustrial incidents
E‑mail: elham12_a@yahoo.com
has increased recently.[1] These agents are toxic materials
which may do harm to people and living organisms. Release
Access this article online of these materials may be due to accidental or intentional
Quick Response Code: incidents.[2] These are incidents of generally low possibility,
Website:
www.ijhsdm.org
but may have significant impacts on citizens and the society.
Whenever and wherever these incidents happen, they
require a multidimensional and stepwise (regional, national,
DOI: and international) approach because these incidents will
10.4103/2347-9019.162553 bring about severe unexpected physical, mental, social,
economic, and political impacts which can easily go beyond
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Anbari, et al.: From investigation of hospital protocols and guidelines
national borders.[3] Each day, huge amounts of hazardous
chemical materials are produced, transferred, stored
and used for home and industrial purposes. Moreover,
formula and instructions for producing many of chemical
materials which may have military or terrorist applications
are available to public on the internet and social networks
without safety supervisions. The worst industrial disaster of
the world is the Bhopal incident happened in December 3,
1984 with 150,000 injured and 2500 dead.[4] Sarin attack in
Japan in 1994 is among chemical terrorist incidents which
injured 5000 and killed 11 people; more than 300 of injured
people were responsive emergency staff (police, firefighters,
doctors, and ambulance services).[5] Nuclear energy and
radioactive materials also have numerous applications in
medicine, industry, agriculture, energy supply, and scientific
research. With the extended use of this technology in various
fields, the possibility of incidents resulting in exposure of
environment and human communities to impermissible
radiations is inevitable. Therefore, despite the observance
of safety measures and compliance with international
standards, numerous cases of nuclear incidents cause severe
human exposure each year along with many unreported
cases which also must be taken into account. Other scenarios
such as terrorist attacks with radioactive materials, suitcase
nuke, the possibility of being used in international conflicts,
and accidental or intentional incidents in nuclear power
plants must be added to the list.[6] Among the unintentional
incidents is the earthquake and tsunami in March 11, 2011 in
Japan which led to release of radioactive materials from
Fukushima Daiichi nuclear power plant to its surrounding.[7]
Casualties were reported to be over 14,000.[8]
Chernobyl disaster is another instance of unintentional
incidents in which, because of dispersion of radioactive
materials from nuclear fuel rod (despite the small scale of
the incident), expected health risks were quite noticeable.
Among intentional nuclear incidents is the US atomic attack
to Japan which dropped the first atomic bomb on Hiroshima
in August 6, 1945; more than 60,000 people were killed and
120,000 people injured at the very time of bombing. Three
days later, a larger atomic attack on Nagasaki claimed the
lives of 74,000 people with the same number of injuries.[9] A
biological incident, either intentional or accidental explicit
or implicit, also can be described as a biological agent such
as the probability of a pandemic flu or terrorist groups’
threats to use biological weapons against civilians. [10]
Among the intentional biological incidents, the most
recent one goes back to late 2001 after September 11 attacks
where anthrax spores were dispersed through US Mail and
contaminated several people.[11] The issue of bioterrorism
is so important and serious that in 2002, World Health
Assembly called for proper policies in order to provide safe
and out of bioterrorists’ reach food;[12] in its 2007 report,
WHO also underscored the threat of bioterrorism through
intentional food contamination and provided warnings
and guidelines accordingly.[13] Iranian authorities have
also repeatedly emphasized the battle against terrorist
acts of extremist groups, and policies to eliminate terrorist
196
groups across the world.[14] Therefore, since release of
CBRN agents may occur anywhere and anytime, hospitals
need to be prepared to respond to chemical, biological,
and nuclear incidents because when a crisis or emergency
occurs in society, most people will go to hospital because
it gives them a sense of safety and they presume that it has
necessary antidotes, medications, or therapies.[15] Moreover,
since the biggest challenge for healthcare services would be
the sudden rush of contaminated people, protection and
decontamination against chemical, biological, radiological,
and nuclear (CBRN) agents which are potentially very
harmful will be of critical importance.[16] For example,
secondary contamination might shut down emergency
centers which could endanger the staff and cause the loss
of a social capital. In an incident occurred in a healthcare
center in Australia, a patient was not decontaminated
before treatment in emergency ward; therefore, the
ward was quarantined for 20 h.[1] Since hospitals are the
forefronts of confronting CBRN incidents and given the
importance of decontamination and prevention of secondary
contamination, hospitals must have a comprehensive plan
to confront CBRN incidents. The goal of the present research
is to provide a generic protocol for CBRN incidents through
a comparative review of CBRN protocols and guidelines of
different countries and also reviewing various Iranian and
international books, handbooks and papers.
Methods
The integrative approach or research synthesis was adopted
in this study.   First a simple narrative review, both library
and online, of programs, books, handbooks, and papers
about response to CBRN incidents in Iran and other
countries was carried out.  Then the most important and
functional information was put together in the form of a
generic protocol. This protocol was discussed by experts
and specialists in the field and subsequently confirmed in
order to be used for healthcare staff at the time of incidents.
Results
Review of international protocols, guidelines, and papers
revealed that since the late 19th century, most countries have
developed protocols, national guidelines, handbooks, and
papers about preparedness and response of hospitals and
especially emergency ward to CBRN incidents, incidents
containing hazardous materials, and weapons of mass
destruction and terrorism‑related incidents.
Medical response, personal protective equipment,
decontamination of contaminated patients, and even
secondary contamination of emergency staff and
psychological recommendations were topics covered in
the reviewed guidelines and papers. In Iran, however,
except for books written on preparedness in incidents and
disasters and preparedness and response to radiological
incidents, no protocol or guidelines existed for hospital
preparedness, and response to CBRN incidents. On the
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Anbari, et al.: From investigation of hospital protocols and guidelines

other hand, papers on radiological/nuclear incidents
focused more on awareness and attitudes of medical and
nursing personnel toward about the subject. However,
several papers were written on topics such as necessities
of establishing nuclear emergency centers, providing a
model for emergency wards’ preparedness and response
to nuclear incidents, external nuclear decontamination, and
health‑related impacts of nuclear explosion. In addition,
there were numerous Iranian review and research papers on
bioterrorism. Other papers focused on crisis management
and hospital preparedness for disasters.
The final outcome of the research synthesis was a 50 page
generic protocol whose main topics included introduction,
definition and classification of CBRN agents, four major
phases of incident and disaster management cycle, hospital
response management plan, equipment, and recommended
supplies and antidotes for decontamination (radiological/
nuclear, chemical, biological); each of these also had
subtopics. Personal protective equipment (A, B, C, and
D) discussed in the plans and papers had the same basis
so that weakness of one piece of equipment would be
covered by the strength of the other and each level was
explained more systematically and comprehensively.
Moreover, the same held true for incident command
chart, which also was expressed more systematically and
comprehensively especially in terms of CBRN incidents.
Activation process of hospital incident management
plan, notions of contamination and decontamination,
A to D levels of personal protective equipment, and
necessary equipment, supplies, antidote and medications
for CBRN decontamination were stated systematically
and comprehensively in this protocol. Despite some of
the reviewed protocols and guidelines, however, the
activation process of hospital response management and
early warning system were explained exhaustively in the
present protocol. The figures 1-4 depicts a schematic view
of the protocol.
Discussion
According to the present research, most countries have
various protocols, guidelines, and handbooks for hazardous
materials or CBRN incidents as well as handbooks and
articles on hospital preparedness for intentional incidents
such as terrorism. In the majority of international protocols,

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Figure 1: CBRN generic protocol

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Personal protective equipment
Decontamination supplies
Medical equipment
Washing devices
Patient privacy
Miscellaneous supplies
Patient identification and belongings
Necessary antidotes
Figure 2: Equipment, supplies and antidotes for chemical decontamination
Personal protective equipment
Decontamination supplies
Medical equipment
Washing devices
Patient privacy
Miscellaneous supplies
Patient identification and belongings
Necessary antidotes
Figure 3: Equipment, supplies and antidotes for biological decontamination
Staff personal protective equipment
Radiation detection and measurement devices
Decontamination supplies
Medical equipment
Washing devices
Patient privacy
Miscellaneous supplies
Patient identification and belongings
Necessary antidotes
Figure 4: Equipment, supplies and antidotes for radiological/nuclear
decontamination
guidelines, handbooks and also international and Iranian
books and papers, there is an emphasis on the importance
198
Anbari, et al.: From investigation of hospital protocols and guidelines
Equipment, supplies and antidotes
for chemical decontamination
Equipment, supplies and antidotes
for biological decontamination
Equipment, supplies and antidotes
for radiological/nuclear
decontamination
International Journal of Health System and Disaster Management | Vol. 3 | Issue 4 | Oct‑Dec 2015
of incident command system, determining the safety degree
of decontamination zones, maps of decontamination zones,
decontamination process, triage classifications, personal
protective equipment, and supplies and antidotes for
decontamination; these are the least requirements for such
incidents and also consistent with the provided generic
protocol.[1,2,4,11,17‑30]
Conclusion
Therefore, given the fact that most countries have several
protocols, national guidelines, and handbooks for
responding to intentional and unintentional CBRN incidents
and that such incidents are unexpected  and daunting for
people, it is necessary that Iranian health centers especially
hospitals have protocols and guidelines for confronting
industrial and nonindustrial CBRN incidents.
Suggestions
Finally, it is suggested that more research be carried out on
hospital management and medical response to industrial
and nonindustrial chemical incidents.
Acknowledgments
This paper is part of the Master’s thesis entitled “The survey of
Generic response management to CBRN incidents in teaching
hospitals affiliated with Isfahan University of Medical Sciences” in
(2013-2014) with the registration code 393328 supported by Isfahan
University of Medical Sciences.
References
1. Tan GA, Fitzgerald MC. Chemical‑biological‑radiological (CBR) response: A
template for hospital emergency departments. Med J Aust 2002;177:196‑9.
[Last accessed on 2014 Oct 14].
2. Flett  P. Operational Directive: Protection Against Chemical, Biological,
Radiological and Nuclear  (CBRN) Agents; 2008. Available from: http://
www.health.wa.gov.au/circularsnew/pdfs/12367.pdf. [Last accessed on
2014 Oct 12].
3. Richardt A, Hulseweh B, Niemeyer B, Sabath F. CBRN Protection: Managing
the Threat of Chemical, Biological, Radioactive and Nuclear Weapons.
Singapore: Markono Print Media Pte Ltd., Wiley‑VCH Verlag GmbH and Co.
KGaA; 2013.
4. Chan  JT, Yeung  RS, Tang  SY. Hospital preparedness for chemical and
biological incidents in Hong Kong. Hong Kong Med J 2002;8:440‑6.
5. Australia EM. Health Aspects of Chemical, Biological and Radiological (CBR)
Hazards. Australia: Emergency Management Australia; 2000.
6. Tavakoli  H, Modarresi  SM. Requirements of design and foundation of
emergencies based on treatment protocols of nuclear injured. J Mil Med
2009;11:19‑20.
7. World Health Organization. Health Risk Assessment from the Nuclear
Accident After the 2011 Great East Japan Earthquake and Tsunami, Based
on a Preliminary Dose Estimation. Geneva: World Health Organization;
2013. p. 172.
8. Delshad H, Azizi F. Health risk of nuclear‑power‑plant accidents on thyroid
gland and human health. Int J Endocrinol Metab 2013;14:586‑96.
9. Badrian R. Crisis management in nuclear incidents. Isfahan: Isfahan
University of Medical Science; 2012. p. 463 [In Persian].
10. Brown N, Crawford I, Carley S, Mackway‑Jones K. A Delphi‑based consensus
study into planning for biological incidents. J  Public Health  (Oxf )
2006;28:238‑41.
[Downloaded free from http://www.ijhsdm.org on Saturday, March 4, 2023, IP: 186.96.29.100]
Anbari, et al.: From investigation of hospital protocols and guidelines
11. Monfared MN, Atashzadeshorideh F, Anboohi SZ. Management of victims
of chemical chemical, nuclear and biological incidents: Including acute
care duration 72 h after the crisis. Tehran: Light of Knowledge; 2006.
12 World Health organization. Terrorist Threats to Food - Guidelines for
Establishing and and Strengthening Prevention and Response Systems,
Department of Food Safety, Zoonoses and Foodborne Disease. Geneva:
2008. Available from: http://seafood.oregonstate.edu/.pdf%20Links/
WHO%20Food%20Safety%20Issues%20-%20Terrorist%20Threats%20
to%20Food.pdf [Last accessed on 2014 Oct 15].
13 World Health Organization. The world health report 2007 - A safer future:
global public health security in the 21st century. Geneva: 2007. Available
from: http://apps.who.int/iris/bitstream/10665/42619/1/9241545844.pdf
[Last accessed on 2014 Oct 15].
14. Rohani H. Conference on World Against Voilence and Extremism, Tehran;
9‑10 December, 2014.
15. Fallon LF, Zgodzinski EJ. Essentials of public health management. Canada:
Jones and Bartlett Learning; 2005.
16. Macintyre AG, Christopher GW, Eitzen E Jr, Gum R, Weir S, DeAtley C, et al.
Weapons of mass destruction events with contaminated casualties:
Effective planning for health care facilities. JAMA 2000;283:242‑9.
17. Would C. Major Incident Plan. England: Peninsula Community Health; 2013.
18. U.S.Departmet of Human Services, Public Health Service , Agency for Toxic
Substance and Disease Registry. Vol. II. Managing Hazardous Materials
Incidents; 1992. Available from: http://wonder.cdc.gov/wonder/prevguid/
p0000019/p0000019.asp [Last accessed on 2014 Aug 16].
19. Par t of the Common wealth Attorney-General’s Depar tment.
Australain emergency management handbook series: Disaster Health,
Handbook 1. 1 st ed. Australia: Australian Emergency Management
Institute; 2011. Available from: https://www.em.gov.au/Publications/
Australianemergencymanualseries/Documents/Australian%20
Emergency%20Handbook%20-%20Disaster%20Health%20-%20
Handbook%201.DOC. [Last accessed on 2014 Jul 18].
20. Lake  WA, Fedele  PD, Marshall  SM. Guidelines for Mass Casualty
Decontamination during a Terrorist Chemical Agent Incident. DTIC
Document; 2001.
21. EU Comission, DG Health and Consumer Protection, Health Treats unit.
Biological incident response and Environment sampling: A European
Guidline on Principles of field investigation 2006. Available from: http://
ec.europa.eu/health/ph_threats/com/preparedness/docs/biological.pdf.
[Last accessed on 2014 Nov 17].
22. Branch  EM. Decontamination guidance for hospitals. Melbourne:
Government of Victoria, Department of Human Services, Emergency
Management Branch; 2007.
International Journal of Health System and Disaster Management | Vol. 3 | Issue 4 | Oct‑Dec 2015
23. Cross  AR, Brigade  AF, Police  AF, Brigade  NF. The CBRN Psychosocial
Response Guidelines and the CBRN SAFE Incident Pocket Guide are an
emergency services collaboration supported by the National Security,
Science and Technology Unit of the Office of Prime Minister and
Cabinet  (NSST Project 06‑062). CBRN Psychosocial Guidelines Project
Partners; 2008.
24. Smith JM, Spano MA, National Center for Environmental Health, Division of
Environmental Hazardsand Health Effects. Interim guidelines for hospital
response to mass casualties from a radiological incident. Radiation
emergencies. U.S.A: Centers for Disease Control and Prevention; 2003.
http://www.bt.cdc.gov/radiation/pdf/masscasualtiesguidelines.pdf. [Last
accessed on 2014 Nov 13].
25. Hospital and Healthcare System Disaster Interest Group and California
Emergency Medical Services Authority. Patient decontamination
recondaminations for hospitals; 2005. Available from: http://www.emsa.
ca.gov/Media/Default/PDF/emsa233.pdf. [Lats accessed on 2014 Dec 19].
26. Hasani SA, Marzie F. Disaster preparedness and response to radiation
treatment centers. Tehran: Simin; 2009. [In Persian].
27. Kaszeta D. CBRN and Hazmat Incidents at Major Public Events: Planning
and Response. USA: Hoboken, N.J.: J. Wiley and Sons; 2013. Available from:
http://ezproxy.torontopubliclibrary.ca/login?url=http://proquestcombo.
safaribooksonline.com/?uiCode=torontopl&xmlId=9781118288191. [Last
accessed on 2014 Dec 10].
28. Canestra J, Solomon S, McLaren A, Pengilley A, Byrne J, Canestra J. Australian
Clinical Guidelines for Radiological Emergencies, September 2012. Australia:
Common wealth of Australia; 2012. Available from: http://www.health.gov.
au/internet/publications/publishing.nsf/Content/CA2578620005D57ACA2
57ACD000965A8/$File/Aust-Rad-Guidelines-Sept2012.pdf. [Last accessed
on 2014 Dec 11].
29. Golfam F. Step by step training: Radiological accidents countermeasures 2.
Tehran: Atomic Energy Organization of Iran; 2011.
30. Khanke H. Hospital preparedness in Emergencies and Disaster: Country
plan. Tehran: University of Social Welfare and Rehabilitation Sciences; 2012.
[In Persian].
How to cite this article: Anbari E, Yarmohammadian MH,
Isfahani MN. From investigation of hospital protocols and guidelines
to designing a generic protocol for responding to chemical, biological,
radiological, and nuclear incidents. Int J Health Syst Disaster Manage
2015;3:195-9.
Source of Support: Nil, Conflict of Interest: None declared.
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