[Federal Register Volume 60, Number 123 (Tuesday, June 27, 1995)]
[Notices]
[Pages 33308-33312]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-15657]




[[Page 33307]]

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Part IV





Department of Health and Human Services





_______________________________________________________________________



Centers for Disease Control and Prevention



_______________________________________________________________________



CDC Recommendations for Civilian Communities Near Chemical Weapons 
Depots: Guidelines for Medical Preparedness; Notice

  Federal Register / Vol. 60, No. 123 / Tuesday, June 27, 1995 / 
Notices   
[[Page 33308]] 

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention


CDC Recommendations for Civilian Communities Near Chemical 
Weapons Depots: Guidelines for Medical Preparedness

AGENCY: Centers for Disease Control and Prevention (CDC), Public Health 
Service, HHS.

ACTION: Publication of final recommendations.

-----------------------------------------------------------------------

SUMMARY: On July 27, 1994, CDC published in the Federal Register, 59 FR 
38191, ``CDC Recommendations for Civilian Communities Near Chemical 
Weapons Depots: Guidelines for Medical Preparedness'' and requested 
public comment. Seven people sent comments; many were responding on 
behalf of governments or other institutions in affected communities. 
These comments are available upon request. These recommendations 
incorporate changes made in response to the comments received and 
constitutes CDC's final recommendations for minimum standards for 
prehospital and hospital emergency medical services' readiness in 
communities near the eight locations where the U.S. stockpile of lethal 
chemical weapons is stored. The eight locations are: Umatilla Army 
Depot Activity, Oregon; Tooele Army Depot, Utah; Pueblo Army Depot 
Activity, Colorado; Pine Bluff Arsenal, Arkansas; Newport Army 
Ammunition Plant, Indiana; Anniston Army Depot, Alabama; Lexington 
Bluegrass Depot Activity, Kentucky; and Edgewood Area, Aberdeen Proving 
Ground, Maryland.
    These recommendations were prepared to assist emergency planners in 
determining emergency medical services' readiness in communities near 
the 8 locations where the U.S. stockpile of lethal chemical weapons is 
stored. These guidelines should not be used for any purpose other than 
planning for the Chemical Stockpile Emergency Preparedness Program.

FOR FURTHER INFORMATION CONTACT: Linda W. Anderson, Chief, Special 
Programs Group, National Center for Environmental Health (NCEH), CDC, 
4770 Buford Highway, NE., Mailstop F29, Atlanta, GA 30341-3724, 
telephone number (404) 488-7071, Facsimile Number (404) 488-4127, or 
Internet Address [email protected].

SUPPLEMENTARY INFORMATION:

CDC Recommendations for Civilian Communities Near Chemical Weapons 
Depots: Guidelines for Medical Preparedness

I. Executive Summary

    In 1985, Congress mandated that unitary chemical warfare agents be 
destroyed in such a manner as to provide maximum protection for the 
environment, the public, and personnel involved in destroying the 
agents. The Centers for Disease Control and Prevention (CDC) was 
delegated review and oversight responsibility for any Department of the 
Army (DA) plans to dispose of or transport chemical weapons (Public Law 
91-121 and 91-441, Armed Forces Appropriation Authorization of 1970 and 
1971).
    As part of its ongoing efforts to improve medical preparedness 
within the medical sector of civilian communities surrounding chemical 
agent depots, CDC has developed the following medical preparedness and 
response guidelines. These guidelines represent minimum standards of 
medical preparedness for civilian communities that might be exposed to 
chemical warfare agents during the incineration or storage process. 
These guidelines were developed in cooperation with a panel of 
recognized experts in the fields of emergency medicine, disaster 
preparedness, nursing, chemical warfare preparedness, and the 
prehospital emergency medical system.

II. Background

    In 1985, Congress mandated that unitary chemical warfare agents be 
destroyed in such a manner as to provide maximum protection for the 
environment, the public, and the personnel involved in destroying the 
agents. This mandate was further defined in the Department of Defense 
(DOD) Authorization Act of 1986, Pub. L. 99-145. Consistent with its 
desire to promote the most environmentally safe method of destroying 
chemical agents, the National Research Council determined that 
incineration is the best method for disposing of the weapons (1). In 
1988, the Authorization Act was amended to permit DA to set up a 
prototype incineration facility on Johnston Island in the Pacific in 
order to verify the safety of such an operation. To date, more than 
700,000 pounds of chemical agent have been safely incinerated there.
    CDC was delegated the responsibility of reviewing and overseeing 
any DA plans to dispose of or transport chemical weapons (Pub. L. 91-
121 and 91-441, Armed Forces Appropriation Authorization of 1970 and 
1971). In addition, an interagency agreement between CDC and DA 
requires CDC to provide technical assistance to the DA in protecting 
the public health in nearby communities during the destruction of 
unitary chemical agents and weapon systems.
    Currently, large quantities of chemical warfare agents are stored 
in eight facilities \1\ in the continental United States. These 
chemical stockpiles consist primarily of nerve agents, mustard agents, 
or a combination of both. In Tooele, Utah, construction of the chemical 
agent incinerator is now complete, and destruction of the weapons and 
chemicals in this depot is scheduled to begin in the Fall of 1995. To 
improve the ability of local health care personnel to handle 
emergencies related to a chemical agent release, CDC has presented 
medical preparedness courses to civilian medical personnel on sites 
adjacent to the 8 chemical weapons depots on 13 occasions. Emergency 
physicians, nurses, internists, surgeons, hospital administrators, and 
prehospital emergency medical responders have attended these courses.

    \1\ Umatilla Army Depot Activity, Oregon; Tooele Army Depot, 
Utah, Pueblo Army Depot Activity, Colorado; Pine Bluff Arsenal, 
Arkansas; Newport Army Ammunition Plant, Indiana; Anniston Army 
Depot, Alabama; Lexington-Bluegrass Depot Activity, Kentucky; and 
Edgewood Area, Aberdeen Proving Ground, Maryland.
    As part of its ongoing efforts to improve medical readiness in 
civilian communities surrounding chemical agent depots, CDC developed 
medical preparedness and response guidelines. These guidelines 
represent minimum standards for medical preparedness in civilian 
communities that might be inadvertently exposed to chemical warfare 
agents during the incineration or storage process. These guidelines 
were developed in cooperation with a working group of recognized 
experts in the fields of emergency medicine, disaster preparedness, 
nursing, chemical stockpile emergency preparedness, and prehospital 
emergency medical systems. These guidelines do not supersede current 
medical or public health practices and requirements (e.g., precautions 
for handling bodily fluids). Local health and emergency management 
officials, working with Army personnel, must analyze the nature of 
possible releases at each location, determine what kinds of 
intoxication and what level of contamination might be possible, and 
match local or regional resources to the potential task. 
[[Page 33309]] 
    The following recommendations for civilian community response to 
the release of a chemical agent are divided into prehospital and 
hospital arenas. The recommendations are designed to ensure medical 
preparedness for chemical agent emergencies. Appendix A is a summary of 
important questions to ask when evaluating medical preparedness in the 
civilian prehospital and hospital environments. The prehospital 
environment encompasses all response areas which are outside both the 
installation boundaries and the hospital grounds. People potentially 
affected in the prehospital environment include the general public and 
first responders. First responders include police, sheriff's, and fire 
department personnel, hazardous materials response teams, and medical 
response teams (including emergency medical technicians, paramedics, 
and any other medically trained personnel responding to the site of 
injury with the ambulance teams). The hospital environment includes 
primarily the emergency department but encompasses outdoor areas on the 
hospital grounds that might be used for triage and decontamination and 
other hospital departments that might support the hospital's response.
    We cannot emphasize too strongly that actions taken within the 
scope of these guidelines must also comply with all other applicable 
regulations. In particular, responders considered in this paper falls 
under the provisions of the Occupational Safety and Health 
Administration's (OSHA) Hazardous Waste Operations and Emergency 
Response (HAZWOPER) regulations (29 CFR 1910.120), the respiratory 
protection regulations (29 CFR 1910.134), and other regulations 
pertaining to personal protective equipment (29 CFR 1910.132, 133, 135, 
and 136).

III. Recommendations for Prehospital Medical Preparedness

     Integrate all local medical emergency response plans 
related to the release of a chemical agent into the all-hazards State 
and local disaster response plans.
     Provide protective equipment for all members of the local 
medical response team.
     Train members of the local medical response team in these 
measures:

--prevention of secondary contamination from chemically exposed 
patients.
--decontamination procedures.
--evaluation of the medical needs of chemically exposed patients.
--treatment of large groups of patients.
--transportation of victims to a medical facility.
1. Personal Protective Equipment (PPE)
    Chemical protective clothing and respiratory protection enable 
responders to care for patients exposed to chemicals while protecting 
themselves from secondary contamination.
     Ensure that such equipment protects the skin, eyes, and 
respiratory tracts of the emergency responders.
     HHS have recommended the use of DA battledress 
overgarments (BDOs) and portable air-purifying respirators (PAPRs) with 
a combined high-efficiency particulate (HEPA) and organic vapor 
cartridge to protect civilians from chemical warfare agents. OSHA is 
reviewing this matter and will make a determination when the review 
process is completed. BDOs can be used for up to 24 hours in an agent-
contaminated environment at levels of up to 10 grams of agent per 
square meter of surface area. This recommendation should not be 
construed as discouraging civilian emergency responders from using more 
protective equipment, such as completely encapsulating suits with 
supplied air respirators, providing that they have and normally use 
such equipment in conformity with applicable regulations and can 
perform their required duties in that equipment.
     Train personnel required to use personal protective 
equipment when responding to chemical agent-related emergencies in 
accordance with the guidelines published by OSHA.
     Establish and use work practice guidelines to ensure that 
responders remain outside areas where their equipment might not be 
fully protective and that they leave immediately if conditions change 
such that there is uncertainty about the safety of the environment.
     Use new cartridges or canisters when entering an area 
where agent may be present and change them before the next use of the 
respirator.
     Use a buddy system and provide adequate communications and 
rescue capability for each responder working near a plume area. If a 
worker should experience symptoms of agent exposure and require 
assistance leaving the area, rescue should be accomplished using level 
A protection only.
2. First Responders
     Ensure that all persons (e.g., medics, paramedics, fire 
fighters, or medical personnel) designated by the State or local 
disaster plans as members of the initial medical team that responds to 
a chemical warfare agent release have the appropriate level of PPE and 
are trained in its proper use (2).
     Ensure that equipment of first responders is adequately 
maintained and available at all times.
     Schedule frequent drills and training sessions designed to 
maintain first responders' familiarity with equipment and their role in 
State and local disaster plans.
3. The Public
    CDC does not recommend distributing PPE (e.g., gas masks or 
protective suits) to the public. In the unlikely event that a chemical 
agent release threatens the civilian population adjacent to a military 
facility, CDC recommends the following graded emergency response:
     Evacuate the population at risk in accordance with State 
or local disaster management guidelines. If no local guidelines exist, 
follow the Federal Emergency Management Agency (FEMA) and DA joint 
guidelines for evacuating civilian populations threatened by chemical 
warfare agents (3).
     Follow FEMA and DA recommendations for sheltering the 
population in place (e.g., keep people in their homes, institutions, or 
places of business and seal windows and doors from an external vapor 
threat) if it is not practical to evacuate the population (3).
4. Decontamination
    Decontamination is the careful and systematic removal of hazardous 
substances from victims, equipment, and the environment. Transporting 
contaminated patients exposes emergency response personnel to chemical 
warfare agents and contaminates rescue vehicles. Proper decontamination 
prevents secondary contamination and chemical injury to medical and 
rescue personnel. Acceptable decontamination guidelines for persons who 
may possibly have been exposed to chemical warfare agents are published 
by FEMA and DA (3,4). Decontamination must comply with the HAZWOPER 
regulation, 29 CFR 1910.120(k).
     Decontamination of patients can be achieved by 
mechanically removing, diluting, absorbing, or neutralizing the 
chemical agent.
     Decontaminate all persons who are believed to be 
contaminated with a chemical warfare agent before they are transported 
to a hospital.
     Decontamination substances should be readily available. 
Suitable decontamination substances include soap, water, and 5% 
hypochlorite.
     To protect the environment, include in State and local 
disaster plans a [[Page 33310]] method for containing and disposing of 
contaminated runoff. CDC does not recommend establishing fixed 
decontamination units in prehospital areas because of the expense and 
inflexibility of such units.
5. Level of Medical Preparedness Training
     At a minimum, train persons designated as prehospital 
medical responders in evaluating patients exposed to chemical warfare 
agents, managing patients' airways (excluding intubation), transporting 
patients, and decontaminating patients.
     Train prehospital responders who have been designated in 
State or local disaster plans to operate in environments contaminated 
by a chemical warfare agent in the proper use of PPE in accordance with 
OSHA guidelines (2).
     Ensure that, at a minimum, physicians who have been 
designated in State and local disaster plans to provide medical 
supervision for prehospital emergency responders and to provide medical 
care for victims of a chemical agent release receive specialized 
training through continuing education in the emergency response areas 
specified for prehospital responders.
6. Patient Triage
    The basic premise of patient triage, to provide maximum benefit to 
the greatest number of victims, is of utmost importance during a mass-
casualty event involving chemical agents.
     Have the responder most experienced in evaluating patients 
conduct the triage.
     Base decisions regarding patient triage on local 
resources, the extent of patient contamination, the type of chemical 
warfare agent to which the patient is exposed, the patient's clinical 
status, and the likelihood of additional traumatic injuries.
7. Public Information
     Provide the Joint Information Center (JIC) with 
appropriate information to inform the public accurately and rapidly 
about chemical agent exposures that have or may have occurred. If 
possible, monitor information coming from the JIC and assist in 
ensuring the accuracy and timeliness of that information.
     Establish, through the local emergency medical services 
(EMS) and hospital community, a coordinated public information policy 
for all chemical emergencies.
     Work with public health and emergency management officials 
to contact local and regional news media in advance and establish an 
accurate and rapid way of disseminating critical information to the 
public concerning a chemical agent emergency.
     Ensure that hospital and EMS personnel coordinate their 
plans to provide public information with the plans of those who have 
overall responsibility for emergency response.
8. Communication
    Medical personnel must have access to the emergency communication 
network 24 hours a day. Such a network should link the chemical agent 
depot, local and regional EMS, and all potential receiving hospitals. 
During any evaluation of preparedness for a chemical warfare release 
into civilian communities:
     Have medical personnel demonstrate the ability to access 
the emergency communications network.
     Ensure that the hospitals' emergency communications system 
allows hospital personnel to verify rapidly whether a chemical warfare 
agent release has occurred.
9. Transporting Exposed Victims
     Coordinate the transportation of chemical agent-exposed 
victims with the overall disaster response plan and include a method 
for tracking transported patients during an emergency response.
     Transport contaminated patients only after they have been 
properly decontaminated.
     Transport decontaminated patients to medical facilities 
(e.g., hospitals, clinics, and urgent care centers).
     Formal agreements such as memorandums of understanding 
(MOUs) between organizations that transport patients and the medical 
facilities that receive them must be part of the planning process. 
Medical facilities designated to receive these patients should be 
capable of evaluating and managing those exposed to chemical agents as 
described later in the hospital section (Section IV) of this document.
     Base decisions regarding urgent and emergency transfers of 
decontaminated patients on the capabilities of the receiving 
facilities, transportation resources, demand for hospital services, and 
the clinical condition of the patients. Certain medical care (e.g., for 
burns, pediatric emergencies, trauma, or pulmonary complications) might 
require prearrangements for patients to be transferred to a tertiary 
treatment center. CDC recommends that transfer and evacuation plans for 
victims exposed to chemical warfare agents call for land--rather than 
air--transportation.
10. Medical Evaluation and Treatment
     Train medical response personnel specifically to assess 
and manage patients exposed to chemical agents stored at the nearby 
military depot.
     Decontaminate all exposed patients as described above.
     Provide medical treatment (during or after contamination), 
according to accepted treatment modalities, to patients exposed to 
nerve or mustard agents. If antidotes to nerve agents are used in the 
field by civilian medical responders as designated in State or local 
disaster plans, CDC recommends using single-dose, pre-armed auto 
injectors, unless a higher level of medical response has already been 
integrated into EMS operations. Additional information on the effects 
of chemical warfare agents and accepted medical protocols for caring 
for patients exposed to mustard or nerve agents is available (5-14).

IV. Recommendations for Hospital Preparedness

1. Primary Receiving Hospitals
    A primary receiving hospital is a hospital that is designated by 
State or local disaster plans to provide initial medical care to the 
civilian population in the event of a chemical warfare agent release. 
Such hospitals must have established protocols detailing evaluation, 
decontamination, and treatment procedures for patients exposed to 
chemical warfare agents. These hospitals should include:
     Evaluation, treatment, and decontamination protocols in 
the hospitals' disaster plans.
     Chemical warfare agent scenarios in disaster drills for 
hospitals that have been designated in State or local disaster plans to 
receive patients exposed to chemical warfare agents.
2. Triage Considerations
     Do not allow patients exposed to a chemical warfare agent 
to enter the emergency department without adequate evaluation and 
decontamination. Signs of mustard agent exposure, in particular, may 
require 24-48 hours before they become clinically evident.
     Train medical staff designated by the hospital disaster 
plan to perform triage during an emergency related to chemical warfare 
agents to recognize the physical signs and symptoms of patients who 
have been exposed to such agents.
     Base modifications to patient triage procedures on the 
extent of patient contamination, the type of chemical warfare agent to 
which the patient has been exposed, the patient's clinical 
[[Page 33311]] status, and the possibility of additional traumatic 
injuries. Priorities for medical treatment of patients should be 
determined by the most appropriately trained and experienced medical 
professional.
3. Security
     Address issues related to emergency department security 
during disasters in the hospital disaster plan.
     Restrict access to the hospital to prevent contaminated 
patients from entering the hospital. During a chemical agent release, 
security personnel should direct all patients to enter the hospital 
only through the triage area.
4. Decontamination
     Decontaminate all persons who may have been contaminated 
with a chemical warfare agent. Proper decontamination prevents 
secondary contamination and chemical injury to medical and rescue 
personnel. Acceptable decontamination guidelines for persons exposed to 
chemical warfare agents are published by FEMA and DA (3,4). 
Decontamination must comply with the HAZWOPER regulation, 29 CFR 
1910.120(k).
     Have decontamination substances readily available. 
Suitable decontamination substances include soap, water, and 5% 
hypochlorite.
     In the hospital disaster plan, detail a method for 
catching contaminated runoff from patients whether decontamination is 
done inside or outside the hospital.
     At a minimum, be capable of decontaminating at least one 
non-ambulatory patient.
     During and after chemical agent releases that cause mass 
casualties, decontaminate patients outdoors. Having indoor 
decontamination facilities does not obviate a hospital's need to have 
plans for decontaminating patients outdoors during mass casualty 
situations. Outdoor facilities must have a means of containing the 
runoff from the decontamination process until it can be tested and 
disposed of safely.
     Design hospital disaster plans, keeping in mind the 
possibility of integrating local emergency response resources. Such 
resources could include hazardous materials emergency response teams or 
portable decontamination vehicles or facilities.
     In cold weather, set up temporary shelters and heaters to 
protect patients from extreme environmental conditions when undergoing 
decontamination outdoors.
     Have in place a method of controlling the flow of air in 
the decontamination area to prevent such air from contaminating other 
areas of the hospital.
     Set up a system to allow medical personnel in the 
decontamination area to be in continuous communication with other 
medical personnel in the emergency department.
5. Personal Protective Equipment (PPE)
    Chemical protective clothing and respiratory protection enable 
responders to care for chemically exposed patients while protecting 
themselves from secondary contamination. This equipment must protect 
the skin, eyes, and respiratory tracts of the responders.
     HHS have recommended the use of DA BDOs and PAPRs with a 
combined high-efficiency particulate (HEPA) and organic vapor cartridge 
to protect civilians from chemical warfare agents. OSHA is reviewing 
this matter and will make a determination when the review process is 
completed. BDOs can be used for up to 24 hours in an agent-contaminated 
environment at levels of up to 10 grams of agent per square meter of 
surface area. This recommendation should not be construed as 
discouraging civilian emergency responders from using more protective 
equipment such as completely encapsulating suits with supplied air 
respirators, providing that they have and normally use such equipment 
in conformity with applicable regulations and can perform their 
required duties in that equipment.
     Hospital personnel should follow Environmental Protection 
Agency (EPA) and National Institute for Occupational Safety and Health 
(NIOSH) guidelines when managing patients exposed to unknown chemicals.
     This recommendation should not be construed as 
discouraging civilian emergency responders from using more protective 
equipment such as completely encapsulating suits with supplied air 
respirators, providing that they have and normally use such equipment 
in conformity with applicable regulations and can perform their 
required duties in that equipment.
     Response personnel should be trained to use PPE when 
responding to a chemical agent emergency according to OSHA guidelines 
(2).
6. Level of Training
     Medical staff designated by the hospital disaster plan 
should be trained to provide direct patient care during a chemical 
warfare agent emergency to a level of medical preparedness that allows 
them to assess, decontaminate, and manage the treatment of victims of 
chemical warfare agent releases.
     Medical staff who are required to wear decontamination 
attire in decontamination procedures must receive training in the use 
of PPE according to OSHA regulations (2-4).
7. Transportation of Patients to other Medical Facilities
     Have prearranged written agreements with those medical 
facilities that agree to accept patients who are exposed to military 
chemical agents.
     Do not transfer patients without notifying the hospital 
and having the patient accepted by a physician.
     Have standardized forms available to record patient 
information and management status.
8. Specific Antidotes
     Have decontaminating solutions available in the emergency 
department. If nerve agents are stored adjacent to the civilian 
community, have atropine in multiple-dose units available in the 
emergency department and in the hospital pharmacy. In addition, have 
the hospital pharmacy stock atropine and pralidoxime in sufficient 
quantities to cope with the anticipated number of patients who could be 
managed by that facility in response to a chemical warfare agent 
release. Atropine and pralidoxime should be administered intravenously 
in the emergency environment.
9. Hospital Disaster Plan
     Include plans for providing medical care for patients 
exposed to chemical agents in the hospital's disaster plan.
     Have in place a method for using the emergency 
communication system so that reports of a chemical warfare agent 
release can be verified rapidly. Also, include provisions to coordinate 
activities with State and local disaster plans for mass 
decontamination.
     Include in disaster drills scenarios in which patients 
have become exposed to chemical warfare agents.
     Use the hospital quality assurance program to review 
disaster drills and decontamination procedures and to assist in 
maintaining the professional skills of hospital personnel necessary to 
treat the effects of exposure to a chemical warfare agent.
10. Tertiary Hospitals
    A tertiary receiving hospital is a hospital that receives referrals 
from primary receiving hospitals. Additional services such as burn 
care, psychiatric service, and toxicologic consultation are available 
at the tertiary level of care.
     Ensure that tertiary hospitals designated by State or 
local disaster plans to provide care for persons exposed to chemical 
warfare agents have, at a minimum, emergency [[Page 33312]] response 
capabilities similar to those of the primary receiving hospital.
     Ensure that tertiary hospitals coordinate their disaster 
plans with State and local disaster plans for mass decontamination of 
persons exposed to chemical warfare agents.

V. References

1. National Research Council. Disposal of chemical munitions and 
agents. Washington, D.C.: National Academy Press, 1984.
2. Occupational Health and Safety Administration. Hazardous waste 
operations emergency response. Washington, D.C.: OSHA Instruction 2-
2.59, 29 CFR 1910.120, paragraph (q), 1993.
3. Federal Emergency Management Agency and the Department of the 
Army. Planning guidance for the chemical stockpile emergency 
preparedness program. Washington, D.C., FEMA, 1992.
4. United States Army Medical Research Institute of Chemical 
Defense. Medical management of chemical casualties. Aberdeen Proving 
Ground, MD: Department of the Army, 1992.
5. Dunn M, Sidell F. Progress in medical defense in nerve agents. 
JAMA 1989;262:649-52.
6. Borak J, Sidell F. Chemical warfare agents: sulfur mustard. Ann 
Emerg Med 1992;21: 303-8.
7. Sidell F, Borak J. Chemical warfare agents: II. nerve agents. Ann 
Emerg Med 1992;21:865-71.
8. Wright P. Injuries due to chemical weapons. Br Med J 1991;302:39.
9. Sidell F. What to do in case of an unthinkable chemical warfare 
attack or accident. Postgrad Med 1990;88:70-84.
10. Moneni A. Skin manifestations of mustard gas: a clinical study 
of 535 patients exposed to mustard gas. Arch Dermatol 1992;128:775-
80.
11. Smith W. Medical defense against blistering chemical warfare 
agents. Arch Dermatol 1991;127:1207-13.
12. Tafuri J. Organophosphate poisoning. Ann Emerg Med 1987;16:193-
202.
13. Merril D. Prolonged toxicity of organophosphate poisoning. Crit 
Care Med 1982;10: 550-1.
14. Merrit N. Malathion overdose: when one patient creates a 
departmental hazard. J Emerg Nursing 1989;15:463-5.

    Dated: June 20, 1995.
Joseph R. Carter,
Acting Associate Director for Management and Operations, Centers for 
Disease Control and Prevention (CDC).
Appendix A

Summary of Important Medical Preparedness Considerations for 
Communities Surrounding Chemical Agent Stockpiles

    1. Do the communities that surround chemical warfare agent 
depots have a disaster plan that details the role of the prehospital 
and hospital medical community during a chemical warfare agent 
emergency?
    2. If medical personnel are designated to treat chemical warfare 
agent casualties, do they have adequate training to meet minimal 
standards for evaluating, decontaminating, and treating victims of a 
chemical warfare agent release?
    3. Do medical personnel who are designated by State, local, and 
hospital disaster plans to use PPE in response to an emergency 
related to chemical warfare agents have the necessary OSHA level of 
training to use these devices effectively and safely?
    4. If the local disaster plan has provisions to evacuate or 
transfer patients to other hospitals for further treatment and 
evaluation, do existing MOUs cover the transfer of chemically 
contaminated patients?
    5. Do hospitals named in the State or local disaster plans have 
an adequate stockpile of antidotes and decontamination solutions to 
provide complete medical treatment to at least one chemically 
contaminated patient?
    6. Are the hospitals that are designated in the State or local 
disaster plans able to decontaminate at least one non-ambulatory 
patient exposed to chemical warfare agent?
    7. Do the disaster plans of hospitals designated to receive 
patients by State and local disaster plans have specific provisions 
that detail how they will control access to their medical facilities 
during a chemical warfare agent emergency?
    8. Are all levels of the medical community that are designated 
by State or local disaster plans to respond to a chemical warfare 
agent emergency able to communicate via either the State or local 
disaster communication network?

Appendix B

Working Group Participants

Mr. Lawrence Gallagher, Associate Director, Plant Technology and 
Management, Joint Committee on Accreditation of Health Care 
Organizations, Oakbrook, Illinois.
Mr. Kenneth Gray, Fire Chief, Confederate Tribes of the Umatilla 
Indian Reservation, Pendleton, Oregon
Mr. Howard Kirkwood, Jr., Chief, Emergency Response Services, Oregon 
Department of Human Resources, Portland, Oregon
Mr. Denzel Fisher, Emergency Preparedness Officer, Office of the 
Assistant Secretary of the Army, (Installations, Logistics, and 
Environment), Washington, D.C.
John A. Grant, M.D., M.P.H., Health Officer, Kent County Health 
Department, Chestertown, Maryland
Deborah Kim, M.S.N., R.N., Trauma Coordinator, University of Utah 
Medical Center, Salt Lake City, Utah
Ms. Laurel Lacy, Acting Chief, Chemical Stockpile Branch, Federal 
Emergency Management Agency, Washington, D.C.
Howard Levitin, M.D., F.A.C.E.P., Emergency Staff Physician, St. 
Francis Hospital Beech Grove, Indiana
Carole A. Mays, M.S., R.N., C.E.N., Clinical Nurse, Saint Joseph 
Hospital,Towson, Maryland
Captain Jeff Rylee, Hazardous Materials Coordinator, Salt Lake City 
Fire Department, Salt Lake City, Utah
Matthew Rice, M.D. J.D.,Chief, Department of Emergency Medicine, 
Madigan Army Medical Center, Tacoma, Washington
Mr. Allen Short, Health Department Emergency Coordinator, Utah 
Department of Health, Salt Lake City, Utah
Yehuda L. Danon, M.D., Director, The Children's Medical Center of 
Israel, Petah-Tikva, Israel
Frederick Sidell, M.D.,U.S. Army Medical Research Institute for 
Chemical Defense, Aberdeen Proving Ground, Maryland
Henry J. Siegelson, M.D., F.A.C.E.P., Clinical Assistant Professor, 
Emory University School of Medicine, Atlanta, Georgia
Stephen B. Thacker, M.D., M.Sc., Acting Director, NCEH, CDC,
Linda Anderson, M.P.H., Chief, Special Programs Group, NCEH, CDC,
Sanford Leffingwell, M.D., M.P.H., Medical Director, Special 
Programs Group, NCEH, CDC,
Vernon N. Houk, M.D.,Former Director, NCEH (deceased), Assistant 
Surgeon General, NCEH, CDC,
Thomas E. O'Toole, M.P.H., Deputy Chief, Special Programs Group, 
NCEH, CDC
Scott Lillibridge, M.D., Medical Officer, Division of Environmental 
Hazards and Health Effects, NCEH, CDC
Harvey Rogers, M.S., Environmental Engineer, Special Programs Group, 
NCEH, CDC
Sharon Dickerson, M.P.A., Program Specialist, Special Programs 
Group, NCEH, CDC
Henry Falk, M.D., M.P.H.,Director, Division of Environmental Hazards 
and Health Effects, NCEH, CDC
Jose Cordero, M.D., M.P.H., Deputy Director, National Immunization 
Program, CDC
Eric Noji, M.D., M.P.H., Chief, Disaster Assessment & Epidemiology 
Section, Division of Environmental Hazards and Health Effects, NCEH, 
CDC
[FR Doc. 95-15657 Filed 6-26-95; 8:45 am]
BILLING CODE 4163-18-P