Exposure monitoring for first responders must become a higher priority.
Although outstanding progress in national disaster preparedness and response has been accomplished, one important piece of unfinished business remains: the lack of effective and timely environmental exposure analyses throughout the response effort. In part, the issue results from inadequate disaster-exposure characterization tools and the absence of clear protocols for invoking exposure-assessment technologies. In a broader sense, however, this deficiency illustrates the lack of adequate importance put on the timely use of exposure sciences during and after disasters, as well as recognition of how those omissions can impact the health of the responder community.
Limited resources have been invested in improving the ability to identify, monitor and collect real-time toxic exposure data. Without this capability, the window of opportunity to caution first responders and conduct subsequent exposure analysis and toxicity estimates is missed. As a result, the evidence needed to accurately define risk levels and associated cause-and-effect factors is lost.
Timely exposure analysis
Real-time exposure analysis equips decision-makers and first responders with the information necessary to estimate acute risks and define approaches to manage those risks safely and effectively. To illustrate, consider the 2006 hazmat explosion and fire at the EQ Industrial Services plant in Apex, N.C. A malodorous vapor cloud traveled the sky over Apex, fireballs shot hundreds of feet into the sky and explosions roared. The source of the fire was identified quickly as the EQ facility that housed a virtual witches' brew of toxic chemicals. First responders immediately were warned of the seriousness of this fire and wore the requisite personal protection gear.
Still, 40 people required medical attention for respiratory distress and skin irritations, including 13 police officers and one firefighter. The fact is, not all first responders have adequate information on exposure risks and also may not have or use personal protection gear. Protecting responders and the public from shifting airborne contaminants is difficult for disaster-scene managers who lack the ability to monitor exposures to toxic particles and gases on a real-time basis.
Critical exposure information absolutely is necessary to adjust safety boundaries accordingly. On multiple occasions during the Apex response, the command center was relocated due to shifting winds and movement of the vapor cloud — but based almost solely on visual and olfactory observations. Long after the fire was extinguished, many questions remained unanswered about the exact characterization of human exposures. In fact, a scientific investigation was not undertaken to determine the precise nature of the toxic exposures until the second day, as the EQ chemical manifest burned in the fire.
Just imagine the potential for adverse human health consequences in a similar situation with less obvious warning signs. The fact is that failure to immediately and correctly characterize the exposure greatly increases the likelihood of unnecessary adverse health outcomes, as protective gear is not always worn without explicit warning. Equally important is the vital need to capture relevant, archivable exposure samples to assist, if required, in the medical aftermath of any disaster.
Archived exposure samples
Despite access to state-of-the-art, high-tech personal protection gear, today's first responders still face the risk of exposure to harmful chemical, physical and biological agents while fulfilling their duties. In these situations, it is essential to capture real-time samples of the airborne contaminants to identify acute risks, as well as integrated samples that reflect their likely event exposures. Archived samples can be invaluable in providing the knowledge needed to characterize the exposures, better estimate the toxicity of the contaminants and understand potential health consequences, all of which assist in the subsequent medical treatment of those exposed.
Consider the lessons learned at Ground Zero on Sept. 11, 2001. While most firefighters initially protected themselves from hazardous inhalation by wearing all-hazard protection gear such as air packs, the gear itself is not without issue. For instance, while air packs significantly increase workload, tanks must be replaced every 20 minutes. In addition, their use can hinder communication and occasionally interfere with the mission. Consequently, firefighters began removing their personal protection. They were simply unaware of existing danger. This lack of adequate information regarding their air quality left more than one-third of all firefighters exposed to toxic contaminants.
A paucity of archived samples exists today to help understand what individual firefighters were exposed to and, more importantly, how the medical community can better serve their ongoing needs. At a minimum, archived samples could answer important medical questions and validate the cause and effect of their suffering.
The FDNY WTC Medical Monitoring and Treatment Program found that during the first week post-exposure, 99% of the 12,000 FDNY fire and rescue workers reported at least one new respiratory symptom. Six months later, 38% still reported a severe cough and 25% reported persistent and severe nasal or sinus congestion. Of those with persistent respiratory symptoms, 85% reported new or increased gastro-esophageal reflux disorder and 332 firefighters required extensive ongoing medical leave for "WTC Chronic Cough Syndrome." Regrettably, long-term sampling of airborne contaminants at Ground Zero did not begin until Sept. 21, long after the toxins were inhaled by thousands of first responders.
"[They] go into the most dangerous situation imaginable to save someone like me or you, and all they ask in return is that we will be there to medically treat and care for them when they come out," says program co-director Dr. David Prezant, who also is the chief medical officer of FDNY's Office of Medical Affairs. "Hopefully at the same time, what we are learning and understanding will help the medical profession be more proactive should a situation like this ever happen again."
Off the back burner
Consider the important exposure-science lessons learned years later during the Hurricane Katrina clean-up efforts. The third-strongest hurricane ever to hit land in the United States, Katrina caused nearly 2,000 deaths, displaced hundreds of thousands of families and has topped $80 billion in clean-up costs, making it the costliest natural disaster in the country's history. In an effort to house those who were displaced, the Federal Emergency Management Agency dispatched 120,000 travel trailers to the affected region for temporary-housing purposes.
Almost immediately, hundreds of families began complaining of itching and burning eyes, nose bleeds, coughing, sinus infections, bronchitis, asthma-like symptoms, and other more serious conditions. When the trailers finally were tested, after most residents had been moved out, high levels of formaldehyde were discovered. But, questions remained: were the illnesses caused by high formaldehyde levels in the trailers, or were they caused by exposure to other toxins related to the clean-up efforts? While these exposures did not put firefighters at risk, the situation further illustrates that without timely collection and archival of exposure samples, robust analyses to conclusively answer critical health questions are, once again, not possible.
Before the next disaster, it is imperative that this nation puts exposure-characterization protocols in place and tools on the ground, and works toward learning how and when to collect data throughout all stages of a disaster. Such progress must start with the Department of Homeland Security.
The DHS's mission is to mitigate the effects of disasters and assist first responders by ensuring that emergency response professionals are prepared, equipped and trained for any situation. To this end, the DHS has formulated a comprehensive National Response Framework. The NRF, published in January 2008, details how the nation should conduct all-hazard response, from the smallest incident to the largest catastrophe. It was built upon the National Incident Management System, which provides a consistent framework for incident management at all jurisdictional levels regardless of the cause, size or complexity of the disaster. But surprisingly, the NRF core document fails to mention exposure analysis or mandate exposure monitoring for responders or the public during any phase of disaster response.
Recognizing this weakness, Rep. David Price (D-N.C.), the chairman of the Subcommittee on Homeland Security, and his staff are working with a panel of governmental and industry experts to determine whether it would make sense to amend the NRF to incorporate a greater awareness of exposure monitoring.
Once the NRF is amended, exposure characterization hopefully would then be integrated into disaster simulation and training exercises that are carried out in major cities across the country. Today, most exercises overlook exposure-assessment issues. Only through seamless integration into overall disaster-response protocols can the next generation of exposure-monitoring tools and protocols be purposefully designed, developed and accessible for future emergencies.
Today and tomorrow
Today, palm-sized, state-of-the-art, portable exposure-monitoring technologies that can be deployed easily in large numbers across a disaster area — or placed on a fire truck for those monitoring the pumps and hoses and not wearing protection — are very limited. Those that are available lack the critical capability of detecting a complete range of potential airborne contaminants and the ability to provide real-time information. To move forward, more sophisticated and miniaturized sensors must be developed that can provide real-time information. Ideally, these technologies would be at a personal level — each firefighter would be monitored in much the same way as dosimeters are used to protect radiological health workers. However, making such technological advancements possible and available for first responders requires funding and support.
The next generation of exposure-analysis tools must address and overcome the following challenges:
Location of the monitoring device
For maximum utility, monitoring devices should be easily deployed at multiple locations or, optimally, worn in a personal mode in close proximity to the air being breathed by first responders. To illustrate, the Army determined that stationary exposure monitors at a limited number of locations in Iraq could not reliably predict soldier illnesses. This was due in large part to their distance from the actual toxic air breathed as soldiers walked past problem sources — such as the heavy smoke from burn piles. There is an exact parallel to firefighters' likely inhalation exposures during periods when personal protection is not being used.
Functionality
Exposure-analysis devices must be capable of sensing both toxic gases and particles to provide samples that can be archived for later analysis. Although the quality of data generated by larger, more expensive fixed monitors can't be expected, usable data quality and capture rates can be anticipated from these miniature counterparts, especially when they are used to detect life-threatening toxicity levels. The ability to handle both acute- and chronic-level exposure scenarios are a must. Also, parallel collection of data-quality indicators is required to reduce both false positives and negatives. Power management is another critical consideration, as first responders do not have the time to deal with changing batteries or changing out devices.
Compliance
Such devices only can help first responders perform their duties better when they are being used. Moreover, exposure monitors must be used in compliance with deployment protocols; otherwise the resulting data will not represent the true exposures. Additionally, exposure-monitoring should be fully integrated with other vital monitoring functions such as heart rate and air supply. Device deployment and the viewing of data both must be extremely easy. Ideally, the technology would include automated alarms to both the firefighters and central command.
Affordability
Absolute preparedness will require every first responder to be equipped with this protective technology. However, very exact exposure characterizations will result in very expensive technology that even the most well-endowed, big-city fire departments cannot afford. Consequently, programs developing new technologies to protect first responders from harmful exposures must strike a balance between critical accuracy and ultimate affordability to ensure that they are widely available and accessible.
Charles Rodes, Ph.D., is a senior fellow at the nonprofit research organization RTI International and is expert in aerosol technology and environmental exposure.
