What to Do After a Chemical, Biological, or Nuclear Incident

BRUSSELS — Are Belgian hospitals ready to face a chemical, biological, radiologic, or nuclear (CBRN) incident? On March 24, experts from Ghent University Hospital shared information, guidance, and advice at a well-attended online seminar.

Since 1991, lawmakers have required all hospitals with a recognized emergency department to be prepared for minor CBRN incidents, meaning that they anticipate admitting at least one or two contaminated victims. But how is this requirement implemented? What are the specific characteristics and dangers of this type of incident? And what is the potential impact? Ghent University Hospital organized a webinar on the subject. Two hundred fifty doctors, nurses, prevention consultants, and emergency plan coordinators from various hospitals participated.

Wetteren Derailment

This high turnout reflects a growing concern about such incidents. Belgium is no stranger to the threat of Russian President Vladimir Putin deploying nuclear weapons or launching attacks against Ukrainian nuclear power plants. But accidents are also possible, as the Chernobyl and Fukushima nuclear disasters and the large-scale chemical disaster in Bhopal, India, have shown.

In Belgium, a freight train derailed in Wetteren in 2013. As a result of that incident, acrylonitrile, a toxic chemical product, seeped into the sewers via the fire extinguishing water. One person died, eight others were severely poisoned, and 438 people went to emergency departments in the area. New accidents are not beyond the realm of possibility. In Belgium, hazardous substances such as acrylonitrile are still regularly transported by rail.

To show the potential magnitude of chemical terrorism, Peter De Paepe, MD, PhD, the head of the Ghent University Hospital’s Emergency Department, presented a simulation of a chemical attack on a chlorine storage tank. In this US simulation, terrorists infiltrate an industrial site and rupture a chlorine storage tank with a small pack of explosives. A cloud of chlorine gas spreads to urban areas and results in 17,500 deaths, 10,000 persons severely injured, and 100,000 hospitalizations. De Paepe’s conclusion was truly sobering — these are numbers that no healthcare system can manage adequately.

An Invisible Danger

As Katleen Gardeyn, emergency plan coordinator at Ghent University Hospital, explained, the true scale of a CBRN incident is often difficult to estimate. The danger is not always immediately obvious, and the health effects may only become apparent over the long term. According to Gardeyn, the challenge of a hospital emergency plan is keeping contaminated patients and regular patient areas strictly separate. Additionally, medical actions aimed at saving lives must always take priority over decontamination processes, she said. It is also important to report incidents to the competent authorities.

According to De Paepe, when it comes to chemical attacks, much can be learned from the 1995 sarin gas attack that took place in the Tokyo, Japan, subway. Twelve people died, 54 were seriously injured, and more than 5000 people were admitted to various hospitals. First, it is essential to have adequate protective equipment. Ten percent of the first responders and 23% of the hospital personnel involved suffered secondary contamination because of a lack of protective equipment. In one of the hospitals, victims were taken into a poorly ventilated chapel because of a lack of space. Sixty percent of the caregivers who worked there suffered secondary contamination.

De Paepe emphasized how important it is to have adequate protective equipment or to decontaminate patients before they enter the hospital. He also recommended taking advantage of trained and experienced clinical personnel who have in-depth knowledge of toxidromes. He added that healthcare providers should be sufficiently familiar with the symptoms and management of exposure to chemical products. Having immediately accessible stocks of antidotes is equally important, and a global supply strategy is crucial.

During the webinar, Tania Desmet, MD, of the Ghent University Hospital Emergency Department, focused on the consequences of a biological attack, which is the deliberate spreading of a virus or bacterium to cause infection. A very serious threat for the healthcare sector, biological terrorism is often hard to detect. Because the incubation period is often longer than with a chemical attack, healthcare providers are not initially aware of what is happening. A characteristic range of symptoms, larger groups of individuals exhibiting similar symptoms, or a connection between multiple patients and a single event or place may indicate a possible attack. The same is true for germs that show up out of season or germs that are not naturally present. For example, if many people in Belgium suddenly become sick after being infected with dengue fever, it would raise suspicions, because the mosquito responsible for dengue fever is not usually found in this region.

Looking for Patterns

Desmet stressed the need to look for models. It is difficult to know whether you are dealing with a bioterrorist on the basis of the germ itself. An intelligent bioterrorist will choose a germ that can be manipulated slightly. Such manipulation will alter the clinical features, change resistance patterns, and require different treatments. The RAIN (recognize, avoid, isolate, notify) principle describes the approach: try to recognize the model, make sure you can provide safe care, isolate the victims or, if necessary, the healthy segment of the population, and notify the competent authorities. This last point is always important, even if the case seems to be an isolated one. There may be similar cases at other hospitals. Consistent reporting and recognition of patterns go hand in hand.

With respect to treatment, Desmet advises healthcare providers not to get lost in the details. The plague, smallpox, botulism, tularemia, anthrax, and viral hemorrhagic fever are some of the common germs that bioterrorists might deploy. A detailed examination of all the treatments is extremely complex. Fortunately, two types of antibiotics are effective for anthrax, the plague, and tularemia ― fluoroquinolone and doxycycline.

Polonium Poisoning

Tom Boterberg, MD, PhD, an oncologist at Ghent University Hospital, spoke on radiologic and nuclear incidents. There is a significant risk for accidents, inasmuch as Belgium still transports many isotopes by road. And although 90% of those isotopes are used in medicine, they can very much be used for ill, as the 2006 poisoning of Alexandr Litvinenko with polonium showed.

For such cases as well, protective measures and decontamination are crucial, especially because the victims may themselves be a source of radiation. In many cases, safely removing contaminated clothing reduces the radiation level considerably, unless the source is internal. In the United Kingdom, people are considered contaminated if they emit three times the natural background radiation. People who emit ten times more radiation than their environment must be decontaminated. Different treatments are possible, depending on the radiation doses received. Hospitals must also provide separate areas with controlled access for these types of victims.

Hot Zone

How healthcare providers can protect themselves and other patients was discussed in greater detail in a presentation by Steve D’hoker, head nurse at the Ghent University Hospital Emergency Department. The type of contamination is important, as is knowing whether the contamination is internal or external. D’hoker explained the organization of decontamination areas. It is important to make sure there is enough distance between regular patient areas and the contaminated area where victims are treated, he said. For example, caregivers can use a shower space between the “hot zone” and “cold zone” to decontaminate themselves.

According to D’hoker, emergency departments need a decontamination plan appropriate to their size and resources. In any case, contaminated victims cannot be in the regular hospital area. It is essential to have a safe way to undress after providing care and good procedures. An exercise is planned at Ghent University Hospital for the near future.

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