Community health impacts after a jet fuel leak contaminated a drinking water system: Oahu, Hawaii, November 2021.

BACKGROUND: In 2021, a large petroleum leak contaminated a water source that supplied drinking water to military and civilians in Oahu, Hawaii. METHODS: We conducted an Assessment of Chemical Exposures (ACE) survey and supplemented that information with complementary data sources: (1) poison center caller records; (2) emergency department visit data; and (3) a key informant questionnaire. RESULTS: Among 2,289 survey participants, 86% reported ≥1 new or worsening symptom, 75% of which lasted ≥30 days, and 37% sought medical care. Most (n = 1,653, 72%) reported new mental health symptoms. Among equally observable symptoms across age groups, proportions of children ≤2 years experiencing vomiting, runny nose, skin rashes, and coughing (33, 46, 56, and 35%, respectively) were higher than other age groups. Poison center calls increased the first 2 weeks after the contamination, while emergency department visits increased in early December 2021. Key informant interviews revealed themes of lack of support, mental health symptoms, and long-term health impact concerns. DISCUSSION: This event led to widespread exposure to petroleum products and negatively affected thousands of people. Follow-up health surveys or interventions should give special consideration to longer-term physical and mental health, especially children due to their unique sensitivity to environmental exposures.

Anhydrous Ammonia Chemical Release - Lake County, Illinois, April 2019.

On April 25, 2019, a farm tractor towing two 2-ton ammonia tanks on a county road in Lake County, Illinois, experienced a mechanical failure that resulted in the release of anhydrous ammonia, a colorless, pungent, irritating gas that can cause severe respiratory and ocular damage (1). Approximately 80% of anhydrous ammonia produced in the United States is used as a fertilizer in agriculture (1). Eighty-three persons, including first responders, motorists, and neighborhood residents, were evaluated at area hospitals because of exposure to the gas. Two weeks after the release, the Agency for Toxic Substances and Disease Registry (ATSDR) and CDC's National Center for Environmental Health (NCEH) collaborated with the Lake County Health Department and the Illinois Department of Public Health on an investigation using ATSDR's Assessment of Chemical Exposures program to describe the release, review the emergency response, and determine health effects associated with the exposure. First responders, community residents, and hospital personnel reported communication challenges related to the nature of the gas release and effective protective measures. Among the 83 persons evaluated at six area hospitals for effects of the chemical release, 14 (17%) were hospitalized, including eight (10%) who were admitted to the intensive care unit (ICU), seven (8%) of whom required endotracheal intubation and mechanical ventilation; no deaths occurred. In addition, ICU health care providers experienced symptoms of secondary exposure. The National Institute for Occupational Safety and Health's Emergency Responder Health Monitoring and Surveillance Program has specific recommendations and tools to protect responders during all phases of a response (2). Hospitals also need to review institutional policies and procedures for chemical mass casualty events, including decontamination (3). Prompt and correct identification of hazardous material (hazmat) events, and clear communication among responding entities, including on-scene and hospital responders, is important to ensure effective response after a chemical release.

Hazardous Chemical Releases Occurring in School Settings, 14 States, 2008-2013.

Children are considered to be a vulnerabletion when it comes to exposures to hazardous substances. Schools, where children spend about one third of their day, are expected to be a safe environment. Yet, there are many hazardous substances in schools that can be inadvertently or intentionally released and harm the health of students and teachers alike. The purpose of this analysis is to characterize acute chemical release incidents in school settings and identify prevention practices. The acute chemical incident surveillance programs of the Agency for Toxic Substances and Disease Registry (ATSDR) captured 24,748 acute chemical release incidents from 14 states that participated during 2008-2013. We examined 335 of these incidents that occurred at schools. While only 1.3% (n = 335) of all chemical incidents reported to ATSDR occurred in schools, these incidents represented a larger part of the total impacts, including 8.5% of incidents with persons injured, 5.7% of evacuations ordered, and 31.1% of people evacuated. Natural gas (21.8%) and mercury (18.2%) were the chemicals most frequently released. Collecting and analyzing data on acute school chemical releases allows stakeholders to target prevention initiatives and provide a school environment safe from these chemical exposures.

Injuries from Methamphetamine-Related Chemical Incidents - Five States, 2001-2012.

Methamphetamine (meth), a highly addictive drug, can be illegally manufactured using easily acquired chemicals; meth production can cause fires, explosions, injuries, and environmental contamination. To analyze injury incidence and trends, data on 1,325 meth-related chemical incidents reported to the Agency for Toxic Substances and Disease Registry's (ATSDR) Hazardous Substances Emergency Events Surveillance (HSEES) system and National Toxic Substance Incidents Program (NTSIP) by the five participating states (Louisiana, Oregon, Utah, New York, and Wisconsin) with complete information during 2001-2012 were examined. The findings suggested that meth-related chemical incidents increased with the drug's popularity (2001-2004), declined with legislation limiting access to precursor chemicals (2005-2007), and increased again as drug makers circumvented precursor restrictions (2008-2012). Seven percent of meth-related chemical incidents resulted in injuries to 162 persons, mostly members of the general public (97 persons, including 26 children) and law enforcement officials (42). Recent trends suggest a need for efforts to protect the general public, particularly children and law enforcement officials. Because individual state legislative actions can result in increased illegal meth production in neighboring states, a regional approach to prevention is recommended.

Severe Illness from Methyl Bromide Exposure at a Condominium Resort--U.S. Virgin Islands, March 2015.

On March 22, 2015, the Agency for Toxic Substances and Disease Registry (ATSDR) was notified by the U.S. Environmental Protection Agency (EPA) of four cases of suspected acute methyl bromide toxicity among family members vacationing at a condominium resort in the U.S. Virgin Islands. Methyl bromide is a pesticide that has been banned in the United States for use in homes and other residential settings. An investigation conducted by the U.S. Virgin Islands Department of Health (VIDOH), the U.S. Virgin Islands Department of Planning and Natural Resources (DPNR), and EPA confirmed that methyl bromide had been used as a fumigant on March 18 in the building where the family had been residing, 2 days before they were transported to the hospital; three family members had life-threatening illness. On March 25, 2015, a stop-use order for methyl bromide was issued by DPNR to the pest control company that had performed the fumigation. Subsequent investigation revealed that previous fumigation with methyl bromide had occurred on October 20, 2014, at the same condominium resort. In addition to the four ill family members, 37 persons who might have been exposed to methyl bromide as a result of the October 2014 or March 2015 fumigations were identified by VIDOH and ATSDR. Standardized health questionnaires were administered to 16 of the 20 persons for whom contact information was available; six of 16 had symptoms consistent with methyl bromide exposure, including headache and fatigue. Pest control companies should be aware that use of methyl bromide is banned in homes and other residential settings, and clinicians should be aware of the toxicologic syndrome that exposure to methyl bromide can cause.

The distribution and public health consequences of releases of chemicals intended for pool use in 17 states, 2001-2009.

To keep swimming pool water clean and clear, consumers purchase, transport, store, use, and dispose of large amounts of potentially hazardous chemicals. Data about incidents due to the use of these chemicals and the resultant public health impacts are limited. The authors analyzed pool chemical release data from 17 states that participated in the Agency for Toxic Substances and Disease Registry's chemical event surveillance system during 2001-2009. In 400 pool chemical incidents, 60% resulted in injuries. Of the 732 injured persons, 67% were members of the public and 50% were under 18 years old. Incidents occurred most frequently in private residences (39%), but incidents with the most injured persons (34%) occurred at recreational facilities. Human error (71.9%) was the most frequent primary contributing factor, followed by equipment failure (22.8%). Interventions designed to mitigate the public health impact associated with pool chemical releases should target both private pool owners and public pool operators.

National Toxic Substances Incidents Program - Nine States, 2010-2014.

PROBLEM/CONDITION: Every year in the United States, thousands of toxic substance incidents harm workers, first responders, and the public with the potential for catastrophic consequences. Surveillance data enable public health and safety professionals to understand the patterns and causes of these incidents, which can improve prevention efforts and preparation for future incidents. PERIOD COVERED: 2010-2014. DESCRIPTION OF SYSTEM: In 2010, the Agency for Toxic Substances and Disease Registry (ATSDR) initiated the National Toxic Substance Incidents Program (NTSIP), and it was retired in 2014. Nine state health departments participated in NTSIP surveillance: California, Louisiana, North Carolina, New York, Missouri, Oregon, Tennessee, Utah, and Wisconsin. The states conducted surveillance on acute toxic substance incidents, defined as an uncontrolled or illegal acute (lasting <72 hours) release of any toxic substance including chemical, biologic, radiologic, and medical materials. Surveillance focused on associated morbidity and mortality and public health actions. This report presents an overview of NTSIP and summarizes incidents and injuries from the nine participating states during 2010-2014. RESULTS: During 2010-2014, participating state health departments reported 22,342 incidents, of which 13,529 (60.6%) met the case definition for acute toxic substance incidents, and included 6,635 injuries among 5,134 injured persons, of whom 190 died. A trend analysis of the three states participating the entire time showed a decrease in the number of incidents with injuries. NTSIP incidents were 1.8 times more likely and injured persons were 10 times more likely to be associated with fixed facilities than transportation. Natural gas, carbon monoxide, ammonia, and chemicals used in illegal methamphetamine production were the most frequent substances in fixed-facility incidents. Sodium and potassium hydroxide, hydrochloric acid, natural gas, and sulfuric acid were the most frequent substances in transportation-related incidents. Carbon monoxide was the most frequent substance in incidents with a large number of injured persons, and chemicals used in illegal methamphetamine production were the most frequent substance in incidents involving decontamination. Incidents most frequently occurred during normal business days (Monday through Friday) and hours (6:00 a.m.-5:59 p.m.) and warmer months (March-August). The transportation and warehousing industry sector had the largest number of incidents (4,476); however, most injured persons were injured in their private residences (1,141) or in the industry sectors of manufacturing (668), educational services (606), and real estate rental and leasing (425). The most frequently injured persons were members of the public (43.6%), including students. Injured first responders, particularly police, frequently were not wearing any chemically protective equipment. Respiratory system problems (23.9%) were the most frequently reported symptoms among injured persons and, in a related finding, volatilization was the most frequent type of release in incidents with injured persons. INTERPRETATION: Industrial and transportation incidents occur frequently and have the potential for catastrophic outcomes. However, exposures to toxic substances occur frequently in other settings. Carbon monoxide, natural gas, and chemicals used in illegal methamphetamine production are commonly found in places where persons live, work, attend school, and recreate and are large contributors to incidents affecting the public. Having active NTSIP state surveillance programs did appear to improve the incidents with morbidity and/or mortality, but these programs have ended. PUBLIC HEALTH ACTION: Archived NTSIP public use data are available to download from the website for analysis. There are also many publications and reports on the website to help understand chemical risks. In addition, jurisdictions might choose to collect surveillance data themselves in a similar manner to what NTSIP states did. Chemical incident surveillance data can be used by public health and safety practitioners, worker representatives, emergency planners, preparedness coordinators, industries, and emergency responders to prepare for and prevent chemical incidents and injuries. As noted by the U.S. Chemical Safety Board, more action needs to be taken to prevent large industrial incidents. Although preventing such incidents might not be in the realm of public health, describing the public health implications and preparing for them is. Another important finding of NTSIP is that industrial incidents are only part of the problem. For example, a large number of persons were injured in a private residence or vehicle (22.2%) and an educational facility (11.8%). Public health professionals must resourcefully target prevention and preparedness to protect vulnerable populations in locations where they might spend time (e.g., schools, daycares, nursing homes, recreational areas, jails, prisons, and hospitals). Reducing the threat of chemical incidents and injuries in the United States will require a concerted effort with a variety of stakeholders including industry and labor, responder groups, policymakers, academia, and citizen advocacy groups.

Hazardous substances releases associated with Hurricanes Katrina and Rita in industrial settings, Louisiana and Texas.

The scientific literature concerning the public health response to the unprecedented hurricanes striking the Gulf Coast in August and September 2005 has focused mainly on assessing health-related needs and surveillance of injuries, infectious diseases, and other illnesses. However, the hurricanes also resulted in unintended hazardous substances releases in the affected states. Data from two states (Louisiana and Texas) participating in the Hazardous Substances Emergency Events Surveillance (HSEES) system were analyzed to describe the characteristics of hazardous substances releases in industrial settings associated with Hurricanes Katrina and Rita. HSEES is an active multi-state Web-based surveillance system maintained by the Agency for Toxic Substances and Disease Registry (ATSDR). In 2005, 166 hurricane-related hazardous substances events in industrial settings in Louisiana and Texas were reported. Most (72.3%) releases were due to emergency shut downs in preparation for the hurricanes and start-ups after the hurricanes. Emphasis is given to the contributing causal factors, hazardous substances released, and event scenarios. Recommendations are made to prevent or minimize acute releases of hazardous substances during future hurricanes, including installing backup power generation, securing equipment and piping to withstand high winds, establishing procedures to shutdown process operations safely, following established and up-to-date start-up procedures and checklists, and carefully performing pre-start-up safety reviews.

Surveillance of hazardous substances releases due to system interruptions, 2002.

The Hazardous Substances Emergency Events Surveillance (HSEES) system collected information on 9014 acute hazardous substance releases in 15 participating states in 2002. There were 3749 fixed-facility manufacturing events, of which 2100 involved "interruptions" to normal processing and 1649 "comparisons" that did not involve interruption. Equipment failure (69%) or intentional acts (20%) were the main root factor. Many events occurred in October and November in three states (Texas, Louisiana, and New Jersey), in three manufacturing industries (industrial and miscellaneous chemicals; petroleum refining; and plastics, synthetics, and resins). In interruption events, the substance categories most often released were mixtures, other inorganic substances, and volatile organic compounds and those most often causing injury were acids, chlorine, bases, and ammonia. Comparison events resulted in more acutely injured persons (408 versus 59) and more evacuees (11,318 versus 335) than interruption events and therefore may receive more public health attention. Because of the large number of interruption events, targeted prevention activities, including management of change procedures, lessons-learned implementation, process hazards analysis, and appropriate protection for workers could be economically advantageous and improve environmental quality. Efforts should focus on the identified areas of greater occurrence. The relationship of weather and equipment failure with interruption events needs further investigation.

Acute hazardous substance releases resulting in adverse health consequences in children: Hazardous Substances Emergency Events Surveillance system, 1996-2003.

Because of their small size and ongoing organ development, children may be more susceptible than adults to the harmful effects of toxic chemicals. The objective of the study reported here was to identify frequent locations, released substances, and factors contributing to short-term chemical exposures associated with adverse health consequences experienced by children. The study examined the Hazardous Substances Emergency Events Surveillance (HSEES) system data from 1996-2003. Eligible events involved the acute release of a hazardous substance associated with at least one child being injured. The study found that injured children were predominantly at school, home, or a recreational center when events took place. School-related events were associated with the accidental release of acids and the release of pepper spray by pranksters. Carbon monoxide poisonings occurring in the home, retail stores, entertainment facilities, and hotels were responsible for about 10 percent of events involving child victims. Chlorine was one of the top chemicals harmful to children, particularly at public swimming pools. Although human error contributed to the majority of releases involving child victims, equipment failure was responsible for most chlorine and ammonia releases. The authors conclude that chemical releases resulting in injury to children occur mostly in schools, homes, and recreational areas. Surveillance of acute hazardous chemical releases helped identify contributing causes and can guide the development of prevention outreach activities. Chemical accidents cannot be entirely prevented, but efforts can be taken to provide safer environments in which children can live, learn, and play. Wide dissemination of safety recommendations and education programs is required to protect children from needless environmental dangers.

Toolkit for Epidemiologic Response to an Acute Chemical Release.

When a large chemical incident occurs and people are injured, public health agencies need to be able to provide guidance and respond to questions from the public, the media, and public officials. Because of this urgent need for information to support appropriate public health action, the Agency for Toxic Substances and Disease Registry (ATSDR) of the US Department of Health and Human Services has developed the Assessment of Chemical Exposures (ACE) Toolkit. The ACE Toolkit, available on the ATSDR website, offers materials including surveys, consent forms, databases, and training materials that state and local health personnel can use to rapidly conduct an epidemiologic investigation after a large-scale acute chemical release. All materials are readily adaptable to the many different chemical incident scenarios that may occur and the data needs of the responding agency. An expert ACE team is available to provide technical assistance on site or remotely. (Disaster Med Public Health Preparedness. 2016;10:631-632).

Threat of Secondary Chemical Contamination of Emergency Departments and Personnel: An Uncommon but Recurrent Problem.

OBJECTIVE: To analyze acute hazardous substance release surveillance data for events involving secondary contamination of hospital emergency departments (EDs). Secondary contamination of EDs may occur when a patient exposed to a hazardous chemical is not decontaminated before arrival at the ED and when ED staff are not wearing appropriate personal protective equipment. This can result in adverse health outcomes among department personnel, other patients, and visitors. Even events without actual secondary contamination risk can be real in their consequences and require the decontamination of the ED or its occupants, evacuation, or temporary shutdown of the ED. METHODS: Events involving secondary contamination were identified by using the Hazardous Substances Emergency Events Surveillance system and the National Toxic Substance Incidents Program from 2007 to 2013. RESULTS: Five incidents involving the threat of secondary contamination (0.02% of all events reported to the surveillance systems [n=33,001]) were detected and are described. Four incidents involved suspected secondary contamination in which the facility was evacuated or shut down. CONCLUSIONS: These results suggest that although rare, incidents involving secondary contamination continue to present a hazard for emergency departments. Suggested best practices to avoid secondary contamination have been described. Hospitals should be made aware of the risks associated with secondary contamination and the need to proactively train and equip staff to perform decontamination.

Challenges During a Chlorine Gas Emergency Response.

OBJECTIVE: A chlorine gas release occurred at a poultry processing plant as a result of an accidental mixing of sodium hypochlorite and an acidic antimicrobial treatment. We evaluated the public health and emergency medical services response and developed and disseminated public health recommendations to limit the impact of future incidents. METHODS: We conducted key informant interviews with the state health department; local fire, emergency medical services, and police departments; county emergency management; and representatives from area hospitals to understand the response mechanisms employed for this incident. RESULTS: After being exposed to an estimated 40-pound chlorine gas release, 170 workers were triaged on the scene and sent to 5 area hospitals. Each hospital redistributed staff or called in extra staff (eg, physicians, nurses, and respiratory therapists) in response to the event. Interviews with hospital staff emphasized the need for improved communication with responders at the scene of a chemical incident. CONCLUSIONS: While responding, hospitals handled the patient surge without outside assistance because of effective planning, training, and drilling. The investigation highlighted that greater interagency communication can play an important role in ensuring that chemical incident patients are managed and treated in a timely manner. (Disaster Med Public Health Preparedness. 2016;10:553-556).

Surveillance of hazardous substance emergency events: identifying areas for public health prevention.

The Hazardous Substances Emergency Events Surveillance (HSEES) system is a comprehensive, state-based surveillance system of hazardous substance releases and public health consequences. Maintained by the Agency for Toxic Substances and Disease Registry (ATSDR) since 1990, the system captures information on acute releases of hazardous substances that need to be cleaned up or neutralized according to federal, state, or local law. Information about threatened releases that result in public health action such as evacuation is also included. Of the 39,766 events reported to HSEES for 1996--2001, 8% resulted in deaths or injuries. Funded through a competitive program announcement, 15 states currently participate in HSEES. State coordinators actively collect data from multiple sources after an eligible event occurs and enter data about the event into a standardized ATSDR-provided web-based system. The information in HSEES describes the distribution and characteristics of hazardous substances emergencies and the morbidity and mortality experienced by employees, responders, and the general public as the result of hazardous substances releases. Analysis of HSEES data helps identify risk factors associated with hazardous substances releases. For example, although events in which chlorine was released account for only 1.6% of all events, they were 3.52 times more likely to result in injuries. Knowledge of these factors is useful in planning public safety interventions and can impact the formulation of guidelines and policies to help reduce the number of events (primary prevention) and the morbidity and mortality associated with these events (secondary prevention). Utilizing state-specific analyses of HSEES data, participating states have been able to develop prevention outreach activities such as awareness training of first responders, primary prevention of spills, and secondary prevention of related injuries and deaths caused by ammonia, chlorine, and mercury. Specific examples involving ammonia, chlorine, and mercury releases will be presented in detail.

Temporal trends of acute chemical incidents and injuries­Hazardous Substances Emergency Events Surveillance, nine states, 1999-2008.

PROBLEM/CONDITION: Widespread use of hazardous chemicals in the United States is associated with unintentional acute chemical incidents (i.e., uncontrolled or illegal release or threatened release of hazardous substances lasting <72 hours). Efforts by industries, government agencies, academics, and others aim to reduce chemical incidents and the public health consequences, environmental damage, and economic losses; however, incidents are still prevalent. REPORTING PERIOD: 1999-2008. DESCRIPTION OF SYSTEM: The Hazardous Substances Emergency Events Surveillance (HSEES) system was operated by the Agency for Toxic Substances and Disease Registry (ATSDR) during January 1991-September 2009 to describe the public health consequences of chemical releases and to develop activities aimed at reducing the harm. This report summarizes temporal trends in the numbers of incidents, injured persons, deaths, and evacuations from the nine states (Colorado, Iowa, Minnesota, New York, North Carolina, Oregon, Texas, Washington, and Wisconsin) that participated in HSEES during its last 10 full years of data collection (1999-2008). RESULTS: A total of 57,975 incidents and 15,506 injured persons, including 354 deaths, were reported. During the surveillance period, several trends were observed: a slight overall decrease occurred in incidents for fixed facilities (R² = 0.6) and an increasing trend in deaths (R² = 0.7) occurred, particularly for the general public (R² = 0.9). The number of incidents increased in the spring during March-June, and a decrease occurred in the remainder of the year (R² = 0.5). A decreasing trend in incidents occurred during Monday-Sunday (R² = 0.7) that was similar to that for the number of injured persons (R² = 0.6). The highest number of incidents occurred earlier in the day (6:00 a.m.-11:59 a.m.) and then decreased as the day went on (R² = 0.9); this trend was similar for the number of injured persons (R² = 1.0). INTERPRETATION: Chemical incidents continue to affect public health and appear to be a growing problem for the general public. The number of incidents and injuries varied by month, day of week, and time of day and likely was influenced by other factors such as weather and the economy. PUBLIC HEALTH IMPLICATIONS: Public and environmental health and safety practitioners, worker representatives, emergency planners, preparedness coordinators, industries, emergency responders, and others can use the findings in this report to prepare for and prevent chemical incidents and injuries. Specifically, knowing when to expect the most incidents and injuries can guide preparedness and prevention efforts. In addition, new or expanded efforts and outreach to educate consumers who could be exposed to chemicals are needed (e.g., education about the dangers of carbon monoxide poisoning for consumers in areas likely to experience weather-related power outages). Redirection of efforts such as promoting inherently safer technologies should be explored to reduce or eliminate the hazards completely.

Acute chemical incidents surveillance­Hazardous Substances Emergency Events Surveillance, nine states, 1999-2008.

PROBLEM/CONDITION: Although they are infrequent, acute chemical incidents (i.e., uncontrolled or illegal release or threatened release of hazardous substances lasting <72 hours) with mass casualties or extraordinary levels of damage or disruption severely affecting the population, infrastructure, environment, and economy occur, and thousands of less damaging chemical incidents occur annually. Surveillance data enable public health and safety professionals to better understand the patterns and causes of these incidents, which can improve prevention efforts and preparation for future incidents. REPORTING PERIOD: 1999-2008. DESCRIPTION OF SYSTEM: The Hazardous Substances Emergency Events Surveillance (HSEES) system was operated by the Agency for Toxic Substances and Disease Registry (ATSDR) during January 1991-September 2009 to describe the public health consequences of chemical releases and to develop activities aimed at reducing the harm. This report provides a historical overview of HSEES and summarizes incidents from the nine states (Colorado, Iowa, Minnesota, New York, North Carolina, Oregon, Texas, Washington, and Wisconsin) that participated in HSEES during its last 10 full years of data collection (1999-2008). RESULTS: During 1999-2008, a total of 57,975 chemical incidents occurred: 41,993 (72%) occurred at fixed facilities, and 15,981 (28%) were transportation related. Chemical manufacturing (NAICS 325) (23%) was the industry with the most incidents; however, the number of chemical incidents in chemical manufacturing decreased substantially over time (R² = 0.78), whereas the educational services category (R² = 0.65) and crop production category (R² = 0.61) had a consistently increasing trend. The most common contributing factors for an incident were equipment failure (n = 22,535, 48% of incidents) and human error (n = 16,534, 36%). The most frequently released chemical was ammonia 3,366 (6%). Almost 60% of all incidents occurred in two states, Texas and New York. A decreasing trend occurred in the number of incidents in Texas, Wisconsin, and Colorado, and an increasing trend occurred in Minnesota. INTERPRETATION: Although chemical manufacturing accounted for the largest percentage of incidents in HSEES, the number of chemical incidents over time decreased substantially for this industry while heightened awareness and prevention measures were being implemented. However, incidents in educational services and crop production settings increased. Trends in incidents and number of incidents varied by state. Only a certain few chemicals, sectors, and areas were found to be related to the majority of incidents and injured persons. Equipment failure and human error, both common casual factors, are preventable. PUBLIC HEALTH IMPLICATIONS: The findings in this collection of surveillance summaries underscore the need for educational institutions and the general public to receive more focused outreach. In addition, the select few chemicals and industries that result in numerous incidents can be the focus of prevention activities. The data in these surveillance summaries show that equipment maintenance, as well as training to prevent human error, could alleviate many of the incidents; NTSIP has begun work in these areas. State surveillance allows a state to identify its problem areas and industries and chemicals for prevention and preparedness. Beginning in 2010, ATSDR replaced HSEES with the National Toxic Substance Incidents Program (NTSIP) to expand on the work of HSEES. NTSIP helps states to collect surveillance data and to promote cost-effective, proactive measures such as converting to an inherently safer design, developing geographic mapping of chemically vulnerable areas, and adopting the principles of green chemistry (design of chemical products and processes that reduce or eliminate the generation of hazardous substances). Because the more populous states such as New York and Texas had the most incidents, areas with high population density should be carefully assessed for preparedness and prevention measures. NTSIP develops estimated incident numbers for states that do not collect data to help with state and national planning. NTSIP also collects more detailed data on chemical incidents with mass casualties. HSEES and NTSIP data can be used by public and environmental health and safety practitioners, worker representatives, emergency planners, preparedness coordinators, industries, emergency responders, and others to prepare for and prevent chemical incidents and injuries.

Public health response to acute chemical incidents­Hazardous Substances Emergency Events Surveillance, nine states, 1999-2008.

PROBLEM/CONDITION: Acute chemical incidents (i.e., uncontrolled or illegal release or threatened release of hazardous substances lasting <72 hours) represent a substantial threat to the environment, public health and safety, and community well-being. Providing a timely and appropriate public health response can prevent or reduce the impact of these incidents. REPORTING PERIOD: 1999-2008. DESCRIPTION OF SYSTEM: The Hazardous Substances Emergency Events Surveillance (HSEES) system was operated by the Agency for Toxic Substances and Disease Registry (ATSDR) during January 1991-September 2009 to describe the public health consequences of chemical releases and to develop activities aimed at reducing the harm. This report summarizes types, frequency, and trends in public health actions taken in response to hazardous substance incidents in the nine states (Colorado, Iowa, Minnesota, New York, North Carolina, Oregon, Texas, Washington, and Wisconsin) that participated in HSEES during its last 10 full years of data collection (1999-2008). RESULTS: Of the 57,975 HSEES incidents that occurred during 1999-2008, a total of 15,203 (26.2%) incidents resulted in at least one public health action taken to protect public health. Evacuations were ordered in 4,281 (7.4%) HSEES incidents, shelter in place was ordered in 509 (0.9%) incidents, and access to the affected area was restricted in 10,345 (25.9%) incidents. Decontamination occurred in 2,171 (3.7%) incidents; 13,461 persons were decontaminated, including 1,152 injured persons. Actions to protect public health (e.g., environmental sampling or issuance of health advisories) were taken in 6,693 (11.5%) incidents. The highest number of evacuations and orders to shelter in place occurred in Washington (n = 558 [16.1%] and n = 121 [3.2%], respectively). Carbon monoxide and ammonia releases resulted in the highest percentage of orders to evacuate and shelter in place. The most frequently reported responders to chemical incidents were company response teams. INTERPRETATION: The most frequent public health response was restricting access to the area (26% of incidents), public health actions (12%), evacuation (7%), decontamination (4%), and shelter-in-place (1%). Ammonia and carbon monoxide were associated with adverse health effects in the population and the most public health response actions. Therefore, these chemicals can be considered a high priority for prevention and response efforts. PUBLIC HEALTH IMPLICATIONS: States and communities can collaborate with facilities to use the information collected through community right-to-know legislation and this report to improve chemical safety and protect public health and the environment, such as being prepared to handle the most common chemicals in their area and probable public health actions.

Persons injured during acute chemical incidents­Hazardous Substances Emergency Events Surveillance, nine states, 1999-2008.

PROBLEM/CONDITION: Persons exposed to chemicals during acute chemical incidents (i.e., uncontrolled or illegal release or threatened release of hazardous substances lasting <72 hours) can experience both acute and chronic health effects. Surveillance of toxic substance incidents provides data that can be used to prevent future incidents and improve the emergency response to those that occur, leading to a decrease in morbidity and mortality from chemical releases. REPORTING PERIOD: 1999-2008 DESCRIPTION OF SYSTEM: The Hazardous Substances Emergency Events Surveillance (HSEES) system was operated by the Agency for Toxic Substances and Disease Registry (ATSDR) during January 1991-September 2009 to describe the public health consequences of chemical releases and to develop activities aimed at reducing the harm. This report summarizes the data collected on injured persons from the nine states (Colorado, Iowa, Minnesota, New York, North Carolina, Oregon, Texas, Washington, and Wisconsin) that participated in HSEES during its last 10 full years of data collection (1999-2008). RESULTS: A total of 57,975 chemical incidents were reported by these states during the 10-year surveillance period. In 4,621 (8%) of these incidents, 15,506 persons were injured. Among them, 354 deaths occurred. The most commonly reported category of injured persons included employees of the responsible party (7,616 [49%]), members of the general public (4,737 [31%]), students exposed at school (1,730 [11%]), and responders to the incident (1,398 [9%]). Deaths occurred among members of the general public (190 [54%]), employees (154 [44%]), and responders (10 [3%]). The most frequent health effects experienced as a result of these incidents included respiratory irritation (7,443), dizziness or central nervous system problems (3,186), and headache (3,167). The three chemicals associated with the largest number of persons injured were carbon monoxide (2,364), ammonia (1,153), and chlorine (763). INTERPRETATION: Company employees, followed by members of the general public, are frequently injured in acute chemical incidents. The chemicals most often associated with these injuries are carbon monoxide, ammonia, and chlorine, all of which are hazardous gases that can be found in various locations including schools and homes. Respiratory irritation is the most common health effect. PUBLIC HEALTH IMPLICATIONS: By understanding the types of persons injured in chemical release incidents, as well as how they are injured and the injuries sustained, prevention outreach activities can be focused to protect the health of these groups in the future. Improved awareness among and training for not just employees but also the public is needed, particularly regarding carbon monoxide, ammonia, and chlorine. Appropriate measures to provide protection from respiratory effects of chemical incidents could prevent injuries.

Public health consequences of mercury spills: Hazardous Substances Emergency Events Surveillance system, 1993-1998.

We analyzed data from states that participated in the Hazardous Substances Emergency Events Surveillance (HSEES) system maintained by the Agency for Toxic Substances and Disease Registry to describe the public health consequences of mercury releases. From 1993 through 1998, HSEES captured 406 events in which mercury was the only substance released. Schools and universities, private residences, and health care facilities were the most frequent locations involved in mercury events, and human error was the contributing factor for most of the releases. Fourteen persons experienced adverse health effects as a result of the releases. An additional 31 persons had documented elevated levels of mercury in the blood. No fatalities resulted. Evacuations were ordered in 90 (22%) of the events, and the length of evacuation ranged from 1 hr to 46 days. Mercury spills have a significant public health impact and economic burden. Some actions that could potentially lessen the consequences of mercury spills are to switch to mercury-free alternatives, train people in the safe handling and disposal of mercury, and keep mercury securely stored when it is necessary to have it on hand.