Optimization of Nonambulant Mass Casualty Decontamination Protocols as Part of an Initial or Specialist Operational Response to Chemical Incidents

© 2018 The Author(s). Published with license by Taylor & Francis.© 2018 Robert P. Chilcott, Hannah Mitchell, Hazem Matar. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-ncnd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.Objective: The UK's Initial Operational Response (IOR) is a new process for improving the survival of multiple casualties following a chemical, biological, radiological or nuclear incident. Whilst the introduction of IOR represents a patient-focused response for ambulant casualties, there is currently no provision for disrobe and dry decontamination of nonambulant casualties. Moreover, the current specialist operational response (SOR) protocol for nonambulant casualty decontamination (also referred to as “clinical decontamination”) has not been subject to rigorous evaluation or development. Therefore, the aim of this study was to confirm the effectiveness of putatively optimized dry (IOR) and wet (SOR) protocols for nonambulant decontamination in human volunteers. Methods: Dry and wet decontamination protocols were objectively evaluated using human volunteers. Decontamination effectiveness was quantified by liquid chromatography–mass spectrometry analysis of the recovery of a chemical warfare agent simulant (methylsalicylate) from skin and hair of volunteers, with whole-body fluorescence imaging to quantify the skin distribution of residual simulant. Results: Both the dry and wet decontamination processes were rapid (3 and 4 min, respectively) and were effective in removing simulant from the hair and skin of volunteers, with no observable adverse effects related to skin surface spreading of contaminant. Conclusions: Further studies are required to assess the combined effectiveness of dry and wet decontamination under more realistic conditions and to develop appropriate operational procedures that ensure the safety of first responders.Peer reviewe

Quantifying the Risk to Health Care Workers of Cough as an Aerosol Generating Event in an Ambulance Setting: A Research Report

© 2022 The Author(s). Published by Cambridge University Press on behalf of the World Association for Disaster and Emergency Medicine. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY), https://creativecommons.org/licenses/by/4.0/Introduction and Objective: United Kingdom Health Security Agency (UKHSA) guidance related to mask use for health care workers in a non-aerosol generating procedure (AGP) setting has remained as Level 2 water repellent paper mask (surgical mask) only. Energetic respiratory events, such as coughing, can generate vast numbers of droplets and aerosols. Coughing, considered to be a non-AGP event, frequently occurs in the relatively small, confined space of an ambulance (∼25 m3 ). The report seeks to explore whether existing research can provide an indication of the risk to ambulance staff, via aerosol transmission, of an acute respiratory infection (ARI) during a coughing event within the clinical setting of an ambulance. Methods: International bibliographic databases were searched (CINAHL Plus, SCOPUS, PubMed, and CENTRAL) using appropriate search strings and a combination of relevant medical subject headings with appropriate truncation. Methodological filters were not applied. Papers without an English language abstract were excluded from the review. Grey literature was sought by searching specialist databases OpenGrey and GreyNet, as well as key organizations’ websites. The initial search identified 2,405 articles. Following screening, along with forward and backward citation of key papers identified within the literature search, 36 papers were deemed eligible for the scoping review. Discussion: Attempts to replicate a clinical environment to investigate the risk of transmission of airborne viruses to health care workers during a coughing event provided evidence for the generation of respirable aerosol particles and thus potential transmission of pathogens. In cases of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), potential to infect versus true airborne transmission is a debate that continues, but there is general consensus that a large variation of cough characteristics and aerosol generation amongst individuals exists. Studies widely endorsed face masks as a source control device, but there were conflicting views about the impact of mask leakage. Conclusion: Further research is required to provide clarity of the risk to health care workers when caring for a coughing patient in the confined clinical ambulance setting and to provide an evidence base to assist in the determination of appropriate respiratory protective equipment (RPE).Peer reviewe

The percutaneous absorption of soman in a damaged skin porcine model and the evaluation of WoundStat™ as a topical decontaminant

PURPOSE: The aim of this study was to evaluate a candidate haemostat (WoundStat™), down-selected from previous in vitro studies, for efficacy as a potential skin decontaminant against the chemical warfare agent pinacoyl methylfluorophosphonate (Soman, GD) using an in vivo pig model. MATERIALS AND METHODS: An area of approximately 3 cm2 was dermatomed from the dorsal ear skin to a nominal depth of 100 µm. A discrete droplet of 14C-GD (300 µg kg-1) was applied directly onto the surface of the damaged skin at the centre of the dosing site. Animals assigned to the treatment group were given a 2 g application of WoundStat™ 30 s after GD challenge. The decontamination efficacy of WoundStat™ against GD was measured by the direct quantification of the distribution of 14C-GD, as well as routine determination of whole blood cholinesterase and physiological measurements. RESULTS: WoundStat™ sequestered approximately 70% of the applied 14C-GD. Internal radiolabel recovery from treated animals was approximately 1% of the initially applied dose. Whole blood cholinesterase levels decreased to less than 10% of the original value by 15 min post WoundStat™ treatment and gradually decreased until the onset of apnoea or until euthanasia. All treated animals showed signs of GD intoxication that could be grouped into early (mastication, fasciculations and tremor), intermediate (miosis, salivation and nasal secretions) and late onset (lacrimation, body spasm and apnoea) effects. Two of the six WoundStat™ treated animals survived the study duration. CONCLUSIONS: The current study has shown that the use of WoundStat™ as a decontaminant on damaged pig ear skin was unable to fully protect against GD toxicity. Importantly, the findings indicate that the use of WoundStat™ in GD contaminated wounds would not exacerbate GD toxicity. These data suggest that absorbent haemostatic products may offer some limited functionality as wound decontaminants.Peer reviewedFinal Accepted Versio

Mass Casualty Decontamination in the United States : An Online Survey of Current Practice

Final publication is available from Mary Ann Liebert, Inc., publishers https://doi.org/10.1089/hs.2016.0047.Mass casualty decontamination is a public health intervention that would be employed by emergency responders following a chemical, biological, or radiological incident. The decontamination of large numbers of casualties is currently most often performed with water to remove contaminants from the skin surface. An online survey was conducted to explore US fire departments' decontamination practices and their preparedness for responding to incidents involving mass casualty decontamination. Survey respondents were asked to provide details of various aspects of their decontamination procedures, including expected response times to reach casualties, disrobing procedures, approaches to decontamination, characteristics of the decontamination showering process, provision for special populations, and any actions taken following decontamination. The aim of the survey was to identify any differences in the way in which decontamination guidance is implemented across US states. Results revealed that, in line with current guidance, many US fire departments routinely use the "ladder-pipe system" for conducting rapid, gross decontamination of casualties. The survey revealed significant variability in ladder-pipe construction, such as the position and number of fire hoses used. There was also variability in decontamination characteristics, such as water temperature and water pressure, detergent use, and shower duration. The results presented here provide important insights into the ways in which implementation of decontamination guidance can vary between US states. These inconsistencies are thought to reflect established perceived best practices and local adaptation of response plans to address practical and logistical constraints. These outcomes highlight the need for evidence-based national guidelines for conducting mass casualty decontamination.Peer reviewedFinal Accepted Versio

Designing and Undertaking a Health Economics Study of Digital Health Interventions.

This paper introduces and discusses key issues in the economic evaluation of digital health interventions. The purpose is to stimulate debate so that existing economic techniques may be refined or new methods developed. The paper does not seek to provide definitive guidance on appropriate methods of economic analysis for digital health interventions. This paper describes existing guides and analytic frameworks that have been suggested for the economic evaluation of healthcare interventions. Using selected examples of digital health interventions, it assesses how well existing guides and frameworks align to digital health interventions. It shows that digital health interventions may be best characterized as complex interventions in complex systems. Key features of complexity relate to intervention complexity, outcome complexity, and causal pathway complexity, with much of this driven by iterative intervention development over time and uncertainty regarding likely reach of the interventions among the relevant population. These characteristics imply that more-complex methods of economic evaluation are likely to be better able to capture fully the impact of the intervention on costs and benefits over the appropriate time horizon. This complexity includes wider measurement of costs and benefits, and a modeling framework that is able to capture dynamic interactions among the intervention, the population of interest, and the environment. The authors recommend that future research should develop and apply more-flexible modeling techniques to allow better prediction of the interdependency between interventions and important environmental influences.This paper is one of the outputs of two workshops, one supported by the Medical Research Council (MRC)/National Institute for Health Research (NIHR) Methodology Research Programme (PI Susan Michie) and the Robert Wood Johnson Foundation (PI Kevin Patrick), and the other by the National Science Foundation (PI Donna Spruitj-Metz, proposal # 1539846). The Health Economics Research Unit is funded in part by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.This is the author accepted manuscript. It is currently under an indefinite embargo pending publication by Elsevier

Illicit COVID-19 products online: A mixed-method approach for identifying and preventing online health risks

© 2023 Catalani et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY), https://creativecommons.org/licenses/by/4.0/Aims: The COVID-19 pandemic triggered a demand for vaccines, cures, and the need of related documentation for travel, work and other purposes. Our project aimed to identify the illicit availability of such products across the Dark Web Markets (DWMs). Methods: A retrospective search for COVID-19 related products was carried out across 118 DWMs since the start of the pandemic (March 2020-October 2021). Data on vendors as well as advertised goods such as asking price, marketplace, listed date were collected and further validated through additional searches on the open web to verify the information relating to specific marketplaces. Both quantitative and qualitative methods were used for data analysis. Results: Forty-two listings of unlicenced COVID-19 cures and vaccination certificates were identified across 8 marketplaces sold by 25 vendors with significant variation in prices. The listings were found to be geographically specific and followed the progression of the pandemic in terms of availability. Correlations between vendor portfolios of COVID-19 products and variety of goods of other illicit nature such as illegal weaponry, medication/drugs of abuse also emerged from our analysis. Conclusion: This study is one of the first attempts to identify the availability of unlicenced COVID-19 products on DWMs. The easy accessibility to vaccines, fake test certificates and hypothetical/illegal cures poses serious health risks to (potential) buyers due to the uncontrolled nature of such products. It also exposes buyers to an unwanted contact with vendors selling a variety of other dangerous illicit goods. Further monitoring and regulatory responses should be implemented to protect the health and safety of citizens especially at times of global crisis.Peer reviewe

Evaluation of absorbent materials for use as ad hoc dry decontaminants during mass casualty incidents as part of the UK’s Initial Operational Response (IOR)

Copyright: © 2017 Kassouf et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.The UK's Initial Operational Response (IOR) is a revised process for the medical management of mass casualties potentially contaminated with hazardous materials. A critical element of the IOR is the introduction of immediate, on-scene disrobing and decontamination of casualties to limit the adverse health effects of exposure. Ad hoc cleansing of the skin with dry absorbent materials has previously been identified as a potential means of facilitating emergency decontamination. The purpose of this study was to evaluate the in vitro oil and water absorbency of a range of materials commonly found in the domestic and clinical environments and to determine the effectiveness of a small, but representative selection of such materials in skin decontamination, using an established ex vivo model. Five contaminants were used in the study: methyl salicylate, parathion, diethyl malonate, phorate and potassium cyanide. In vitro measurements of water and oil absorbency did not correlate with ex vivo measurements of skin decontamination. When measured ex vivo, dry decontamination was consistently more effective than a standard wet decontamination method ("rinse-wipe-rinse") for removing liquid contaminants. However, dry decontamination was ineffective against particulate contamination. Collectively, these data confirm that absorbent materials such as wound dressings and tissue paper provide an effective, generic capability for emergency removal of liquid contaminants from the skin surface, but that wet decontamination should be used for non-liquid contaminants.Peer reviewedFinal Published versio

Effect of ethnicity, gender and age on the amount and composition of residual skin surface components derived from sebum, sweat and epidermal lipids

Background/purpose: The superficial layer on the skin surface, known as the acid mantle, comprises a mixture of sebum, sweat, corneocyte debris and constituents of natural moisturizing factor. Thus, the phrase 'residual skin surface components' (RSSC) is an appropriate term for the mixture of substances recovered from the skin surface. There is no general agreement about the effects of ethnicity, gender and age on RSSC. The aim of this human volunteer study was to evaluate RSSC in relation to ethnicity, gender and age. A suitable acquisition medium for RSSC collection was identified and samples of RSSC were subsequently analysed using gas chromatography-mass spectrometry (GC-MS) and gravimetry. Methods: A total of 315 volunteers participated in the study from a range of self-declared ethnic backgrounds. Six acquisition media were compared to determine the most suitable media for RSSC collection. The effect of age, gender and ethnicity on RSSC collection was evaluated by gravimetric analysis while GC-MS was used to determine the composition of RSSC. Results: Of the six candidate materials assessed, cigarette paper provided the most practical and reproducible sample acquisition medium. There was no significant difference in the amount of RSSC collected when based on gender and ethnic