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An expert panel was convened in October 2007 at the International Society for Exposure Analysis Annual Meeting in Durham, NC, entitled “The Path Forward in Disaster Preparedness Since WTC—Exposure Characterization and Mitigation: Substantial Unfinished Business!” The panel prospectively discussed the critical exposure issues being overlooked during disaster responses and highlighted the needs for an optimal blending of exposure characterizations and hazard controls within disaster settings. The cases were made that effective and timely exposure characterizations must be applied during responses to any disaster, whether terrorist, manmade, or natural in origin. The consistent application of exposure sciences across acute and chronic disaster timelines will assure that the most effective strategies are applied to collect the needed information to guide risk characterization and management approaches. Exposure sciences must be effectively applied across all phases of a disaster (defined as rescue, reentry, recovery, and rehabitation—the four Rs) to appropriately characterize risks and guide risk-mitigation approaches. Failure to adequately characterize and control hazardous exposures increases the likelihood of excess morbidity and mortality. Advancing the infrastructure and the technologies to collect the right exposure information before, during, and immediately after disasters would advance our ability to define risks and protect responders and the public better. The panel provided conclusions, recommendations, and next steps toward effective and timely integration of better exposure science into disaster preparedness, including the need for a subsequent workshop to facilitate this integration. All panel presentations and a summary were uploaded to the ISES1 website (http://www.iseaweb.org/Disaster_Preparedness/index.php).
An expert panel was convened in October 2007 at the International Society for Exposure Analysis (ISEA) Annual Meeting in Durham, NC, entitled “The Path Forward in Disaster Preparedness Since WTC—Exposure Characterization and Mitigation: Substantial Unfinished Business!” The focus of the panel was to prospectively discuss the critical exposure issues being overlooked during disaster responses and to make the case that effective and timely exposure characterizations must be applied during responses to any disaster, whether terrorist, manmade, or natural in origin. Without adequate application of exposure sciences across acute and chronic disaster timelines, the most effective strategies to collect the necessary information to guide risk characterization and management approaches simply cannot be effectively achieved.
Six years after 9/11, we are still struggling to reconstruct and fully characterize exposures that led to adverse health outcomes from various phases of the World Trade Center (WTC) disaster. It is clear we have not made the progress we should have, especially in defining the importance of exposure science for current and future disaster preparedness. The Government Accountability Office (GAO) report on WTC indoor contamination issues (GAO, 2007a) concluded that we still do not have disaster exposure characterization protocols to know how and when to collect data during and after an event.
More recent disasters, such as the October 2006 HAZ-MAT explosion and fire in Apex, NC, suggest that we simply have not made satisfactory progress since 9/11 in integrating exposure science into disaster risk assessment and management processes. This is in part due to an inadequate recognition of the importance of exposure science and its timely application during disasters, and is also driven by the lack of suitable disaster exposure characterization tools and protocols. During the Apex fire, both responders and the public were admitted to emergency rooms, but the exposure characterizations were marginal at best and not conclusive. In light of that example, we must ask the following questions:
This panel was convened to bring together experts and implementers to define and prioritize research leading to better exposure tools (what should be used to characterize exposures) and exposure application protocols (when and how to characterize them). The goal of this panel was to look at insights into exposure-related preparedness for a wide range of disaster types and help show the way forward. Key expert panelists from private, academic, and federal research organizations were selected to identify and present the most critical acute and chronic exposure characterization issues for disasters that affect both responders and the public. An important element of all presentations was a prospective assessment highlighting the need to act on defining a way forward since the WTC disaster. Additional experts were also selected to review the presentations and provide overarching critical discussions to link the selection and timeliness of exposure characterizations more directly to adverse health outcomes and more robustly to the risk assessment process.
The panel was organized and moderated by Dr. Charles Rodes, with rapporteur assistance from Michael Dellarco. Dr. Rodes also provided the charge to the panel. The panel keynote speaker was representative David Price. The panel technical presenters were Edo Pellizzari, Mitchell Erickson, Daniel Vallero, Dori Reissman, and Paul Lioy, whereas the discussants were Morton Lippmann, Thomas Burke, and Bernard Goldstein.
This article summarizes the panel charge, the technical issues presented, and the overarching discussions and conclusions. A set of recommendations and steps next proposed were subsequently made by the panel and are also provided. All presented materials, full discussion summaries and supporting supplemental material, and panelist contact information are available for download from the main ISEA website, http://www.iseaweb.org/Disaster_Preparedness/index.php.
A paper by Lioy et al. (2006) defined the need for better and more timely exposure tools and protocols in disaster responses. This key issue was the impetus for assembling the panel and engaging in a dialog aimed at making dramatic improvements in our ability to protect the health of responders and the public during all phases of disasters.
Lioy et al. highlighted the following key lessons learned from 9/11:
Lioy et al. also highlighted the need to
In the introduction to the panel, Dr. Rodes observed that: “…we’ve not made the progress we should have in the 6 years since 9/11, especially in defining the importance of exposure science in disaster preparedness.” To bolster that observation, he cited the September 2007 GAO report on WTC indoor contamination issues, which concluded that we still do not have disaster exposure characterization protocols to know “…how and when to collect data…” A parallel between the WTC scenario and a much smaller HAZMAT disaster in Apex, NC, illustrated that responders and the public were excessively exposed 6 years after 9/11, and the science behind the available exposure characterization tools had simply not significantly advanced.
Clearly, the key points relative to including appropriate and timely exposure characterizations in disaster preparedness in the recommendations of Lioy et al. must be examined more closely.
The following key charge points were raised:
Representative Price addressed the panel on some of the critical issues in disaster response currently faced by the federal government. The federal government faces significant challenges in prioritizing resources to address a wide variety of potential homeland security threats, including terrorist attacks, natural disasters, and accidental disasters.
Funding is one such challenge. Although the Department of Homeland Security (DHS) has a major role in homeland security activities, it controls only about half of the annual $58 billion homeland security budget. The rest is spread out over other federal agencies. Two of these have the greatest involvement in public health components of homeland security: the Department of Health and Human Services (DHHS; this includes CDC, CEH, NIOSH and NIEHS) and the Environmental Protection Agency (EPA). Thus far, the primary focus of federal homeland security efforts has been on terrorist attacks, specifically biological and nuclear threats (although 9/11 was neither), and environmental exposures from the full range of possible disasters have received less attention. EPA is responsible for protecting the public from environmental exposures during and following disasters, including 9/11, yet its homeland security budget accounts for only 0.2% of the total homeland security budget. The federal government is not adequately considering responder risks and exposures and appropriately setting research priorities. The focus may be broadening somehow to better incorporate natural and accidental disasters, which are more likely to involve environmental exposures. However, budgeting and mission tradeoffs across federal agencies, which may be necessary to adequately incorporate exposure characterization, must be approached cautiously: there are opportunity costs to shifting funding to homeland security missions from other lines of research.
Another set of challenges relates to the state of the science in risk and exposure assessment. Risk in the homeland security context comprises three factors: threat, vulnerability, and consequences. Our ability to measure and quantify those factors, and thus risk, is in its infancy. It is not clear that a single metric to assess overall risk is feasible: what would an all-hazards risk assessment look like? And what role would a robust exposure characterization capability play in developing such a risk assessment? We need more robust science to help us understand to what extent our investments are successfully reducing risk and whether we have the right mix of priorities. We need to understand the capabilities and effectiveness of the technologies we invest in, and the tradeoffs between those and other potential investments.
Timely exposure characterizations in defining risk levels are critically important, and the findings of this panel will be important to the Congress and the Executive Branch.
A series of targeted technical presentations on exposure characterization needs for disasters were made by panelists representing private, university, and federal agency research and development perspectives.
A series of issues clearly detail the current shortfalls in applying exposure science to provide the best estimates of risk and the critical points before, during, and following a disaster. These issues apply to terrorist-based, natural, and accidental disasters and apply to the rescue, reentry, recovery, and rehabitation phases.
We must consider what we have learned from previous terrorist-based, natural, and accidental disasters to prepare us for future with respect to data collection and uncertainty, specifically
With respect to exposure characterization methods and protocols, some of the key questions are as follows:
The critical question is, how do we support the research and development efforts that will be needed to develop the exposure characterization knowledge, tools, and processes to optimally respond to disasters?
We face an enormous range of security threats from nuclear, biological, chemical, or radiological attacks to natural disasters such as hurricanes and earthquakes. These threats can affect thousands of localities, airports, chemical plants, skyscrapers, and others, so the magnitude and complexity of the problem is large. The US National Critical Infrastructure Protection Plan2 identifies 174 sectors with exposure opportunities, as well as key resources that need protection (see box). Adding to the complexity is that most of the infrastructure is owned by private sector entities.
Effective technologies, practices, and policies have made a difference in the past (e.g., fire and smoke detectors) and can continue to do so. Specific future goals might include less vulnerable buildings, escapable high rises, and intelligent personal monitoring equipment.
In the meantime, we need to institutionalize exposure characterization and mitigation processes for disasters. Exposure characterization must be integrated into a national framework for response planning, such as the National Response Framework3, so that exposure characterization organizations are an integral part of the response team from the beginning. Exposure characterization should also be part of appropriate training and simulation exercises, so that it is seamlessly integrated with the overall response efforts. At present, most exercises neglect exposure assessment.
A second component of institutionalizing exposure characterization is the need to develop national standard practices for exposure characterization, including background characterization (both before and after event) and sample analysis. We need to conduct data-gap analyses to identify where sufficient information is already available and, critically, where holes exist.
To achieve this, we need more research and development on various fronts, such as:
Disasters are typically divided into four phases: rescue, reentry, recovery, and rehabitation (see Figure 1). Decisions are made on the basis of the estimated risk at the various stages of a disaster, and exposure characterization of a key component at all stages:
Lessons learned from disasters such as the WTC and Hurricane Katrina have significantly improved our ability to define disaster mitigation needs, characterize disaster exposures, and conduct effective post-disaster remediation. Rapid deployment of equipment is critical, along with integration and sharing of data immediately with first responders: integrated and systematic responses rely on access to high-quality exposure data. EPA is developing uniform guidelines for use of response equipment and compiling a database of all available response equipment throughout the agency. EPA and its collaborators have begun to report the results of the Urban Dispersion Program (UDP)—Prospective Exposure Study, but still needs to translates these findings into new and better procedures and manuals for first responders in cases of acute releases of highly toxic materials (Lioy et al., 2007; Vallero et al., 2008.
When assessing and remediating indoor contamination caused by building collapse or other environmental disaster, subchronic and acute health-based exposure advisory or guidance levels can be used to set emergency response standards for the general public (e.g., provisional advisory levels (PALs) for air or drinking water, EPA/National Research Council acute exposure guidance levels (AEGLs)). Longer-term, risk-based benchmarks define the habitability of dwellings.
Additional insights and lessons-learned are provided at http://www.iseaweb.org/Disaster_Preparedness/wtc_lessons_learned_vallero_addon.pdf.
Critical considerations revolve around a coordinated response that defines who is a responder and then providing the assets and support structure needed to protect workers and responder health. Workers engaged in saving and protecting lives, transportation, communications, medical services, public health, disaster assistance, public works, and construction are some of the occupational groups that need to be considered throughout the four R’s. Large-scale disasters such as the WTC disaster, the anthrax attacks, and Hurricane Katrina taught significant lessons about appropriate disaster safety management, which requires interagency planning, resource and operation coordination, integrated health and safety monitoring, and onsite worker training and outreach (Jackson et al., 2002; LaTourrette et al., 2003; NIOSH/RAND, 2004; Willis et al., 2006; GAO, 2007b). Effective disaster safety management begins before the disaster strikes and involves anticipating scenarios and likely hazards, designating roles, and conducting joint planning to ensure coordinated exposure assessment, safety interventions, and health/injury monitoring. A unified health and safety plan is critical in dealing with the affected workers, and exposure science plays a key role in decisions about medical monitoring of potentially exposed workers. This includes conducting inventories of assets (equipment, skills, personnel) and plans to coordinate exposure assessment, data sharing, joint interpretation, and safety decisions/enforcement for work sites. Previous events have highlighted the need for onsite worker training, frontline dissemination of risk and safety information, and standardization of safe work practices and interoperable safety equipment (e.g., donated equipment caches).
The Worker Safety and Health Support Annex (DHS, 2004b) within the National Response Plan (currently under revision as the National Response Framework—DHS, 2004a) and performance criteria for states and local jurisdictions (Targeted Response Capabilities—DHS, 2005) provide guidance to assist planning and operations to protect workers and responders. These federal guidances were built from lessons learned in the WTC and other disasters. The Occupational Safety and Health Administration (OSHA) coordinates the Worker Safety and Health Support Annex, with assistance from several other federal agencies—including the US Coast Guard, Federal Emergency Management Agency (FEMA), US Army Corps of Engineers, National Institute for Occupational Safety and Health (NIOSH), Agency for Toxic Substances and Disease Registry, Federal Occupational Health, EPA, and DOE. NIOSH provides expertise to assist OSHA with characterizing unknown or complex worker exposures and participates with the US National Response Team (co-led by US Coast Guard and EPA)—an entity called upon to respond to oil and chemical spills or other hazardous material releases. FEMA Safety handles DHS personnel involved in the response and oversees safety issues in the Joint Field Office settings. Essential support function 8 of the National Response Plan addresses public health and medical issues—including worker health and safety—and is coordinated by the DHHS.
NIOSH is engaged in a number of activities aimed at improving exposure assessment, including publishing resources on the Internet for emergency response workers, occupational exposure sampling strategies, personal protective technology, medical screening recommendations, and research and development (see NIOSH Web references).
Exposure science plays a key role in the medical monitoring for exposure to agents released in a disaster event that can lead to clinical disease. We learned a number of lessons from the WTC disaster:
Better reentry protocols are needed to minimize exposures. Other open research questions and needs for disaster response exposure characterization include the following:
One source of new data and results is UDP in New York City (NYC).UDP was designed to understand flow and dispersion in a deep urban canyon and rapid vertical transport and dispersion in recirculating eddies adjacent to very tall buildings. In NYC, UDP characterized human exposure to a perfluorocarbon tracer gas outdoors and in other venues along scripted paths that simulate features of an event. These data need to be thoroughly analyzed and then the key messages translated for “on the ground” use by emergency responders and emergency management teams in planning and implementing the four R’s.
Next steps in disaster exposure characterization include the following:
Overarching discussion issues were then provided.
Our collective past experience demonstrates the critical need for more state-of-the-art and newly developed techniques to be applied to exposure monitoring, analysis, and assessment, given that many current practices are simply inadequate. Application of a robust and consistent national science assessment model in applying exposure characterizations to disasters is critical—the model used by the National Institute of Environmental Health Sciences (NIEHS) following the WTC disaster should be considered as a starting point for optimizing the prompt deployment of resources. NIEHS immediately provided supplemental funds to its academic-based Environmental Health Science Centers to maximize their utilization of existing science capabilities for conducting disaster-associated risk assessments.
A coordinated federal agency action plan is needed to ensure that the considerable capabilities for exposure and environmental assessments within DHS, EPA, OSHA, NIOSH, the National Oceanic and Atmospheric Administration, the US Geological Survey, the Department of Defense, DOE, and the National Aeronautics and Space Administration can be mobilized as needed when future environmental disasters occur. A lead federal agency with rapid-response and research capabilities needs to be identified and given adequate resources for effective emergency mobilization. The Environmental Measurements Laboratory of DHS had such capabilities in the 1960s, when it was known as the Health and Safety Laboratory of the Atomic Energy Commission. Given the proper mandate, new staff, equipment, and leadership, it could play this critically needed role again.
Effectively characterizing acute exposures in the early disaster stages is time critical, with numerous considerations required, including:
Effectively characterizing chronic exposure in the later disaster stages must be instituted at the appropriate times and locations, and the appropriate cohorts defined for prospective studies.
Exposure assessment is essential for decision makers in characterizing risks, protecting public health, guiding the disaster response, and assuring timely recovery. Theses points have clearly been made in National Academy of Science disaster reviews such as that for Hurricane Katrina (NAS, 2007), but translating them into appropriate actions has not always followed. Improved capabilities must be developed for better and more timely exposure characterizations for the wide range of hazards and threats expected in disasters—the current toolbox is simply inadequate to response needs.
Key points from his presentation included the following:
Exposure science has a key role in disaster preparedness and response, encompassing first response to resettlement, and post-event forensic and economic investigations. Current practices and procedures are insufficient to do the job due to the unique aspects of disaster events, and to the kinds of questions asked by policy makers and to the information needs for effective response to an event.
Overarching themes that are apparent from a synthesis of this panel’s presentations and discussions can be summarized as follows:
Specific exposure tools that must be optimized and better integrated into disaster response strategies include these needs:
The most consistent conclusion shared by all presenters and discussants was the need to consistently apply targeted and timely exposure science in disaster preparedness and response. There has been a lack of recognition of the importance of exposure science during all phases—the four R’s—of a disaster. Advancing the state of the science to develop the approaches and tools to collect the right exposure information during and immediately after each disaster phase would advance our ability to define risks and protect the health and safety of both workers (responders) and the public better.
The overarching conclusions reached across all panel presentations and discussions were as follows:
The key issues identified by this Technical Peer Panel should dramatically improve our ability to define risks and address future disasters. It was clear that a broad spectrum of key disaster preparedness players be identified to attend this workshop representing the appropriate federal, academic, and private organizations. It was also clear that Congressional (homeland security) input into the workshop planning process would be critical for successful elucidation and eventual implementation of the resulting recommendations to define an optimal path forward.
The overarching recommendations reached by the panel were as follows:
Steps next proposed for discussion across stakeholders include the following.
Currently, federal response plans have not adequately addressed disaster-related exposure issues. It is critical that issue and subissue ownership questions be addressed to define clear corrective steps for each element raised by the panel. This can only be accomplished if responsibilities and roles are identified at all levels of government and integrated vertically and horizontally. Policy and methodological issues, as well as research and development aspects of exposure characterization are likely to fall under different organizations and agencies, depending on factors such as the subpopulation(s) at risk and the spatial extent of the risks.
Overall policy issues related to the optimal and timely integration of exposure science into disaster response must be reviewed by all agencies that play roles in defining or controlling risks and assuring levels of safety or health. Determining whether “optimal” exposure characterization tools exist for responders and the public must be viewed across the agencies that set demands on the required data quality as well as by the agencies charged with assuring that the devices are usable in real disaster settings. Burdensome personal exposure sensors that are not worn faithfully in disaster settings are no more useful in disaster response frameworks than inappropriately worn personal protection devices. Policies—and tools—must be in place across agencies to assure that acute risks identified by timely determinations of adverse responder or public exposure are fully integrated with all mitigation options. Additionally, recent disasters have made it clear that defining the toxicity levels of contaminants can be extremely difficult, especially in a timely manner. Careful integration across programs charged with defining actual or potential doses, toxicity levels, and exposure characterizations during disasters would foster considerations for the timely development of exposure sample archival programs. This could dramatically enhance assessments of etiology when unexpectedly severe, post-disaster adverse health outcomes are observed. An overarching and coordinated research and development strategy defining the tools needed to support acute and chronic exposure characterizations is essential for a successful disaster response.
Although many steps to optimize disaster preparedness have been taken since 9/11, the various efforts related to exposure characterization are not well known or understood by the potential beneficiaries of these efforts. An information-gathering effort should be supported to assess the current state-of-the(-exposure)-science in each federal agencies programs addressing disaster response, as appropriate to the agency mission, authority, and funding. This would more clearly define what has or has not been done addressing exposure characterizations (across all agencies) to elucidate what still remains to be done. It would also identify and prioritize gaps in capabilities, responsibilities, and funding, especially in the areas of research and development.
One of the most important elements is description of the current state-of-the-art exposure science that could be applied by disaster type. Ownership can only be effectively addressed if the appropriate exposure technologies are currently viable and the exposure devices and procedures are actually available to the end users. Reviews of experiences during disasters such as 9/11, Katrina, and the recent California wildfires suggest that many exposure technologies needed to define risks for both responders and the public are simply not currently available.
Cursory reviews of disaster response policies across different levels of government suggest that, in many cases, specific nomenclature defining the need for “exposure” characterizations in disaster responses has sometimes been subsumed by more general terminology. The requirements for optimal and timely application of exposure science must be explicitly and clearly defined as a component of the risk assessment processes that optimally protect the health of individuals or populations. Just as measures of effective dose are distinctly different from estimates of potential dose, measures of contaminant concentrations are not necessarily equivalent to exposures. Ignoring such distinctions may result in substantially mischaracterizing risk levels, especially in the early disaster phases. It is crucial to apply concise language when defining exposure characterizations that can be clearly communicated to all involved across the disaster response timeline (the four R’s).
The ISES in coordination with the International Programme for Chemical Safety and the World Health Organization have already defined a glossary of exposure science terms leading to risk characterization (see http://www.iseaweb.org/glossary.php) that should be uniformly applied at all disaster response levels. This terminology should be fully integrated into all response protocols, training materials, simulation exercises, and public notifications to be maximally effective.
After defining ownership roles, the status quo, and a consistent exposure language, the lead agency (presumed to be DHS) should organize and expeditiously convene a stakeholder workshop to address the disaster preparedness exposure issues raised by the ISEA panel. At a minimum, the overall goals of the working group should be to:
The working group should plan and convene an initial workshop to bring together the responsible groups and skill sets needed to define and prioritize issues. The elements of the workshop would likely be organized along the lines of agency mission and expertise, with the lead federal agencies identifying stakeholder attendees (across federal, state, local, private, and academic communities) and discussion areas. Through the workshop elements, participants would review the ISES panel recommendations and prioritize them by perceived need. The members of this panel (authors of this article) form an obvious potential resource pool to support such a workshop in the most effective manner.
The assistance of Clifford Weisel (current ISES president) and Dana Barr (current editor of JESEE) in highlighting the critical importance of this exposure topic for both ISEA members and the public is greatly appreciated, as are the efforts of Michael Dellarco and Carol Rougvie in getting the special ISES Web page set up in a timely manner. We are indebted to Representative David Price for his thoughtful keynote comments supporting the critical importance of these issues, as well as to Darek Newby for providing Rep. Price’s material in a downloadable format for posting, especially during a very busy Congressional period. The assistance of Anne Lutes in preparing the initial draft paper from the panel summary material provided a very quick start to the process of getting the panel highlights into a JESEE format. And special thanks to Edo Pellizzari and Paul Lioy for their helpful insights during the panel planning process.
1The International Society for Exposure Analysis (ISEA) was renamed in 2008 the International Society for Exposure Science (ISES).
The United States Environmental Protection Agency through its Office of Research and Development has funded and managed the research mentioned by Vallero. It has been subjected to Agency review and approved for publication. The findings and conclusions of this report are those of the authors and do not necessarily represent the views of the National Institute for Occupational Safety and Health, the US Public Health Service, or the Department of Homeland Security.
Additional NIOSH resources on the Internet: