On 7th July 2005 terrorists attacked the transportation system in London detonating four improvised explosive devices. 56 persons died and over 700 were injured, 45 of them critically. These bombings were unexpected and besides causing major injury and loss of life, longer term health effects were reported. A full major incident command structure was put in place led by the London UK Metropolitan Police, and involved other emergency services, the health system and central government. The transportation system of the capital was severely affected with major disruption of the city transportation system for 24 hours. Road traffic became completely gridlocked in the central area with all transport inside the M25 beltway suspended. Communications failures included the breakdown of the mobile phone system due to overload. Despite previous experience with the management of bombing incidents in the UK, the scale of the attacks was significant and caused considerable strains on the emergency response system and public health as well as on the infrastructure of the city.

The European Union (EU) Mass Casualties and Health (MASH) project that ran between 2008 and 2010 was designed to study the management of mass casualties from chemical and radiological releases and associated health implications. One area of study for this project concerned arrangements within EU Member States for the management of mass casualties following a chemical release. This was undertaken via a confidential online questionnaire that was sent to selected points of contact throughout the EU. Responses were obtained from 18 states from respondents holding senior positions in chemical planning and incident response. Information gathered shows a lack of uniformity within the EU about the organization of responses to chemical releases and the provision of medical care. This article presents the overall findings of the study demonstrating differences between countries on planning and organization, decontamination, prehospital emergency medical responses, clinical diagnoses, and therapy and aftercare. Although there may be an understandable reluctance from national respondents to share information on security and other grounds, the findings, nevertheless, revealed substantial differences between current planning and operational responses within the EU states for the management of mass chemical casualties. The existing international networks for response to radiation incidents are not yet matched by equivalent networks for chemical responses yet sufficient information was available from the study to identify potential deficiencies, identify common casualty management pathways, and to make recommendations for future operations within the EU. Improvements in awareness and training and the application of modern information and communications will help to remedy this situation. Specialized advanced life support and other medical care for chemical casualties appear lacking in some countries. A program of specialized training and action are required to apply the findings revealed by the MASH study into a unified cross-border emergency medical response.

Toxicology is the study of the nature and mechanism(s) of toxic effects of substances on living organisms and other biological systems. This chapter summarizes a chemical incident where the source–pathway–receptor concept facilitated the investigation and remediation using environmental epidemiology tools.Toxicology is one of the key disciplines informing environmental epidemiology as it identifies harmful toxins and the precise nature of the potential harm. One of the main criteria for inferring causality proposed by(Bradford Hill 1965) is biological plausibility, and toxicology is fundamental to understanding the way in which a given toxin enters the body and acts on specific biological systems. The source–pathway–receptor model is a crucial part of our understanding of how environmental toxins can reach humans (and the susceptibility of particular population groups). This is particularly important in environmental epidemiology where exposures are often to complex mixtures of chemicals (waste sites, industrial effluent, smoke plumes, etc.) with multiple routes of exposure (air, water, soil) and levels of exposure are often relatively low. Toxicological information is vital in identifying which chemicals are most likely to cause toxic effects and in which form, so that any investigation of health effects correctly classifies individuals as exposed or unexposed. An understanding of chemical behaviour in the body informs the correct evaluation of environmental exposure and gives an indication of which media to sample in order to determine the relevant environmental exposure levels.

The immediate patterns of injury from explosions are well documented, from both military and civil experience. However, few studies have focused on less immediately apparent health consequences and latent effects of explosions in survivors, emergency responders and the surrounding community. This review aimed to analyze the risks to health following an explosion in a civil setting. A comprehensive review of the open literature was conducted, and data on 10 relevant military, civilian and industrial events were collected. Events were selected according to availability of published studies and involvement of large numbers of people injured. In addition, structured interviews with experts in the field were conducted, and existing national guidelines reviewed. The review revealed significant and potentially long-term health implications affecting various body systems and psychological well-being following exposure to an explosion. An awareness of the short- and long-term health effects of explosions is essential in screening for blast injuries, and identifying latent pathologies that could otherwise be overlooked in stressful situations with other visually distracting injuries and, often, mass casualties. Such knowledge would guide responsible medical staff in implementing early appropriate interventions to reduce the burden of long-term sequelae. Effective planning and response strategies would ensure accessibility of appropriate health care resources and evidence-based information in the aftermath of an explosion.

Chapter 1 explains the commonly used terms and definitions in toxicology, the role of toxicology in health protection, how to classify toxicological agents and toxins based on physico-chemical properties, and on types of toxic effects, discusses and describes the routes of exposure, the fate of toxins in the body, the principles of risk assessment, and how to apply acquired knowledge in the analysis and management of hazardous situations.

I suppose that many of us would choose to have known Leonardo da Vinci of all possible historical figures.I count myself most unfortunate, therefore,

Odour pollution is generally regarded as a local issue. The long range transport of odorants at levels sufficient to generate odour complaints far from their source is not normally given serious consideration, let alone subject to legislation. We argue that such an event led to an odour incident affecting much of southern and eastern England and use emission and dispersion modelling to support the contention.The specific incident discussed in this paper occurred in April 2008 with an initially unknown source and cause that resulted in hundreds of notifications of odour complaints across affected regions of England. Detailed analysis of the incident illustrates how a combination of the geographical distribution of odour reports together with emission and dispersion modelling can be utilised to trace the source location and source term of the odour. Two levels of dispersion modelling were applied. One was a simple integral model, which was used for quick feasibility and sensitivity studies, and the other a detailed trajectory and meteorological model from the UK Met. Office. Both approaches were used to assess the range of emission rates required to explain the incident.The analysis suggests that the source of the odorant was indeed not local, with Germany and the Benelux Countries the likely source region. The proposed source, sufficient to lead to odour perception hundreds of kilometres away, is the widespread application of agricultural slurry or manure. This is common practice in Europe during the spring and this has implications for future reports of odour travelling extensive distances and resulting in long range pollution events. The likelihood of further long range odour incidents in the UK is discussed, as are the general implications of the case study. (C) 2012 Elsevier Ltd. All rights reserved.

To develop a common structure for reports on health crises and critical health events guidelines have recently been published (Kulling et al 2010). They try to capture the experiences gained and for promoting a standardized methodology for sharing results and lessons. If future reporting follows common standards, then the documented findings would be comparable and could be used to learn and apply lessons within an individual field of activity and to apply those lessons learned also to other related preparedness activities. It could also facilitate the implementation of joint activities and joint reports involving different sectors. The development of this proposed method for common reporting on health crises and critical health events has been derived mainly from the following processes: (i) Health Disaster Management: Guidelines for Evaluation and Research in the Utstein Style; (ii) the Swedish Disaster Medicine Study Organization (KAMEDO); (iii) the Swedish Emergency Management Agency network of observers; (iv) the WHO Regional Office for Europe project (supported by the EU Health Programme) ‘Support Health Security, Preparedness Planning and Crisis Management in the EU, EU accession and neighboring (ENP) countries’ including expert consultations. The guidelines include the following headlines: Title, Preface, Authors, Executive Summary, Introduction/Material/Methodology, Pre-Event Status (Background, Preparedness, Hazard(s)involved, Risks, Vulnerability, Resilience), Health Crises and Critical Health Events (Damage, Consequences of Damage (Changes in Functions/Disturbances), Responses (Relief Responses, Recovery Responses), Development, Discussion, Lessons Identified and Actions Recommended, Conclusions, References, Appendices, Keywords, Index, Abbreviations. Pilot testing is suggested followed by an extensive review process. The guidelines should be supplemented further with determinants and indicators when the guidelines are used for in depth reporting to evaluate crisis response operations. Reference Kulling P, Birnbaum M, Murray V, Rockenschaub G. Guidelines for Reports on Health Crises and Critical Health Events.

Contaminated mass fatalities following the release of chemical, biological, or radiological agents pose a potential major health hazard. A United Kingdom government investigation has identified a number of areas of risk. This paper presents an outline of the findings of the study and describes specific pathways for the management of contaminated and non-contaminated fatalities. Factors determining the choice between cremation and burial are discussed. Effective decontamination remains a neglected area of study for both fatalities and casualties.

In the world today over 23 million chemical compounds are known to man.1 Of these chemicals, about 70 000 are in regular use and some 500 new ones are introduced every month into the market.2 The extensive use of chemicals in industrial processes and their storage, disposal and transport present hazards of chemical accidents (incidents) with the potential to harm humans and the environment. The mass disaster at Bhopal,3 the sarin subway attacks in Tokyo4 and the Lake Nyos incident5 have increased public awareness of the dangers of large acute chemical incidents in modern society. The majority of chemical incidents can do harm if incorrectly managed. The role of public health agencies, emergency response agencies, health providers and related organizations is to prevent, anticipate and respond to chemical incidents so as to reduce the impact on man and his environment.6 All these agencies have a duty to ensure the health and safety of their personnel in such incidents.7 There are well-defined procedures in place for the management of chemical incidents, including advice on incident scene management, decontamination of casualties and use of personal protective equipment for emergency responders.6,8–10 These guidelines are designed to contain the hazards of a chemical incident and minimize the environmental and human impact. However, in certain cases, chemical incidents have resulted in a spread of contamination from the scene to other locations.11,12 This contamination arising from activities subsequent to the actual chemical incident is known as secondary contamination. A hospital emergency room may be contaminated by chemicals from a patient who has primary contamination with material from the scene of the incident. Secondary contamination can occur from a patient even after death and may pose a serious health risk to persons in contact with the body. Recent incidents of secondary chemical contamination from human fatalities have revealed a need for a plan to manage chemically contaminated bodies effectively. Incidents involving chemically contaminated victims have resulted in confusion and adverse health effects in responders.13–15 The absence of guidance on the efficient management of chemically contaminated victims has increased the negative impact of these incidents. This paper aims to promote awareness of the potential impact of secondary contamination from chemically contaminated victims and offers preliminary guidance to those involved.

INTRODUCTION:Flooding accounts for about 40 per cent of all natural disasters that occur worldwide. In 2002-2003 many counties in England experienced severe floods. Floods are particularly important in public health terms as they may have multiple environmental consequences.METHODS:Details of floods reported to Chemical Hazards and Poisons Division, London [CHaPD(L)] were analysed and a literature review was undertaken to identify published reports of flood-related chemical incidents that have had an impact on public health.RESULTS:Epidemiological evidence shows that chemical material may contaminate homes and that in some cases flooding may lead to mobilization of dangerous chemicals from storage or remobilization of chemicals already in the environment, e.g. pesticides. Hazards may be greater when industrial or agricultural land adjoining residential land is affected. Less evidence exists to support the hypothesis that flooding that causes chemical contamination has a clear causal effect on the pattern of morbidity and mortality following these flooding events.CONCLUSION:In the light of this evidence, a checklist/pro forma for public health response to and investigation of flooding events that may result in chemical contamination was needed. This is available from CHaPD(L).

Agents of chemical warfare continue to pose a threat to human life. Organophosphorus compounds are possibly the best known and most used agents in recent times. These are known to produce acute ill health and death and, probably equally important, many diverse delayed effects, many of which are not clinically nor pathologically well defined. The immediate and delayed effects of organophosphorus compounds, in particular, and those of other known agents of chemical warfare, such as mustard gas, Lewisite, phosgene, cyanides and the newer crowd control agents, are reviewed. Environmental sequelae of these agents are gaining importance as probable causes of chronic ill health amongst those living in regions where these agents have been used. The need to study the pattern of disease in exposed populations is emphasised.

There is much debate about the need for clinical trials to prove the efficacy of complementary medicine. The UK Foundation for Integrated Medicine held a joint meeting of medical practitioners and complementary therapists in May, 1998. Two discussion documents1NHS ConfederationComplementary medicine in the NHS: managing the issues. NHS Confederation, Birmingham1997Google Scholar, 2Foundation for Integrated Healthcare 1997Integrated healthcare—a way foward for the next five years.J Alhern Complement Med. 1998; 4: 209-247Crossref PubMed Scopus (32) Google Scholar have repeated the call for further research. However, research takes time, and these demands do not take account of the fact that patients are seeking out and using these remedies irrespective of the absence of scientific evidence of efficacy or safety. We are concerned that medical practitioners may not take adequate notice of the use of complementary remedies by their patients.Since 1991, we have assessed reports of suspected adverse health effects of traditional and herbal remedies. We found that these remedies are fairly safe,3Shaw D Leon C Kolev S Murray V Traditional remedies and food supplements—a 5 year toxicological study (1991–1995).Drug Safety. 1997; 17: 342-356Crossref PubMed Scopus (245) Google Scholar but that many patients are afraid to inform their doctors of their use of herbal treatments for fear of a negative response.Physicians should seek to identify what complementary medicine is being taken whilst keeping an open-mind—negative and dismissive attitude to these medicines will not prevent their use. Lack of information exchange between doctor and patient may have many adverse outcomes. For example, doctors may not be kept informed of what herbal medicines their patients use, patients may stop using their prescribed medicines without informing their doctors, drug interactions between pharmaceuticals and herbal medicine may not be recognised, and adverse or beneficial effects may not be correctly attributed or investigated. Discussion between medical professionals and herbal practitioners when treating the same patient would reduce the chance of interactions and would also give the patient the confidence to discuss treatments with both therapists.Concern about the competence of the practitioners has been a barrier to the acceptance of complementary medicine.1NHS ConfederationComplementary medicine in the NHS: managing the issues. NHS Confederation, Birmingham1997Google Scholar A system of registration of herbal practitioners to ensure standards and professional standing would ease dialogue and improve mutual respect.Doctors and herbal practitioners should look for ways to collaborate in the care of patients to provide the most effective treatment. There is much debate about the need for clinical trials to prove the efficacy of complementary medicine. The UK Foundation for Integrated Medicine held a joint meeting of medical practitioners and complementary therapists in May, 1998. Two discussion documents1NHS ConfederationComplementary medicine in the NHS: managing the issues. NHS Confederation, Birmingham1997Google Scholar, 2Foundation for Integrated Healthcare 1997Integrated healthcare—a way foward for the next five years.J Alhern Complement Med. 1998; 4: 209-247Crossref PubMed Scopus (32) Google Scholar have repeated the call for further research. However, research takes time, and these demands do not take account of the fact that patients are seeking out and using these remedies irrespective of the absence of scientific evidence of efficacy or safety. We are concerned that medical practitioners may not take adequate notice of the use of complementary remedies by their patients. Since 1991, we have assessed reports of suspected adverse health effects of traditional and herbal remedies. We found that these remedies are fairly safe,3Shaw D Leon C Kolev S Murray V Traditional remedies and food supplements—a 5 year toxicological study (1991–1995).Drug Safety. 1997; 17: 342-356Crossref PubMed Scopus (245) Google Scholar but that many patients are afraid to inform their doctors of their use of herbal treatments for fear of a negative response. Physicians should seek to identify what complementary medicine is being taken whilst keeping an open-mind—negative and dismissive attitude to these medicines will not prevent their use. Lack of information exchange between doctor and patient may have many adverse outcomes. For example, doctors may not be kept informed of what herbal medicines their patients use, patients may stop using their prescribed medicines without informing their doctors, drug interactions between pharmaceuticals and herbal medicine may not be recognised, and adverse or beneficial effects may not be correctly attributed or investigated. Discussion between medical professionals and herbal practitioners when treating the same patient would reduce the chance of interactions and would also give the patient the confidence to discuss treatments with both therapists. Concern about the competence of the practitioners has been a barrier to the acceptance of complementary medicine.1NHS ConfederationComplementary medicine in the NHS: managing the issues. NHS Confederation, Birmingham1997Google Scholar A system of registration of herbal practitioners to ensure standards and professional standing would ease dialogue and improve mutual respect. Doctors and herbal practitioners should look for ways to collaborate in the care of patients to provide the most effective treatment.

In response to your July 18 editorial,1Editorial“Safety” of chemical batons.Lancet. 1998; 352: 159Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar we draw your attention to our surveillance into crowd control agents (CCA)—eg, CS (orthochlorobenzylidene malonitrile) gas, mace (chloracetothenon, CNgas), and pepper spray—and possible adverse health effects after exposure. The National Poisons Information Service (London) (NPIS[L]) collates information concerning patient inquiries. In 1994, NPIS(L) was contacted about 327 casualties exposed to CCAs. In 1995, this figure rose to 654, in 1996, 810, and in 1997, 597. Enquiries to NPIS(L) are made in cases in which patient management advice for patients is required. It is likely that as the legal use of CS spray becomes more widespread, medical personnel will become familiar with the recommended treatment and will not seek advice from poisons centres.2Volans GN Wiseman HM Surveillance of poisons—the role of poison control centres.in: Eylenbosh WJ Noah NI Surveillance in health and disease. Oxford University Press, Oxford1988: 258Google Scholar Therefore, the data reported above, and on which our research and surveillance for 1998 are based, are likely to be only the tip of the iceberg. In 1996, various English police forces started to use CS sprays for their immediate short-lived effects. The police incapacitant used in England contains CS (5% concentration), the solvent methyl isobutyl ketone (MIBK), and a nitrogen propellant. A review of The English-language press found no reports of the use of MIBK, and CS in field conditions, although concerns have been expressed. Analysis of the CCA enquiries made to NPIS(L) in 1997 found that 454 (76%) were within 6 h of exposure and 143 (24%) were made after 6 h, with 11% of these latter enquiries made more than 36 h after exposure. Patients are not always exposed to CCA alone, and clinical effects may be due to other agents. The Table shows the differences in observed clinical effects occurring within 6 h of exposure and later. Crude analysis of the results suggests significant differences in dermal and gastrointestinal symptoms between the two periods. CS spray has been reported to cause erythematous contact dermatitis and allergic contact dermatitis with vesicles, blisters, and crusts.4Parnix-Spake A Theisen AJ Roujeau JC Revuz J Severe cutaneous reactions to selfdefense sprays.Arch Dermatitis. 1998; 20: 316Google Scholar CS was tested extensively by Himsworth3Himsworth H Black DAK Crawford I et al.Report of the inquiry into the medical and toxicological aspects of CS (orthochlorobenzylidine malonitrile), part I: and part II: enquiry into the medical situation following the use of CS in Londonderry on 13 and 14 August, 1969, and enquiry into toxocilogical aspects of CS and its use for civil purposes. HM Stationery Office, London1969Google Scholar, 4Parnix-Spake A Theisen AJ Roujeau JC Revuz J Severe cutaneous reactions to selfdefense sprays.Arch Dermatitis. 1998; 20: 316Google Scholar and others5Wheeler H Use and management of crowd control agents.Emergency Nurse. 1998; 5: 18-21Google Scholar and is generally shown to be safe and efficient with short-lived, self-limiting effects. However, the initial findings that we now report show that delayed adverse effects may be occurring as a result of CS spray. As a consequence of this crude analysis we are undertaking a further study to investigate adverse health effects after exposure to CCAs. We have followed up all CCA incidents reported to the NPIS(L) over 7 months (January to July, 1998) with three aims.TableTotal clinical effects of Crowd Control Agents in 1997 in 597 patients reported to the National Poisons Information Service (London)Clinical effects reported within 6 h of exposureNo (%)Clinical effects reported after 6 h of exposureNo (%)Crude differences between proportions p-value (95% CI)Ocular (irritation, lacrimation)191 (32)Ocular (irritation, corneal abrasions215 (36)0·2 (20·05 to 0·4)Dermal (rash, irritation, erythema, dermatitis)54 (9)Dermal (blisters, bullae, eczema, oedema)203 (34)<0·0001 (0·15–0·30)Respiratory (coughing, short of breath)30 (5)Respiratory (coughing, short of breath)24 (4)0·37 (0·02–0·11)Neurological (headache, drowsy)60 (10)Neurological (headache, drowsy)42 (7)0·02 (20·09 to 0·4)Cardiac (tachycardia, hypotension)24 (4)Cardiac (chest pain)36 (6)0·26 (20·04 to 0·14)Gastrointestinal (buccal irritation, vomiting)42 (7)Gastrointestinal (buccal irritation, vomiting)66 (11)<0·0001 (0·04 to 0·14)None48 (8)None6 (1)·Clinical effects not stated by inquirer119 (20)Clinical effects not stated by inquirer3 (0·5)·Other30 (5)Other3 (0·5)· Open table in a new tab First to determine short-term and medium-term clinical effects of exposure to CCAs; second, the proportion of enquiries in which police incapacitant spray was used; and third, whether the clinical symptoms resulting from exposure to police CS incapacitant (containing MIBK) are different from symptoms reported after exposure to other CCAs.

The relation between concentration of blood lead and ethnic background in 779 children was examined with the analytical results from the trace element service at the Medical Toxicology Unit (MTU), Guy's and St Thomas's Hospital Trust for the period 1980-94. The ethnic identity was determined with the first and the second names of the investigated subjects. Of the patients of European origin (European) studied 72.8% v only 50.6% of the children with origins in the Indian subcontinent (Asian) had a concentration of blood lead < 100 micrograms/l. The percentage of subgroups with concentrations above the upper acceptable limit of 200 micrograms/l was significantly higher in Asian subjects (European 5% v Asian 26.5%), with the most pronounced difference in those with concentrations of blood lead of 500 micrograms/l (European 0.8% v Asian 10.5%). This study shows that a correlation exists between Asian ethnic background and concentration of blood lead in children. Factors such as cultural habits-for example, use of traditional remedies, cosmetics, diet- and socioeconomic status, may have contributed to this results.

blood dyscrasias, including 12 of aplastic anaemia, possibly related to topical administration of chloramphenicol have been registered at the National Registry of Drug-Induced Ocular Side Effects in the United States.2The duration of treatment ranged from 18 to 1460 days (median 120 days).Doona and Walsh affirm that framycetin and fusidic acid are equally effective.These agents do not cover the wide range of bacterial pathogens implicated in eye infections, and when used alone they promote rapid emergence of resistance.Fusidic acid is an antistaphylococcal agent, and framycetin lacks activity against anaerobes and streptococci.The treatment whose antibacterial spectrum approaches that of chloramphenicol, but with reduced anaerobic activity, is a combination of neomycin, polymyxin B, and gramicidin.This costs C5.36 for 5 ml, compared with 50p for 10 ml of chloramphenicol eye drops.Although there is potential for topical chloramphenicol to produce aplastic anaemia, more hard data on the absolute risk are needed before such a hard judgment is passed on a product that is effective, cheap, and well tolerated.To minimise toxicity even further, treatment with chloramphenicol should be short and avoided in patients with a personal or family history of bone marrow abnormality.