Outline 17/07/2014. Chemical fatality and self-harm incidents: Managing the risk to health. Japanese suicide outbreak in 2008

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1 Chemical fatality and self-harm incidents: Managing the risk to health Centre for Radiation, Chemical and Environmental Hazards (CRCE) Outline Background: Japanese suicide outbreak and incidents in the United States PHE (HPA) involvement: Incidents in England and Wales Common scenarios and case studies: Health implications Chemical fatalities management guidance document 2 Chemical Fatalities PROTECT Japanese suicide outbreak in 2008 Morii D, Miyagatani Y, Nakamae N, Murao M, Taniyama K. Japanese experience of hydrogen sulphide: the suicide craze in Journal of Occupational Medicine and Toxicology 2010; 5(28). Japanese Cabinet Office reported 220 gas suicide attempts (208 deaths) between March and June 2008, compared to 29 in Spate of detergent suicides involving homemade hydrogen sulphide (H 2 S) gas. Method commonly involves mixing household chemicals Outbreak was blamed on new method of making the gas, transmitted through message boards on the internet. 3 Chemical Fatalities PROTECT 1

2 Example: Japanese girl commits suicide with detergent, April 24 th 2008 (Associated Press) 14-year-old Japanese girl in Konan, southern Japan, killed herself in her bathroom by mixing laundry detergent with liquid cleanser, releasing hydrogen sulphide (H 2 S) gas. Sign affixed to outside of bathroom door warning gas being emitted. Gas escaped from the girl's bathroom window and entered neighbouring apartments. 90 neighbours in the apartment block reported symptoms - none were severely ill, although 10 were admitted to hospital. 4 Chemical Fatalities PROTECT 5 Chemical Fatalities PROTECT Background: Increase in chemical suicides in the United States, 2009 Most victims were males in their teens or early twenties. Again victims find instructions on the internet: - use a confined space with little air exchange e.g. small room or car. - some websites recommend taping plastic sheets over windows and doors to prevent gases escaping. - websites commonly suggest using signs to warn of toxic gas and prevent others being harmed. 6 Chemical Fatalities PROTECT 2

3 Chemical fatality inside a vehicle, New York State, Chemical Fatalities PROTECT 8 Chemical Fatalities PROTECT Chemical fatality management guidance note: background Chemical fatality incidents reported to HPA (2007 to 2012) Other Inert P CN H2S Chemical Fatalities PROTECT 3

4 Access 10 Chemical Fatalities PROTECT Chemical fatalities: Common scenarios 1. Ingestion Ingestion of a substance that reacts with acid (e.g. stomach acid) or moisture (e.g. mucous membrane) to produce a toxic gas. Chemical reaction inside the body. Potential risk of exposure to toxic gas produced from off-gassing from the body and/or contaminated bodily fluids (e.g. vomitus). E.g. cyanide salts, aluminium phosphide pellets, sulphide salts 11 Chemical Fatalities PROTECT An example of an ingestion scenario Chemical fatality in the North West England 60 year old male was found dead at his home after ingesting sodium azide (NaN 3 ) mixed in a glass of orange juice Suicide note present at scene Local Police, Ambulance Hazardous Area Response Team (HART), Fire and Rescue Service HAZMAT officer attended the scene PHE (HPA) initially contacted by local hospital to advise on the potential risk from secondary contamination 12 Chemical Fatalities PROTECT 4

5 Sodium azide (NaN 3 ) CAS: Colourless-white, crystalline solid Toxic by ingestion, inhalation, and through skin contact Reacts with stomach acid to form hydrazoic acid (HN 3 ) an irritant gas 13 Chemical Fatalities PROTECT Health protection considerations A risk to first responders at the scene? - Potential exposure to sodium azide residues - Potential risk from off-gassing of hydrazoic acid from the body - Confined space How to move the body? - Cautious approach as potential risk of off-gassing - Use chemical-resistant body-bag - Use appropriate PPE Decontamination of equipment/kit? - Non-persistent chemical double-bag and then clean with soapy water 14 Chemical Fatalities PROTECT Health protection considerations Need to evacuate neighbours? - Ventilation of property Transporting the body? - Transport to mortuary - Ideally use ventilated undertaker s van Other issues: - Need for post mortem? - Contamination from burial? 15 Chemical Fatalities PROTECT 5

6 Chemical fatalities: Common scenarios 2. Inhalation Inhalation of a toxic gas Gas may be produced by a chemical reaction external to body Low risk of secondary exposure from off-gassing of the body Risk of exposure to elevated airborne concentrations of gas and contamination from chemicals present at the scene - e.g. hydrogen sulphide (H 2 S) gas, hydrogen cyanide (HCN) gas, phosphine (PH 3 ) gas Inert gases may also be used for asphyxiation e.g. argon, helium, nitrogen Also carbon monoxide (CO) & carbon dioxide (CO 2 ) 16 Chemical Fatalities PROTECT Double chemical fatality in Essex Two people found dead in car at 8.20 am. Signs in car window indicating hydrogen sulphide gas inside. Mixed lime sulphur with hydrochloric acid. Police, Fire Service with Detection Identification and Monitoring (DIM) equipment, and Ambulance Hazardous Area Response Team (HART) attended the scene. Workers in the local area were evacuated. 17 Chemical Fatalities PROTECT Chemical hazards Hydrogen sulphide gas (H 2 S) Colourless gas, odour of rotten eggs Highly toxic by inhalation Hydrochloric acid (HCl) Colourless-yellow liquid (fumes at high concentrations) Corrosive by ingestion, inhalation, eye contact and skin contact Lime sulphur (CaS x ) Red-orange solid or solution Irritant by ingestion, inhalation, eye contact and skin contact 18 Chemical Fatalities PROTECT 6

7 Health protection considerations Risk from the body? - Inhalation of hydrogen sulphide gas, therefore potential for off-gassing reduced - Chemical resistant body bag unlikely to be required Risk from vehicle? - Explosive risk? - Risk to contractors disposing of car? 19 Chemical Fatalities PROTECT Chemical fatality management guidance note 20 Chemical Fatalities PROTECT Chemical incident Fatality Awareness of potential for secondary contamination Risk assessment: chemical hazard, route of exposure, location, symptoms (patient/bystanders), timing Regular consultation between responsible Agencies Primarily the Coroner, Police, other emergency services - also occupational health, and toxicologists Agent identification Decontamination and containment Transportation and storage Tentative identification based on evidence from scene Detection and identification of chemical by emergency services External decontamination may not remove risks associated with off-gassing Chemical resistant body bags may be required Transportation in a refrigerated vehicle with a separate cab Post-mortem (if required) Risk assessment based on evidence from scene and monitoring data Undertaken in a suitable facility with PPE Disposal of body Burial or cremation within a chemical resistant body bag 21 Chemical Fatalities PROTECT 7

8 Conclusions Potential health implications for emergency responders and the wider public Responders may have limited experience of managing these incidents Importance of early identification of the chemical(s) All routes of potential exposure may not have been considered (e.g. potential risk from off-gassing) Importance of risk assessment 22 Chemical Fatalities PROTECT Acknowledgements: Henrietta Harrison, CRCE Chilton/Bristol Robie Kamanyire, CRCE London Alex Ray, Metropolitan Police Chris Perry, Department of Health Ceri Howells, National Policing Improvement Agency CBRN Gerry Byrne, National Policing Improvement Agency CBRN Simon Churchill, National Policing Improvement Agency CBRN Ian Tippet, Metropolitan Police Tony Biles, London Fire Brigade 23 Chemical Fatalities PROTECT 8