Responding to “Bug Bomb” Incidents

by Michael Heffner

Tuesday, 9:12 a.m., partly sunny, 56°F. Engine 6 and Ladder 4 are dispatched to a familiar senior living facility on a fire alarm. Halfway to the call, dispatch advises that this is a false alarm. The engine company officer subsequently cancels the ladder truck but continues as a nonemergency response to the facility to ensure the alarm is reset properly. However, minutes later, dispatch reports that the alarm was caused by an aerosol canister releasing insecticide (photo 1). Now, five elderly patients are complaining of respiratory distress, skin and eye irritation, abdominal cramps, and malaise. Engine 6 then upgrades to an emergency response to the facility and requests that the call be upgraded to a hazardous materials alarm. This will bring the response of a hazmat team, additional engine companies, a ladder truck, five ambulances, and an emergency medical services (EMS) supervisor.

(1) Photo by author.

Total-Release Fogger Hazards

Bug bombs, or total-release foggers in aerosolized canisters, contain pyrethrins, natural extracts of chrysanthemum flowers that are rapidly absorbed by insects, causing paralysis.1 Increasingly offered as pest control solutions for home and garden use, pyrethrins are replacing more hazardous organophosphate insecticides such as malathion, parathion, and diazanon.

Another hazard to keep in mind is that some total-release foggers may be pressurized with flammable propellants, so keep the vapors away from ignition sources such as pilot lights on furnaces and stoves.2

A manmade variation of pyrethins is pyrethroids. The U.S. Environmental Protection Agency (EPA) notes, “Pyrethroids are synthetic chemical insecticides whose chemical structures are adapted from the chemical structures of the pyrethrins and act in a similar manner to pyrethrins.”3 Pyrethroids are engineered to be more resistant than their natural counterpart and to thrive longer against environmental elements.

Total-Release Fogger Accidents

In a comprehensive study of acute exposures to total-release foggers in 10 states, the Centers for Disease Control and Prevention (CDC) identified 3,222 instances that resulted in illness, injury, or fatality.4 Among these cases, 91 percent occurred in private residences, and the study concluded: “The most commonly reported causes of exposure were failure to vacate treated premises during application, early reentry into treated premises, inability to vacate treated premises before [total-release fogger] discharge, and inadequate ventilation of treated premises.” (4)

In an earlier CDC study, 466 injuries were identified as resulting from total-release fogger incidents in eight states (California, Florida, Louisiana, Michigan, New York, Oregon, Texas, and Washington) between 2001 and 2006.5 Among these cases, 394 (85 percent) occurred in private residences, of which nearly half involved the person activating the total-release fogger.

Health Effects

Although pyrethrins are generally not harmful to humans, contact with the skin or eyes or ingestion may cause illness, especially in those susceptible to asthma or who have preexisting medical conditions.6 Exposure to pyrethrins may result in respiratory distress, skin and eye irritation, gastrointestinal ailments, and neurological symptoms such a paresthesia.7 The recent CDC study noted, “Respiratory signs and symptoms (cough, upper respiratory pain or irritation, and dyspnea) and gastrointestinal signs and symptoms (vomiting, nausea, and abdominal pain or cramping) were the most commonly reported.” (4)

As a guidance document for health care professionals, the EPA’s Recognition and Management of Pesticide Poisonings recommends the following prehospital treatments for patients accidentally exposed to pyrethrins:

Consider antihistamines, bronchodilator inhalers, and systemic corticosteroids to treat allergic reactions.
Treat anaphylaxis with epinephrine, and provide respiratory support.
Flush the eyes with water or saline, and decontaminate the skin to reduce irritation.
As protocols and medical direction allow, consider administration of activated charcoal to treat ingestion of pyrethrins. (1)

Recommended Actions

In situations where evacuating numerous occupants with mobility challenges exceeds the number of personnel and resources needed to do so, it is essential to remove that hazardous environment through ventilation to minimize poor outcomes. Addressing a similar scenario at a structure fire, Assistant Chief (Ret.) John “Skip” Coleman writes, “Look at your staffing levels and the life loss potential, and then consider aggressive ventilation to remove the IDLH [immediately dangerous to life or health] from the victims as opposed to removing the victims from the IDLH.”8

On arrival, Engine 6 initiates command and establishes the tactical priorities of locating and removing victims to fresh air, ventilating the structure, and triaging those exposed to aerosolized contents released by the total-release fogger. Recognizing the potential for a significant number of evacuees with mobility challenges, the incident commander (IC) requests a second alarm and that the local transit authority dispatch buses with wheelchair accessibility to provide evacuees safe refuge from the weather.

EMS Operational Precautions

When a patient cannot be fully decontaminated on scene, EMS responders transporting patients in an ambulance should take precautions to protect themselves, the patient, and the receiving hospital from ongoing exposure.

First, EMS responders must don appropriate personal protective equipment that defends against exposure from inhalation, dermal contact, or ingestion and secondary contamination of uniforms or workwear. Such an ensemble typically includes donning gloves, an appropriate respirator, a disposable fluid-resistant coverall or suit, eye protection, and shoe covers or overbooties. A specialized EMS transport team may be required.

Second, once the patient is removed from the area of the release—or “hot zone”—he should be fully disrobed and then undergo gross decontamination to reduce external chemical residue.1 If specialized decontamination resources are available on scene prior to patient transport and if urgent transport is not warranted to treat life-threatening conditions, the patient should undergo technical decontamination to render contamination to levels as low as reasonably achievable.2

Third, ambulance personnel should notify the receiving hospital of a potentially contaminated patient, transmit what the patient was exposed to, and inquire about specific protocols the hospital may have for receiving a patient exposed to hazardous materials. During transport, consider operating the ambulance’s ventilation system and exhausting any odors or noxious fumes out of the vehicle. Take care to use disposable sheets or blankets to prevent unnecessary contamination of the gurney and other EMS equipment. An emesis bag should be available to contain any patient vomit that might off-gas. (1)

Fourth, after the patient has been properly transferred to the emergency department medical care team, the ambulance crew should ensure that they, their equipment, and the ambulance are conclusively decontaminated. While OSHA notes, “… prevention is the first line of defense for preserving emergency medical resources,” following a standardized approach of decontaminating the ambulance after each run is a worthwhile strategy.3 Decontamination of the ambulance should follow a process of first wiping and/or absorbing potential residual contamination from nonporous surfaces; then applying a neutralizing agent as recommended by the total-release fogger’s material safety data sheet; and, finally, cleaning surfaces with soap and hot water to loosen and remove any remaining organic material. Consider using a decon contractor when in-house resources are not available.

REFERENCES

1. ATSDR. (2001). Medical management guidelines. Retrieved from Agency for Toxic Substances & Disease Registry: https://www.atsdr.cdc.gov/MHMI/mhmi-v1-3.pdf.

2. Chilcott, R., & Amlot, R. (2018). Primary response incident scene management guidance for chemical incidents. Retrieved from Medical Countermeasures: https://www.medicalcountermeasures.gov/media/36872/prism-volume-1.pdf.

3. OSHA. (2009). Best practices for protecting EMS responders during treatment and transport of victims of hazardous substance releases. Retrieved from Occupational Safety and Health Administration: https://www.osha.gov/Publications/OSHA3370-protecting-EMS-respondersSM.pdf.

Firefighters assigned to the Evacuation Group don turnouts and self-contained breathing apparatus, wear medical gloves under their fire-resistant gloves to protect their hands from chemical exposure, and assist occupants out of the building and into the buses. The ladder truck crew isolates the affected area of the facility by closing doorways and systematically ventilates the structure using positive-pressure fans. Members of the hazmat team research the product involved, conduct air monitoring, and prepare a plan to decontaminate patients and responders if needed.

Ultimately, none of the victims are transported to the hospital, as their symptoms begin to resolve once they are outside. All are treated on scene according to the EPA’s guidelines and encouraged to follow up with their primary care physician.

As is becoming a standard practice in the fire service, firefighters perform a gross decontamination of their turnouts on scene and bag them for laundering, wipe off any exposed skin, place themselves out of service until swapping into clean turnouts, take a shower back at the station, and properly launder their contaminated gear to prevent any secondary exposures.

The discharge of pressurized pyrethrins in a senior living facility will present scene management challenges for responders. Given the number of exposures to total-release foggers observed in the CDC studies, this type of response is worth preplanning. First responders, hazmat teams, and EMS crews must train and work together to maximize limited resources and minimize acute health effects. This sample incident serves as a reminder for responders to tour high-density occupancies in their first-due area, develop preplans, and regularly conduct fire and life safety audits to ensure occupants are quickly alerted to emergencies and can be safely evacuated.

References

1. Roberts, J and Reigart, J. (2013). Pyretrhins and pyrethroids. In Recognition and management of pesticide poisoning. Washington, D.C.: U.S. Environmental Protection Agency. https://bit.ly/2MMt7mW.

2. CDPR. (n.d.). Don’t drop the ‘bomb’ without safety check. California Department of Pesticide Regulation. Retrieved from www.cdpr.ca.gov.

3. EPA. (2017, September 15). Pyrethrins and pyrethroids. Retrieved from United States Environtmental Protection Agency: https://bit.ly/1Vqib0k.

4. CDC. (2018, February 2). Acute illnesses and injuries related to total release foggers – 10 states, 2007-2015. Morbidity and Mortality Weekly Report, 67(4), 125-130. Retrieved from Centers for Disease Control and Prevention. https://bit.ly/2xpLlWu.

5. CDC. (2008). Illnesses and injuries related to total release foggers – eight states, 2001-2006. Morbidity and Mortality Weekly Report, 57(41), 1125-1129. Retrieved from Centers for Disease Control and Prevention, https://bit.ly/2NRfCXJ.

6. NPIC. (2014). Pyrethrins general fact sheet. Retrieved from National Pesticide Information Center: https://bit.ly/2xAds4A.

7. Hudson, N., Kasner, E., Beckman, J., Mehler, L., Schwartz, A., Higgins, S., … Calvert, G. (2014). Characteristics and magnitude of acute pesticide-related illnesses and injuries associated with pyrethrin and pyrethroid exposures – 11 states, 2000-2008. American Journal of Industrial Medicine, 15-30. doi:10.1002/ajim.22216.

8. Coleman, J. (2005 March). “Remove the IDLH, not the victims,” Fire Engineering, 158(3), 176-178. https://bit.ly/2O15tHM.

MICHAEL HEFFNER is a 20-year veteran of the fire service and an assistant chief deputy with the Oregon Office of State Fire Marshal, where he oversees the state’s regional hazmat emergency response team program. He has served in operational, administrative, and training roles involving fire, hazmat, and emergency medical services. Heffner has a master’s degree in emergency services administration and is a licensed paramedic.