v Coping With a Traumatic Event–Information for the Public

What is a traumatic event?

An event, or series of events, that causes moderate to severe stress reactions, is called a traumatic event. Traumatic events are characterized by a sense of horror, helplessness, serious injury, or the threat of serious injury or death. Traumatic events affect survivors, rescue workers, and friends and relatives of victims who have been directly involved. In addition to potentially affecting those who suffer injuries or loss, they may also affect people who have witnessed the event either firsthand or on television. Stress reactions immediately following a traumatic event are very common; however, most of the reactions will resolve within ten days.

Why do these injuries occur in mass trauma events?

• Eye injuries and irritation can occur from excess particles (such as soot, dirt, powder, paint chips), fumes or smoke present in the air after a disaster event. More serious eye problems can result from metal or glass fragments that enter the eye at high velocity.

• Sprains and strains are common in these situations and can occur as people escape the scene, fall, are thrown or pushed down by a force, or carry others who are in need of assistance.

• Minor wounds can be caused by flying debris and falling on or scraping against sharp objects.

• Eardrum damage can occur from a foreign body entering the ear, a blow or jolt to the head, or an extreme and sudden noise (i.e., explosion) all of which are likely in a mass trauma event.

What are some common responses?

A person’s response to a traumatic event may vary. Responses include feelings of fear, grief and depression. Physical and behavioral responses include nausea, dizziness, and changes in appetite and sleep pattern as well as withdrawal from daily activities. Responses to trauma can last for weeks to months before people start to feel normal again. 

Most people report feeling better within three months after a traumatic event. If the problems become worse or last longer than one month after the event, the person may be suffering from post-traumatic stress disorder (PTSD). 

What is PTSD?

Post-traumatic stress disorder (PTSD) is an intense physical and emotional response to thoughts and reminders of the event that last for many weeks or months after the traumatic event. The symptoms of PTSD fall into three broad types: re-living, avoidance and increased arousal.

• Symptoms of re-living include flashbacks, nightmares, and extreme emotional and physical reactions to reminders of the event. Emotional reactions can include feeling guilty, extreme fear of harm, and numbing of emotions. Physical reactions can include uncontrollable shaking, chills or heart palpitations, and tension headaches.

• Symptoms of avoidance include staying away from activities, places, thoughts, or feelings related to the trauma or feeling detached or estranged from others.

• Symptoms of increased arousal include being overly alert or easily startled, difficulty sleeping, irritability or outbursts of anger, and lack of concentration.

Other symptoms linked with PTSD include: panic attacks, depression, suicidal thoughts and feelings, drug abuse, feelings of being estranged and isolated, and not being able to complete daily tasks.

What can you do for yourself? 

There are many things you can do to cope with traumatic events.

• Understand that your symptoms may be normal, especially right after the trauma.

• Keep to your usual routine.

• Take the time to resolve day-to-day conflicts so they do not add to your stress.

• Do not shy away from situations, people and places that remind you of the trauma.

• Find ways to relax and be kind to yourself.

• Turn to family, friends, and clergy person for support, and talk about your experiences and feelings with them.

• Participate in leisure and recreational activities.

• Recognize that you cannot control everything.

• Recognize the need for trained help, and call a local mental health center.

Let your child know that it is okay to feel upset when something bad or scary happens.

• Encourage your child to express feelings and thoughts, without making judgments.

• Return to daily routines.

When should you contact your doctor or mental health professional?

About half of those with PTSD recover within three months without treatment. Sometimes symptoms do not go away on their own or they last for more than three months. This may happen because of the severity of the event, direct exposure to the traumatic event, seriousness of the threat to life, the number of times an event happened, a history of past trauma, and psychological problems before the event. 

You may need to consider seeking professional help if your symptoms affect your relationship with your family and friends, or affect your job. If you suspect that you or someone you know has PTSD, talk with a health care provider or call your local mental health clinic.

v Coping With a Traumatic Event–Information for Health Professionals

How do you interact with patients after a traumatic event?

The clinician should be alert to the various needs of the traumatized person.

• Listen and encourage patients to talk about their reactions when they feel ready.

• Validate the emotional reactions of the person. Intense, painful reactions are common responses to a traumatic event.

• De-emphasize clinical, diagnostic, and pathological language.

• Communicate, person to person rather than "expert" to "victim," using straightforward terms.

What can you do to help patients cope with a traumatic event? 

Explain that their symptoms may be normal, especially right after the traumatic event, and then encourage patients to:

• Identify concrete needs and attempt to help. Traumatized persons are often preoccupied with concrete needs (e.g., How do I know if my friends made it to the hospital?).

• Keep to their usual routine.

• Help identify ways to relax.

• Face situations, people and places that remind them of the traumatic event— not to shy away.

• Take the time to resolve day-to-day conflicts so they do not build up and add to their stress.

• Identify sources of support including family and friends. Encourage talking about their experiences and feelings with friends, family, or other support networks (e.g., clergy and community centers).  

Who is at risk for severe and longer lasting reactions to trauma? 

Some people are at greater risk than others for developing sustained and long-term reactions to a traumatic event including disorders such as post-traumatic stress disorder (PTSD), depression, and generalized anxiety. Factors that contribute to the risk of long-term impairment such as PTSD are listed.

• Proximity to the event. Closer exposure to actual event leads to greater risk (dose-response phenomenon).

• Multiple stressors. More stress or an accumulation of stressors may create more difficulty.

• History of trauma.

• Meaning of the event in relation to past stressors. A traumatic event may activate unresolved fears or frightening memories.

• Persons with chronic medical illness or psychological disorders.

What can you do to treat patients in response to a traumatic event?

Helping survivors of traumatic events, their family members, and emergency rescue personnel requires preparation, sensitivity, assertiveness, flexibility and common sense.

• Refer patients to a mental health professional in your area who has experience treating the needs of survivors of traumatic events.

• Provide education to help people identify symptoms of anxiety, depression, and PTSD (see resources).

• Offer clinical follow-up when appropriate, including referrals to mental health professionals.

What can health departments do to prepare for a mass trauma event?

1. Notify doctors and hospitals in advance about the kinds of injuries to expect following a disaster.

2. Review CDC’s Mass Trauma Response Tools, including the Rapid Assessment Instrument for Injuries and Other Medical Conditions.

3. Establish partnerships with hospitals in your state to develop protocols for rapid assessment, casualty prediction, hospital capacity information, and patient care.

4. Prepare signs. Persons with hearing damage as a result of a recent explosion may not be able to follow verbal directions. They would benefit from explicit, easy-to-read signs and handouts that are strategically located and distributed in hospitals and clinics.

5. Communicate to health care professionals, media, and general public that medical personnel should examine all cuts and wounds resulting from mass trauma events. Tiny debris particles from explosions, building collapse, or other disaster events can be embedded into wounds and are often highly contaminated. Even minor wounds are at risk for infection. Medical personnel should evaluate all wounds, and a tetanus shot should be considered.

What can health departments do after a mass trauma event?

Mass trauma events can create both real and perceived difficulties in accessing medical care. Outpatient and inpatient services at the hospitals closest to the event will likely be the ones most affected during the first 16 hours after an event. In the days following a mass trauma event, all health care facilities are often underutilized. Health Departments can:

• Contact area and regional hospitals to assess their capacity to care for new patients. If the capacity of individual hospitals cannot be confirmed, recommend that less severely injured patients go to hospitals outside the immediate area of the event. If individual hospital capacity can be confirmed, publicize more specific information about where people should go for medical care.

• Work with news media to release information that encourages all injured persons to seek medical treatment because these injuries can have lasting effects and can become infected if not treated properly.

• Conduct a rapid assessment of injuries using CDC’s Rapid Assessment Instrument for Injuries and Other Medical Conditions.

• American Red Cross focuses on meeting people’s immediate emergency needs after a disaster, such as shelter, food, and physical and mental health services. They also feed emergency workers, handle inquiries from concerned family members outside the disaster area, provide blood and blood products to disaster victims, and help those affected connect with other resources.

• Anxiety Disorders Association of America (ADAA) informs the public, healthcare professionals and legislators that anxiety disorders are real, serious and treatable. The ADAA promotes early diagnosis and treatment of anxiety disorders, and works to improve the lives of the people who suffer from them.

• National Center for Post-Traumatic Stress Disorder (NCPTSD) is part of the Department of Veterans Affairs. They work to improve the clinical care and social welfare of America’s veterans through research, education, and training in the science, diagnosis, and treatment of PTSD and stress-related disorders. NCPTSD works with many different agencies and groups including veterans and their families, government policymakers, scientists and researchers, doctors and psychiatrists, journalists, and the public. This website is provided as an educational resource concerning PTSD and other consequences of traumatic stress.

www.ncptsd.org

• National Institute on Mental Health (NIMH) is part of the U.S. government’s National Institutes of Health. NIMH is responsible for research on mental health and mental disorders, including research on the mental health consequences of and interventions after disasters and acts of mass violence.

• Posttraumatic Stress Disorder (PTSD) Alliance is an alliance of professional and advocacy organizations that provide educational resources to individuals diagnosed with PTSD and their loved ones; those at risk for developing PTSD; and medical, healthcare and other professionals.

• Substance Abuse and Mental Health Services Agency (SAMHSA) is the lead mental health services agency of the Department of Health and Human Services. SAMHSA helps assess mental health needs and mental health training for disaster workers. SAMHSA also helps arrange training for mental health outreach workers, assesses the content of applications for federal crisis counseling grant funds, and addresses worker stress issues and needs.

v Burns

Mass trauma and disasters such as explosions and fires can cause a variety of serious injuries, including burns. These can include thermal burns, which are caused by contact with flames, hot liquids, hot surfaces, and other sources of high heat as well as chemical burns and electrical burns. It is vital that people understand how to behave safely in mass trauma and fire situations, as well as comprehend basic principles of first aid for burn victims.

• On average in the United States in 2000, someone died in a fire every 2 hours, and someone was injured every 23 minutes (Karter 2001). 

• Each year in the United States, 1.1 million burn injuries require medical attention (American Burn Association, 2002).

- Approximately 50,000 of these require hospitalization; 

- Approximately 20,000 have major burns involving at least 25 percent of their total body surface; 

- Approximately 4,500 of these people die. 

• Up to 10,000 people in the United States die every year of burn-related infections. 

• Only 60 percent of Americans have an escape plan, and of those, only 25 percent have practiced it (NFPA, 1999). 

• Smoke alarms cut your chances of dying in a fire in half (NFPA, 1999).  

• Install smoke detectors on each floor of your home. One must be outside the bedroom.

• Change batteries in smoke detectors at least once a year. (Never borrow smoke alarm batteries for other purposes).

• Keep emergency phone numbers and other pertinent information posted close to your telephone.

• Draw a floor plan and find two exits from each room. Windows can serve as emergency exits.

• Practice getting out of the house through the various exits.

• Designate a meeting place at a safe distance outside the home.

• Respond to every alarm as if it were a real fire.

• Call the fire department after escaping. Tell them your address and don’t hang up until you’re told to do so. Let them know if anyone is trapped inside.

• Never go back into a burning building to look for missing people, pets, property, etc. Wait for firefighters.

Hotel and Workplace Fire Safety

• Become familiar with exits and posted evacuation plans each time you enter a building. 

• Learn the location of all building exits. You may have to find your way out in the dark.

• Ensure that fire exits are unlocked and clear of debris.

• All buildings, whether homes, workplaces or hotels, should have working smoke alarm systems. Make sure you know what the alarm sounds like.

• Respond to every alarm as if it were a real fire. If you hear an alarm, leave immediately and close doors behind you as you go.

• Establish an outside meeting place where everyone can meet after they’ve escaped.

• Call the fire department after escaping. Tell them your address and don’t hang up until you’re told to do so. Let them know if anyone is trapped inside.

• Never go back into a buming building to look for missing people, pets, property, etc. Wait for firefighters.

• Smoke rises, so crawl low to the ground where the air will be cleanest.

• Get out quickly if it is safe to leave. Cover your nose and mouth with a cloth (moist if possible).

• Test doorknobs and spaces around doors with the back of your hand. If the door is warm, try another escape route. If it’s cool, open it slowly.

• Slam it shut if smoke pours through.

• Use the stairs, never use an elevator during a fire.

• Call the fire department for assistance if you are trapped. If you cannot get to a phone, yell for help out the window. Wave or hang a sheet or other large object to attract attention.

• Close as many doors as possible between yourself and the fire. Seal your door with rags. Open windows slightly at the top and bottom, but close them if smoke comes in.  

What you do to treat a burn in the first few minutes after it occurs can make a huge difference in the severity of the injury.

1. "Stop, Drop, and Roll" to smother flames.

2. Remove all burned clothing. If clothing adheres to the skin, cut or tear around burned area.

3. Remove all jewelry, belts, tight clothing, etc., from over the burned areas and from around the victim’s neck. This is very important; burned areas swell immediately.

Types of Burns

First-Degree Burns

First-degree burns involve the top layer of skin. Sunburn is a first-degree burn.

• Red

• Painful to touch

• Skin will show mild swelling

• Apply cool, wet compresses, or immerse in cool, fresh water. Continue until pain subsides.

• Cover the burn with a sterile, non-adhesive bandage or clean cloth.

• Do not apply ointments or butter to burn; these may cause infection.

• Over-the-counter pain medications may be used to help relieve pain and reduce inflammation.

• First degree burns usually heal without further treatment. However, if a first-degree burn covers a large area of the body, or the victim is an infant or elderly, seek emergency medical attention.

Second-Degree Burns

Second-degree burns involve the first two layers of skin.

• Deep reddening of the skin

• Pain

• Blisters

• Glossy appearance from leaking fluid

• Possible loss of some skin

Treatment

• Immerse in fresh, cool water, or apply cool compresses. Continue for 10 to 15 minutes.

• Dry with clean cloth and cover with sterile gauze.

• Do not break blisters.

• Do not apply ointments or butter to burns; these may cause infection.

• Elevate burned arms or legs.

• Take steps to prevent shock: lay the victim flat, elevate the feet about 12 inches, and cover the victim with a coat or blanket. Do not place the victim in the shock position if a head, neck, back, or leg injury is suspected, or if it makes the victim uncomfortable.

• Further medical treatment is required. Do not attempt to treat serious burns unless you are a trained health professional.

A third-degree burn penetrates the entire thickness of the skin and permanently destroys tissue.

Signs

• Loss of skin layers

• Often painless. (Pain may be caused by patches of first- and second-degree burns which often surround third-degree burns).

• Skin is dry and leathery.

• Skin may appear charred or have patches which appear white, brown or black.

Treatment

• Cover burn lightly with sterile gauze or clean cloth. (Don’t use material that can leave lint on the burn).

• Do not apply ointments or butter to burns; these may cause infection.

• Take steps to prevent shock: lay the victim flat, elevate the feet about 12 inches. Have person sit up if face is burned. Watch closely for possible breathing problems.

• Elevate burned area higher than the victim’s head when possible. Keep person warm and comfortable, and watch for signs of shock.

• Do not place a pillow under the victim’s head if the person is lying down and there is an airway burn. This can close the airway.

• Immediate medical attention is required. Do not attempt to treat serious burns unless you are a trained health professional.

REFERENCES

1. Ahrens M. (2001) The U.S. fire problem overview report: Leading causes and other pattems and trends. Quincy (MA): National Fire Protection Association.

2. American Burn Associations (2002) Burn Incidence Fact Sheet.

3. Burn Foundation (2002) Travel Safe Guide - Surviving a Hotel Fire.

4. CDC, National Center for Health Statistics (NCHS). (1998) National vital statistics system. Hyattsville (MD): U.S. Department of Health and Human Services, CDC, National Center for Health Statistics.

5. Gibran NS, Heimbach DM. (2000) Current status of burn wound pathophysiology. Clinical Plastic Surgery; 27 (1): 11-22.

6. Gueugniaud PY, et al. (2000) Current advances in the initial management of major thermal burns. Intensive Care Med; 26 (7): 848-56.

7. Hall JR. (2001) Burns, toxic gases, and other hazards associated with fires: Deaths and injuries in fire and non-fire situations. Quincy (MA): National Fire Protection Association, Fire Analysis and Research Division.

8. Hilton G. (2001) Emergency. Thermal burns. AJ7N, American Journal of Nursing . 101(11):32-4.

9. Istre GR, McCoy MA, Osbom L, Bamard JJ, Bolton A. (2001) Deaths and injuries from house fires. New England Joumal of Medicine; 344:1911—16.

10. Karter MJ. (2001) Fire loss in the United States during 2000. Quincy (MA): National Fire Protection Association, Fire Analysis and Research Division.

11. National Fire Protection Association (1999) NFPA National Fire Escape Survey.

12. Parker DJ, Sklar DP, Tandberg D, Hauswald M, Zumwalt RE. (1993) Fire fatalities among New Mexico children. Annals of Emergency Medicine; 22(3):5 17—22.

13. Yowler CJ, Fratianne RB. (2000) Current status of burn resuscitation. Clinical Plastic Surgery; 27 (1): 1-10.   Page content last revised 2/18/03.

Brain injuries can occur during mass trauma events. If you think you or someone you know has brain injuriy, seek medical attention.

What is a brain injury?

Brain injuries are caused by a blow or jolt to the head that can disrupt the normal function of the brain. These injuries can range from mild to severe. Mild brain injuries are also known as "concussions" and are usually not life threatening. But sometimes even mild brain injuries can cause serious, long-lasting problems.

Why are brain injuries a problem in mass trauma events?

In mass trauma events such as the World Trade Center attack or the Oklahoma City bombing, brain injuries were caused by flying debris or by a person falling and hitting their head. A blast from an explosion can also cause a brain injury, even when there is no direct contact with an object.

What are some common signs of a brain injury?

The signs of a brain injury may be slight and patients, family members and doctors may miss these problems. People with a brain injury may look fine even though they’re acting or feeling differently. The most common signs include:

• Problems with thinking or remembering, speaking, or reading;

• Difficulty paying attention or concentrating;

• Confusion, disorientation (getting lost);

• Mood changes (feeling sad or angry for no reason);

• Easily irritated;

• Depression;

• Changes in sleeping pattern;

• Headaches that won’t go away;

• Loss of energy and motivation (feeling tired);

• Neck pain;

• Blurred vision;

• Dizziness.

What can you do to get help?

If you or someone you know has been in a mass trauma event and you think you may have a brain injury, see your doctor or health care provider. Show them this fact sheet and tell them about the problems you are having. The doctor may be able to help you find a health care provider who has special training in the treatment of brain injury. Your doctor may refer you to a neurologist, neuropsychologist, neurosurgeon, or specialist in rehabilitation (such as a speech pathologist). Getting help soon after the injury by trained specialists may speed your recovery.

For More Information

The Brain Injury Association of America (BIAA)

• Call the toll-free help line at 1-800-444-6443 for help in English or Spanish

• Visit the website at www.biausa.org

The Centers for Disease Control and Prevention (CDC)

• Visit the website fact sheet about traumatic brain injury at www.cdc.gov/ncipc/factsheets/tbi.htm

• Order a free brochure, Facts about Concussion and Brain Injury, (in English and Spanish) online at www.cdc.gov/ncipc/tbi/default.htm

v Brain Injuries and Mass Trauma Events–Information for Clinicians 512

Brain Injury Facts 

• An estimated 1.5 million Americans sustain a traumatic brain injury (TBI) each year, most often due to motor vehicle crashes, falls and violence. 

• TBIs can range from mild to severe. The term mild traumatic brain injury (MTBI) refers to the relatively minor presenting symptoms of the individuals, and not to the long-term consequences, which may be serious.

• In disaster events such as the World Trade Center attack or the Oklahoma City bombing, MTBIs can be caused by flying debris, falls or blast waves from an explosion. 

• In the chaos following mass casualty events, diagnosis of MTBIs may be missed. 

• Timely diagnosis and treatment of long term consequences of MTBI is needed. 

Early MTBI symptoms may appear mild, but they can lead to a significant, life-long impairment, affecting an individual’s ability to function cognitively, physically, and psychologically. In addition to the obvious, look for these signs and symptoms:

¨ Cognitive

• Attention difficulties

• Concentration problems

• Memory problems

• Orientation problems

¨ Physical

• Headaches

• Dizziness

• Insomnia

• Fatigue

• Uneven gait

• Nausea

• Blurred Vision

¨ Behavioral

• Irritability

• Depression

• Anxiety

• Sleep disturbances

• Problems with emotional control

• Loss of initiative

• Problems related to employment, marriage, relationships, and home or school management

Diagnosing an MTBI can be a challenge because symptoms are often common to other medical problems, and the severity of the symptoms can change over time. Any patient with a history of head trauma suffering from confusion, disorientation, or amnesia of events around the time of injury, loss of consciousness of 30 minutes or less, neurological or neuropsychological problems, or with a Glasgow Coma Scale (GCS) Score of 13 or higher, may have an MTBI. Taking a careful medical history can be key to detecting an MTBI. Any unusual or unexplained signs or symptoms should be evaluated further.

MTBI treatment varies from person to person. Educating the patient and his/her family about the possibility of a brain injury and the symptoms that may be experienced as a result of such an injury is critical. Referral to specialists in neurology, neuropsychology, or rehabilitation may be appropriate. 

Additional Resources for Clinicians

• American Academy of Family Physicians, American Academy of Pediatrics. Management of Minor Closed Head Injury in Children (AC9858), 1999. (also available onlne at: http://www.aap.org/policy/ac9858.html).

• Brian Injury Association of America

• Centers for Disease Control and Prevention TBI Fact Sheet 

• Centers for Disease Control and Prevention Heads Up: Facts for Physicians About Mild Traumatic Brain Injury (MTBI), 2002. Available online January 2003.

• Glascow Coma Scale (adapted from Womack Army Medical Center, internet version). 

• Gordon WA, et al. The Enigma of "Hidden" Traumatic Brain Injury, 1998.

• Jagoda AS, Cantrill SV, Wears, RL, et al. Clinical Policy: Neuroimaging and Decision Making in Adult Mild Traumatic Brain Injury in the Acute Setting, 2002.

• Kibby MY, Long CJ. Review: Minor Head Injury: Attempts at Clarifying the Confusion, 1996. 

• Kushner D. Mild Traumatic Brain Injury, 1998. 

• McCrea M, Kelly JP, Randolph C, Cisler R, Berger L. Immediate Neruocognitive Effects of Concussion, 2002.

• National Institutes of Health Consensus Development Conference Statement: Rehabilitation of Persons with Traumatic Brain Injury, 1998. (also available online at: http://odp.od.nih.gov/consensus/cons/109/109_statement.htm). 

• Thurman DJ, et al. Traumatic Brain Injury in the United States: A Report to Congress. Centers for Disease Control and Prevention, 1999.

Some kinds of chemical accidents or attacks may cause you to come in contact with dangerous chemicals. Coming in contact with a dangerous chemical may make it necessary for you to remove and dispose of your clothing right away and then wash yourself. Removing your clothing and washing your body will reduce or remove the chemical so that it is no longer a hazard. This process is called decontamination.

People are decontaminated for two primary reasons:

1. to prevent the chemical from being further absorbed by their body or from spreading on their body, and

2. to prevent the chemical from spreading to other people, including medical personnel, who must handle or who might come in contact with the person who is contaminated with the chemical.

Most chemical agents can penetrate clothing and are absorbed rapidly through the skin. Therefore, the most important and most effective decontamination for any chemical exposure is decontamination done within the first minute or two after exposure.

How to know if you need to wash yourself and dispose of your clothing

In most cases, emergency coordinators will let you know if a dangerous chemical has been released and will tell you what to do.

In general, exposure to a chemical in its liquid or solid form will require you to remove your clothing and then thoroughly wash your exposed skin. Exposure to a chemical in its vapor (gas) form generally requires you only to remove your clothing and the source of the toxic vapor.

If you think you have been exposed to a chemical release, but you have not heard from emergency coordinators, you can follow the washing and clothing disposal advice in the next section.

What to do

Act quickly and follow the instructions of local emergency coordinators. Every situation can be different, so local emergency coordinators might have special instructions for you to follow. The three most important things to do if you think you may have been exposed to a dangerous chemical are to (1) quickly remove your clothing, (2) wash yourself, and (3) dispose of your clothing. Here’s how:

¨ Removing your clothing:

• Quickly take off clothing that has a chemical on it. Any clothing that has to be pulled over your head should be cut off instead of being pulled over your head.

• If you are helping other people remove their clothing, try to avoid touching any contaminated areas, and remove the clothing as quickly as possible.

¨ Washing yourself:

• As quickly as possible, wash any chemicals from your skin with large amounts of soap and water. Washing with soap and water will help protect you from any chemicals on your body.

• If your eyes are burning or your vision is blurred, rinse your eyes with plain water for 10 to 15 minutes. If you wear contacts, remove them and put them with the contaminated clothing. Do not put the contacts back in your eyes (even if they are not disposable contacts). If you wear eyeglasses, wash them with soap and water. You can put your eyeglasses back on after you wash them.

¨ Disposing of your clothes:

• After you have washed yourself, place your clothing inside a plastic bag. Avoid touching contaminated areas of the clothing. If you can’t avoid touching contaminated areas, or you aren’t sure where the contaminated areas are, wear rubber gloves or put the clothing in the bag using tongs, tool handles, sticks, or similar objects. Anything that touches the contaminated clothing should also be placed in the bag. If you wear contacts, put them in the plastic bag, too.

• Seal the bag, and then seal that bag inside another plastic bag. Disposing of your clothing in this way will help protect you and other people from any chemicals that might be on your clothes.

• When the local or state health department or emergency personnel arrive, tell them what you did with your clothes. The health department or emergency personnel will arrange for further disposal. Do not handle the plastic bags yourself.

After you have removed your clothing, washed yourself, and disposed of your clothing, you should dress in clothing that is not contaminated. Clothing that has been stored in drawers or closets is unlikely to be contaminated, so it would be a good choice for you to wear.

You should avoid coming in contact with other people who may have been exposed but who have not yet changed their clothes or washed. Move away from the area where the chemical was released when emergency coordinators tell you to do so.

You can contact one of the following:

• State and local health departments

• Centers for Disease Control and Prevention (CDC)

-  Public Response Hotline (CDC)

   English (888) 246-2675

   Español (888) 246-2857

   TTY (866) 874-2646

-  Emergency Preparedness and Response Web site (http://www.bt.cdc.gov)

-  E-mail inquiries: cdcresponse@ashastd.org

-  Mail inquiries:

Public Inquiry c/o BPRP

Bioterrorism Preparedness and Response Planning

Centers for Disease Control and Prevention

Mailstop C-18

1600 Clifton Road

Atlanta, GA 30333