As if EMS providers haven’t had to learn enough new information during the pandemic, they must now also become experts on the ins and outs of vaccine handling, transport and storage. Within the chain of custody that leads to vaccine distribution, many EMS agencies are tasked with moving, packing and unpacking the vaccines, plus storing them at or below freezing.
Most providers are familiar with freezing cold, hyper- and hypothermic reactions, as well as the signs and symptoms of frostbite. But it is this new realm of vaccine-level cold that opens first responders to make mistakes, underestimate the penalty for lackadaisical behavior, and put lives in danger. History requires a more aware approach of working with hazards.
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Vaccines require dry ice storage
All vaccines require storage at low temperatures in energy-dependent freezers or room coolers, but the first vaccine issued from Pfizer-BioNTech requires extremely low temps. Specifically, that vaccine requires storage at temperatures of -74 degrees C or colder to maintain its efficacy. The next-generation vaccines, while not as severe with their ultra-cold temperature requirement, must still be stored in a cold environment.
Dry ice is the preferred tool to use in transport and in storage of the COVID-19 vaccines. This is where providers are exposed to risk. A chest freezer may use up to 50 pounds of dry ice per day when placed on top of product, whether food or vaccines.
Carbon dioxide is colorless and odorless in low amounts. In high concentrations, carbon dioxide is known to have a sharp acidic odor. When compressed under extreme pressure, it converts into a solid state known as dry ice. If you saw a pound of ice and a pound of dry ice, the dry ice cube would be half the size. CO2 in its solid state is always below -78.5 to -109.3 degrees C.
Dry ice is nothing more than carbon dioxide in solid form. While dry ice may look like ordinary ice, a few seconds of contact with bare skin can result in severe frostbite. Carbon dioxide gas is released directly by dry ice in an “off-gassing” atmospheric process.
The IAFC has identified vaccine distribution, and dry ice in particular, as cause for hazard management – and for good reason. By utilizing dry ice to ensure a viable vaccine for the nation, EMS providers are now exposed to this product in greater quantities every day. While the amounts used in transport and storage may be understood as a solid, the real danger is in the conversion of dry ice to carbon dioxide gas. As dry ice “melts,” it converts directly to gas, and therein lays the danger. It has now gone from acrogenic to asphyxiant.
Storage of dry ice requires a cool environment with ventilation, as carbon dioxide is constantly off-gassing proportional to temperature. This creates increased pressure over time, especially in confined spaces – trailer, box or even vials containers. Imagine stacking multiple coolers of vaccine packed in dry ice while blocking any vent holes in a closed freezer. In perfect proportion, carbon dioxide can explode.
Much like carbon monoxide, carbon dioxide displaces oxygen very quickly. In a confined space, an unsuspecting EMS provider can be rendered unconscious in minutes. Specifically, in an atmosphere of 21% oxygen (normal circumstances), this would be a 5% reduction in the oxygen percentage of the air that is being breathed. A few minutes at 2% reduction (19% oxygen), you’ll have a headache. When you are at 15% or 16% oxygen in air, then you’re facing a carbon dioxide emergency.
Exposure to concentrated levels of carbon dioxide gas can result in headache, dizziness, difficulty breathing and in extreme cases – convulsion, coma and death. Chronic exposure can cause personality disorders and loss of vision.
Proper handling, plus hazard mitigation
When EMS providers must work around dry ice in a well-ventilated area, they should wear gloves, long sleeves and eye protection.
Direct contact with skin is met by removing contaminated clothing, immersing the affected area in warm water and transporting victims to medical facilities. Mucus membranes are extremely sensitive to off-gassing regardless of the amount, and require immediate flushing with water before transport.
If exposure limits are expected to be high, SCBA are required. For physical exposure, gloves, eye protection along with bunkers is acceptable. Level B Tyvek or a similar suit assembly works well as well, but remember, in perfect proportion, carbon dioxide can explode given an ignition source.
In situations where a breach occurs, providers must respond to the hazard accordingly. An accurate size-up that considers the amount of product, ventilation opportunities, victims and location is essential for the successful resolution of a carbon dioxide emergency. Regardless of the size of the breach, treat dry ice as a hazardous material, maintaining standard protocols for a contaminate.
The mitigation goal for carbon dioxide is to coordinate with command to disperse carbon dioxide safely and effectively while preserving vaccine.
An acronym for dry ice situations
Here’s an acronym for these situations: IVECSNR, with an ironic mnemonic to help – I’VE ConSistently Not Remembered. It stands for: Isolation, Ventilation, Evacuation, Containment, Stabilization, Neutralization and Removal.
- Isolation: Determine product, amount and ambient temperatures.
- Ventilation: Visualize a pattern of off-gassing dispersal.
- Evacuation: Remove potential victims and secure area.
- Containment: Assess structural integrity and any breeches in containers – focus on salvage.
- Stabilization: Begin control of material and environment, including vaccine vials accountability and viability.
- Neutralization: Solve the toxic dispersal challenge, protect the vaccine and provide a safe environment.
- Removal: Allow for ventilation to completely disperse the off-gassing of carbon dioxide while the vaccine is being relocated.
Resources
International Association of Fire Chiefs Hazardous Materials Committee White Paper on Dry Ice (Carbon Dioxide) Response – Nov. 23, 2020
Virginia State Fire Marshal Garrett Dyer and the Virginia Department of Fire Programs’ work: VDFP Cautions Against the Mishandling of Dry Ice Used for Shipping and Storing COVID-19 Vaccines.
Note: The Hazardous Material Information System has a rating scale of 0-4. For carbon dioxide, Health has a risk factor of 3, while Flammability and Physical Hazards are rated at 0. While some disagree with the ratings or their classification, the NFPA numbers align with health and flammability ratings while deeming it stable as a reactant.
Editor’s Note: Has your agency been tasked with vaccine storage? Did you feel prepared for the task? Share your experience in the comments below.
