Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event Workshop Report (2009) / Chapter Skim
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A major source of these acute casualties would be the immediate effects of an IND detonation caused by blast overpressure and winds, thermal radiation, and prompt nuclear radiation. Another source of casualties -- if the IND was detonated at or near ground level -- would be the fallout (i.e., radioactive particles)
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The NRF also has a Nuclear/Radiological Incident Annex describing the "policies, situations, concepts of operations, and responsibilities of the Federal departments and agencies governing the Strengthening National Preparedness: Capabilities-Based Planning. A DHS fact sheet at http://www.ojp.usdoj.gov/odp/docs/CBP_041305.pdf (accessed June 23, 2009)
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110-28 of 2007 directed DHS to model the effects of 0.1-kt, 1.0-kt, and 10-kt nuclear detonations in each Tier 1 Urban Area Security Initiative (UASI) city; assess current response and recovery plans; identify ways to improve health outcomes; evaluate medical countermeasure distribution systems; and develop information strategies for the dissemination of protective actions that the public, medical community, and first responders should take to prepare for and respond to a nuclear event. The UASI program of DHS currently provides funds to 45 urban areas for equipment, training, planning, and exercises to respond to the impact of WMDs, including (but not limited to)
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appraise the expected benefit of medical countermeasures, includ ing those currently under development. Committee Process IOM and DHS agreed that the workshop would be based on publicly available information.
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Although the committee is responsible for the overall quality and accuracy of the report as a record of what transpired at the workshop, the views stated in the workshop report are not necessarily those of the committee or IOM. WORKSHOP ASSUMPTIONS AND TOPICS After a day's discussion at the planning meeting, the committee adopted certain assumptions to make the scope of the workshop more manageable.
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7. The workshop would also address preparedness to reduce the psy chological and mental health impacts of a nuclear event (which are anticipated to be substantial)
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evacuate serious casualties to appropriate treatment facilities to statewide and nationally 8. Current preparedness to prevent and treat delayed casualties caused by radioactive fallout as well as the psychological effects of an IND event topic 1: Effects of a 10-kt IND Detonation on Human Health and the Area Health Care System The June workshop began when Daniel Flynn, the committee member who moderated this session, briefly summarized the health effects of an IND detonation.
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The magnitude of each of the blast, thermal, and radiation effects of a nuclear detonation would decrease substantially as a function of distance from the detonation site; but, depending on a number of factors, the consequences of a detonation, such as radioactive fallout, can still be far-reaching. Combined injuries are more likely to occur than a single type of injury from the prompt effects.
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An even larger population would be at risk of exposure in the hours and days after the explosion to enough radioactive fallout to sicken or kill them unless they were able to quickly take appropriate steps to protect themselves (Figure 1)
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. The Nuclear/Radiological Incident Annex to the NRF states, "Even a small nuclear detonation in an urban area could result in over 100,000 fatalities (and many more injured)
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110-28 of 2007 that directed DHS to spon sor the IOM workshop on the current level of medical readiness to respond to a nuclear detonation in Tier 1 UASI cities -- summarized in this report -- also directed DHS to model the effects of 0.1-, 1.0-, and 10-kt nuclear detonations in Tier 1 UASI cities and assess the capacity of current plans to respond to and recover from such effects. DHS assigned the nuclear effects modeling and response and recovery strategy analysis tasks to Lawrence Livermore, Los Alamos, and Sandia National Laboratories and established the Modeling and Analysis Coordination Working Group to oversee the effort.
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, there would be thermal and nuclear radiation effects and flash blindness. Thermal Radiation.
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.12 Almost every person exposed to this level would become ill and about half would die in the coming weeks 12 The workshop presenters used different measures of radiation exposure and biological impact, including the cGy, rem, and rad. Box 3 defines these units and their equivalence and is provided for reference throughout the report.
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-- are still widely used in the United States, in part because they are still used in current government regulations and guides dealing with radiation health and safety, such as the Environmental Protection Agency's (EPA's) Manual of Protective Action Guides and Protective Actions for Nuclear Incidents, issued in 1992.
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Buddemeier concluded that current models are based on data from past nuclear events and provide predictions based on a flat plain in which all structures would be in line of sight of the detonation. Primary effects could cause hundreds of thousands of casualties in the first few minutes within a few miles of the explosion.
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An area extending approximately nine miles downwind would be covered with enough fallout to pose an immediate danger to the life and health of emergency medical and other rescue personnel as well as to inhabitants who were outdoors for even short periods of time during the first several 13 After the workshop, Buddemeier reported results of new modeling work performed at Lawrence Livermore National Laboratory on the effects of low-yield nuclear explosions, including the number and type of prompt injuries likely to result after taking into account the protective effects of buildings. The Washington, DC, scenario would result in approximately 250,000 people injured by blast, thermal, or radiation effects, or by some combination of the three.
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. • Hundreds of thousands of acute casualties from radioactive fallout could occur within an area extending about 9 miles downwind of ground zero.
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At 12 miles, the 2hour accumulated dose would be down to 50 cGy, at which point radiation effects would probably be detectable but not life-threatening.15 Not only does fallout decrease sharply with distance, it also decays quickly with time. It is most dangerous in the first few hours after an explosion.
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The impulse to evacuate might prove to be counterproductive in terms of minimizing radiation exposure and its health impact because, in most cases, the best way to reduce radiation exposure would be to shelter in place initially. Finally, he said there is a lack of scientific consensus on the most appropriate response strategies.
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Given his assumptions18 and estimates of the workday population for the DC simulation, Dallas estimated that approximately 720,000 people would be in this circle in the Washington, DC, area, of whom approximately 105,000 would receive a radiation dose of 150 rem (1.5 Sv) or more from prompt radiation or fallout (an exposure sufficient to cause clinical 16 In January 2009, after the workshop was held, a federal interagency committee under the auspices of the Homeland Security Council and Office of Science and Technology Policy in the Executive Office of the President released a 92-page Planning Guidance for Response to a Nuclear Detonation "to provide [state and local]
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Rather than trying to estimate the number of injured needing hospital care (except for Washington, DC) , Dallas estimated the numbers of hospital beds that could be available within 4, 24, and 48 hours at various distances up to 300 miles from each city.
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Far more problematic than the actual loss of hospitals, however, would be the inability to transport patients to receiving hospitals. Dallas deemed it highly unlikely that most patients could be moved in sufficient time through the chaotic environment following a nuclear detonation to distant hospitals in the unaffected areas.
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There was discussion of the Cold War attitude that it is useless to plan for a nuclear event "because we'll all be dead anyway." Several participants argued that low-yield INDs would be different. An IND explosion would still be catastrophic in terms of casualties, but many people not touched by the initial blast would be able to avoid or reduce exposure to injurious radiation doses stemming from the fallout if they knew what protective actions to take.
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In fact, fallout heavy enough to cause acute injury could arrive too quickly to outrun. Planning for evacuation would be more feasible in areas farther downwind, where dose levels would be too low to cause acute effects but could induce cancer years later (e.g., Delaware would be affected, should there be an IND event in Washington, DC)
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, the number of beds in any major city or even its metropolitan area relative to the number injured would be inadequate. Even if one was able to empty half the beds for 300 miles around and transport patients that far -- very optimistic assumptions -- there still would not be enough beds, especially critical care and burn beds.
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Some responders and health care providers would be victims themselves, and others might be deterred from working by the prospect of radiation exposure or be preoccupied with evacuating their families.20 20 Research on attitudes of first responders and medical personnel toward reporting to work after an incident involving radiation is reviewed by Becker under Topic 5, "Risk Communication, Public Reactions, and Psychological Consequences in the Event of a 10-kt IND Detonation."
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In the military, Mercier said, the medical guidance in a mass casualty event is based on the reality that resources will not be sufficient to provide standard treatment to everyone, and it might be necessary to follow altered standards of care. The military mass casualty guidance for austere situations (i.e., when there are inadequate resources for the patient load and alternate standards of care are necessary)
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Thus, the use of such triage may be problematic in a nuclear event, because victims may have survivable traumatic injuries if treated but will be inevitably doomed by their radiation injuries. Furthermore, the mortality rate at any given dose level of radiation is higher if the radiation is combined with mechanical trauma, burns, or both.
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Those without any trauma or burns who received doses of 150 cGy or larger would be given ambulatory monitoring with routine care in a mass casualty situation, although in a non-mass-casualty setting they would be hospitalized until their bone marrow was back to normal (http://www. remm.nlm.gov/radtrauma.htm, accessed June 23, 2009)
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In a mass casualty situation, however, victims who have received radiation doses that would normally hospitalize them (200 cGy or more) might be examined and then assigned to outpatient monitoring and routine care, unless their condition worsened and they required hospitalization.
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He suggested focusing plans for responding to an IND event on efforts to minimize radiation exposure as the best investment. Discussion of Medical Care of Victims of a Nuclear Detonation A workshop participant expressed his concern that medical personnel might require excessive decontamination of patients before treating them.
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A participant wondered how the civilian sector could learn more from the defense sector about medical preparedness for nuclear events. Mercier said he and others participate extensively in interagency activities addressing this issue, but military experts on nuclear preparedness are a shrinking pool, far fewer than 20 years ago.
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He emphasized that other public health measures to avoid radioactive materials, such as sheltering or evacuation, are better ways to reduce acute radiation exposure from internal contamination when compared with currently available medical countermeasures.
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The SNS includes KI, Prussian Blue, and the DTPAs. While Wiley did not estimate the probabilities of internal contamination from an IND explosion that would require administration of these countermeasures, the earlier presentation by Buddemeier explained that the most dangerous fallout for producing acute injury consists of large particles that fall quickly to the ground and are not respirable.
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From page 35... ...
Finally, FDA-approved decorporation, blocking, and other medical countermeasures exist for only a portion of the radionuclides present in fallout. Wiley then concluded that the necessity to use current FDA-licensed radiation countermeasures (i.e., the decorporating and blocking agents Prussian Blue, zinc- and calcium-DTPA, and KI)
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From page 36... ...
In cases with high levels of exposure to radiation, patients would require the support of critical care or intensive care to survive the period when the blood-forming capacity of their bone marrow has failed. The availability of critical and intensive care beds would be problematic in a mass casualty situation (see, e.g., Rubinson et al., 2008)
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Yet others are undergoing basic pre-clinical testing, including novel cell therapies, such as endothelial cell transplantation and myeloid progenitor cell transplantation. Carmen Maher said FDA's mission includes facilitating the development and availability of medical countermeasures to the effects of WMDs.
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To address the FDA-approval issue with many promising WMD medical countermeasures, the Project Bioshield Act of 2004 amended Section 564 of the Food, Drug, and Cosmetic Act to allow emergency use of medical products during a declared emergency involving a heightened risk of attack on the public or U.S. military forces or a significant potential to affect national security.
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and their household members. The request was based on a September 23, 2008, determination by the secretary of Homeland Security and an October 1 declaration by the secretary of HHS that there is a significant potential for a domestic emergency involving a heightened risk of attack with Bacillus anthracis, the causative agent of anthrax.
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The SNS program can also draw on much larger reserves of managed inventory, which are designed to be delivered to the state by ground or air within 24 to 36 hours. At this point, the SNS has modest amounts of the cytokine filgrastim along with other supplies relevant to an IND event.
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in the early hours before people can be informed whether they should be moving or sheltering where they are to protect themselves; • the potential for disruption to civil authority; and, • absent reliable individual dosimetry, the need to triage and treat based on presumptive estimates of the amount of radiation a victim has received. Discussion of Radiation Countermeasures The importance of colony-stimulating factors, such as filgrastim, in the mass casualty treatment of radiation injury -- and the steps needed to use it -- were discussed further.
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At the time of the workshop, DHS had issued interim guidelines on emergency responder dose limits in an RDD or IND event and was working to finalize 29 See Waselenko et al., 2004.
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In this part of the workshop, Sara DeCair, a health physicist in the Center for Radiological Emergency Preparedness, Prevention, and Response at EPA presented EPA's rules and guidances on radiation exposure and discussed their applicability to an IND event. John MacKinney, deputy director of Nuclear/Radiological/Chemical Threats and Science and Technology Policy in the DHS Office of Policy Development, discussed the work of an interagency committee on protective action guidelines for RDDs and INDs.
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From page 44... ...
These conservative guides are more applicable for EPA's post-event cleanup responsibilities than for response to an IND event. DeCair noted, for example, that the fire departments in the National Capital Region have adopted 10 Roentgen per hour as defining a radioactive zone and 200 Roentgen (0.0516 Curies per kilogram)
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From page 45... ...
However, the interim guide recognizes that, in an IND event, decisions would have to be made much more quickly and with much less information than in a nuclear power plant event to be effective. More important, the EPA PAGs were recognized as inadequate to address the very-high-dose-rate zones and the extensive physical impacts of a nuclear explosion.
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Eric Daxon studies ways to improve the decision making of military field commanders in the stressful environment of a nuclear event. Like civilian incident decision makers, commanders are not usually health experts, but they are required to make decisions that balance the radiation health risks and nonradiation health risks with the benefits of a course of action.
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From page 47... ...
In an IND event, upward of a million people might be in the 1-cGy or higher fallout area, which could extend several hundred miles downwind. Only the population far from the detonation might possibly have enough time to evacuate before 32 should be noted that the National Council on Radiation Protection and Measurements It outlines key elements of preparing emergency responders for nuclear and radiobiological terrorism (NCRP, 2005)
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Summary of Protective Action Guides DHS has issued guidelines developed by an interagency committee for RDD and IND events (DHS, 2008)
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Some participants thought the decision points were appropriate but more detailed guidelines for applying them are needed. Having some of the same concerns, the RDD/IND working group led by DHS is continuing work on protective action guides and recommendations applicable to the zones closest to the detonation point.33 topic 5: risk communication, public reactions, and psychological consequences in the event of a 10-kt IND Detonation The effectiveness of the medical response to an IND detonation would depend to a large extent on the appropriate swift actions of individuals, families, and small groups in the immediate aftermath of a devastating explosion and the associated radioactive fallout.
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Response behaviors include evacuation and sheltering to minimize exposure to radiation. They also include going to health care facilities to be checked for radiation exposure.
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In the remainder of the session, Steven M Becker, associate professor of public health at the University of Alabama at Birmingham, presented the results of studies of how the public, emergency responders, health care workers, and public health officials may respond in an IND event.
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• Fatalistic attitudes about surviving a nuclear event clearly exist in the population, especially in minority populations. This is impor tant and requires special attention, since fatalism can translate into a reduced likelihood that people will undertake protective actions.
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regions. The research found that the biggest concerns of physicians and nurses included • the expectation that health care facilities would be overwhelmed by people worried about radiation exposure; • ensuring the safety of the health care workers' own family members; • uncertainty as to whether portions of the staff would report for duty because of concerns about their own safety, the safety of their families, or both.
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From page 54... ...
Based on the full set of research studies noted above, Becker drew several overarching conclusions: • An IND event will pose huge challenges in terms of emergency communication. • Timely, effective messaging will be vital for reducing morbidity and mortality, preventing psychosocial and behavioral impacts, and maintaining public trust and confidence.
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4. Using the results to draft risk communication 5.
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They might find that most people would try to escape in cars even though they were advised to shelter in place, because they did not understand the substantial shielding effect of buildings compared with cars. After identifying missing or erroneous concepts of nuclear detonation hazards in the lay public, messages designed to counter them would be developed, then tested and refined.
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the rest of the country. In the immediate area of the blast, one of the most important variables would be the speed with which people learned that it was a nuclear event and acted accordingly to avoid injury or further injury.
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More than 8,000 of the 112,000 residents who showed up for examination asked for an official certificate that they were not contaminated. Norwood concluded with remarks about the difficulty of preparing for an IND event.
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Authorities should be perceived as caring, calm, and knowledgeable, which requires consistency in approaches to messaging. The goal should be to create public trust and to shape behavior in such a way as to reduce risk, both among the public and among first responders and health care providers.
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There was discussion of the advisability of giving placebos -- or KI pills, which would be harmless if they were not needed -- to people who fear they have been exposed in order to ease their anxiety and stress. The panelists strongly opposed this because of professional ethics but also because it would undermine public trust in authorities, which would be critical to maintain in such a situation.
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From page 61... ...
For example, a victim arriving at an ED might give off radiation at the rate of 25 millirem per hour. The Geiger counter would sound an ominous audio signal, but even if the patient were in surgery for 20 hours, the accumulated dose to the medical personnel would be half a rem (5 mSv)
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Hauer asserted that the health care system in this country is totally unprepared to handle the surge in demand that will occur in the aftermath of an IND event. This is particularly true of beds for burn patients.
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Much more training is needed for pre-hospital care providers and h ospital medical staff about performing triage in a mass casualty situation. The training is especially needed for responding to a nuclear event because the degree of radiation exposure among victims will be difficult to determine, which in turn will make it difficult to separate those who do not need treatment from those who have received fatal doses or from those who could benefit from treatment.
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topic 6: Federal and state medical resources for responding To an IND EVent Judith Monroe, the committee member moderating this August workshop panel, opened by citing two recent examples of public health emergencies that took place in Indiana -- a full-scale exercise run by the Indiana National Guard (2007) and an actual event, the emergency evacuation of a hospital in Indiana due to flooding (2008)
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Daniel Bochicchio of the National Defense University and, until recently, vice chief surgeon in the National Guard Bureau; and James Blumenstock, who is with the Association of State and Territorial Health Officials. Ann Knebel began by providing an overview of the medical assets that HHS could deploy in a nuclear event as well as of HHS's response plans.
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for 3 days without resupply. A National Medical Response Team with 50 members is trained to provide medical care following a nuclear, biological, or chemical incident, including mass casualty decontamination, medical triage, and primary and second ary medical care to stabilize victims for transportation to tertiary care facilities in a hazardous material environment.
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From page 67... ...
CONOPS specifies the role of each agency, and the action steps include a trigger for each step, a recommended strategy to follow, and specific actions to take. ASPR has put the playbooks for hurricanes and aerosolized anthrax attacks on its website so that state and local planners can see what federal capabilities might be deployed and how.40 ASPR plans to publish each of the playbooks, with the ones for RDD and pandemic influenza events as the next to be posted.41 Alan Remick summarized DOE's resources for responding to a nuclear event such as a terrorist IND attack.
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From page 68... ...
The plume models are based on real-time weather data, a terrain database, and a three dimensional transport and diffusion model. The model results are presented in terms of ground deposition plots, instantaneous and time-integrated doses, and airborne concentrations, which can be used to inform protective action decisions.
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. Located at Oak Ridge, Tennessee, REAC/TS is staffed with physi cians and health physicists who conduct training on the medical aspects of radiation exposure and who are available at all times to deploy and provide EMS at radiation incidents.
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The total number of DOE people involved in the emergency response would be approximately 1,200. Daniel Bochicchio reviewed the assets and expected role of the National Guard in an IND event.
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. These com panies are part of a combat brigade and would deploy with their brigade if it were called on to respond to an IND event; • nine Expeditionary Medical Support+25 (EMEDS+25)
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CERFPs are intended to provide extraction, decontamination, and medical triage and treatment in the period from 6 hours post-incident to the time when substantial National Guard and military forces arrive 72 to 96 hours after detonation. These capabilities would be relatively small, however, relative to the needs generated by an IND event, with 22 and up to approximately 200 personnel, respectively.
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There has been no PHEP funding specifically for radiological or nuclear event preparedness, although states (and localities) could allocate funds for them -- or any other threat -- from their basic PHEP funding, if it was a local priority.
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There is an effort to establish an East Regional Burn Consortium of health care facilities in the Mid-Atlantic and New England. Blumenstock offered several recommendations to advance public health preparedness for the consequences of an IND event.
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On the other hand, in about 15 states, the adjutant general of the state's National Guard is also the state's emergency manager. A participant with military experience said that for many years DoD planning focused on preventing nuclear events because to survive a Cold War nuclear exchange was considered impossible.
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From page 76... ...
topic 7: Current preparedness for responding to the immediate casualties of an IND EVENT George Annas, the committee member moderating the August workshop sessions related to Topic 7, began by noting that the IND detonation scenario in preparedness planning had raised at least six observations or questions regarding its usefulness: 1. Is the inability to quantify the risk, and the question of whether simply asserting it is "greater than zero," sufficient to motivate planners?
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He then highlighted the major points from Hauer's summary of the June session of the workshop (presented earlier in this report) : • No city is prepared for, and few are focusing on, an IND event.
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All-Hazards Preparedness The Tier 1 UASI cities are training for and performing exercises with the Incident Command System, which is designed to coordinate the efforts of multiple agencies in a disaster. Still, it will be challenging to establish a unified command where everyone is working together in the case of an IND event.
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From page 79... ...
Staffing cycles would be established to minimize exposure, and anyone reaching a PAG decision point, such as 50 rem for lifesaving activities, would be assigned to duty in nonradioactive zones. IND Detonation Preparedness There was clear recognition among the city representatives that the detonation of an IND would be at least an order of magnitude more disastrous than an RDD and that at least some of their health care facilities and personnel would be directly affected by the attack and thus unable to contribute
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From page 80... ...
Until recently, where WMDs in general are concerned, first responders have been concentrating primarily on preparedness for chemical and biological attacks; and where radiation threats are concerned, they have been paying more attention, as mentioned above, to planning a response to a radiological rather than a nuclear event. One area of concern is the development of appropriate PAGs for responding to a nuclear detonation.
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From page 81... ...
medical treatment protocols for WMD incidents that apply at both the pre-hospital and hospital levels. In an IND event, both sets of protocols would be applied in conjunction with the triage guidelines for mass casualty incidents.
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; Bryan Hanley from the Los Angeles County EMS Agency; D ouglas Havron from the Southeast Texas Trauma Regional Advisory Council (Houston) ; and Carl Lindgren from the Arlington Fire Department, Virginia (National Capital Region)
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From page 83... ...
It has a mass casualty incident screen that, when activated, alerts hospitals with a flashing blue light and an audible alarm that they need to poll their ED beds and their capacity for receiving patients with either life-threatening or minor injuries. Like California, Texas has substate districts for coordinating services.
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From page 84... ...
Suburban Hospital in Montgomery County, Maryland, next to Washington, DC, is 1 of 5 hospitals in the county and 34 in the National Capital Region. It is a 250-bed facility with the only trauma center in the county, and it expects to receive up to 40,000 people after a major disaster.
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From page 85... ...
The forward-deployed stockpiles include PPE and 8,000 doses of KI, and in the coming year each DRC will receive 4 or 5 radiation monitoring devices and 100 dosimeters (numbers more suitable for an RDD than an IND event)
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From page 86... ...
These mobile clinic alternate care sites would use the mass casualty and austere care protocols used by EMS (described above) , and a workgroup is in progress to adapt the austere care protocol to fixed alternate care facilities.
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CDC has suggested the establishment of community reception centers in radiation emergencies, although in an IND event these would likely be in surrounding communities because local health officials would be focusing on treating the immediately injured rather than on decontamination (CDC, 2007)
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Need for Many Intensive Care Beds for Trauma, Burns, and ARS Although the number and types of severe acute injuries caused by the immediate effects of a 10-kt IND detonation would depend on a variety of factors, such injuries would most likely number in the thousands to tens of thousands. Many patients would require intensive critical care to survive multiple traumas, severe burns, high doses of prompt irradiation, or some combination of these.
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From page 89... ...
The purpose of RHCC is "to ensure patients are delivered to the health care facility most capable of providing definitive patient care, in the shortest and most efficient time possible, through coordination and collaboration with regional partners." While useful in many mass casualty events, NVHA and RHCC would be quickly overwhelmed by the sheer number of injured needing intensive care after the detonation of an IND, and they would be looking for places to send those patients for the intensity and length of care necessary to survive multiple traumas or ARS. NVHA, like NYCDOH, is concerned about the capacity to move patients and, if they can be moved, whether there will be enough places to treat them.
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From page 90... ...
Severely injured patients who are under intravenous treatment, who are taking pain medications or antibiotics, or who are on ventilators would be moved with a three-person Critical Care Air Transport Team, each of which is able to support three patients at once. In an IND event, the plan would be for DMATs to prepare patients for transport at or near the disaster site.
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From page 91... ...
• The capacity to move patients to airports for evacuation by the Air Force would probably be compromised, perhaps severely, in an IND event because of damage to the transportation infrastructure, the crowding of roads still in operation by those self-evacuating, and the possible reluctance of drivers to approach affected areas to pick up passengers. There are only approximately 800 civilian aeromedical helicopters in the country, and they are configured to carry patients in ones or twos.
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From page 92... ...
Again, there is the question whether other states and cities will be willing to dispatch their medical teams to help with an IND event given the risk they might be hit next. There was discussion of the training and education programs that should be established now for an IND event that may not happen for years.
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From page 93... ...
Also, HHS is developing an interactive geographic information system, called MedMap, which will show which medical care sites and assembly center facilities are outside the impact and fallout area and which facilities are available nationally.50 50 This was a reference to recent congressional testimony by Rear Admiral W Craig Vanderwagen, Assistant Secretary of HHS for Preparedness and Response, on HHS's readiness for a radiological or nuclear event.
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From page 94... ...
This would greatly improve the capacity to provide information to the public about whether to shelter in place or to evacuate and could perhaps reduce the amount of self-evacuation and the associated clogging of highways needed to move victims out of the area and medical response teams in. General Discussion of Topic 7: Preparedness for Responding to the Immediate Casualties of an IND Event Public Communication Most of the discussion centered on the need for effective and reliable communication with the public and the mass media, both before an IND event and during the response, and on how to achieve it.
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From page 95... ...
Some places have conducted table-top exercises with media representatives responding to anthrax and hurricanes but not IND events. Planners in the National Capital Region are communicating with the Washington Post.
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From page 96... ...
The UASI priority in at least one city is on improving detection, not response. topic 8: Current preparedness to prevent and treat the delayed casualties of an IND event The participants in this August workshop panel discussion were Thomas Ahrens from the California Department of Public Health, Los Angeles and San Francisco; Brooke Buddemeier from Lawrence Livermore National L aboratory; Kathleen "Cass" Kaufman from the Los Angeles County Department of Public Health; Jeanine Prud'homme from the New York City Department of Health and Mental Hygiene; Irwin Redlener, Columbia University; Adela Salame-Alfie from the New York State Department of Health; Reuben Varghese from Arlington Public Health, Virginia (National Capital Region)
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From page 97... ...
The medical response to fallout therefore encompasses both the possibility of prevention of injuries where possible as well as their treatment. The panel touched on the following issues dealing with local preparedness to prevent and treat "delayed" casualties of an IND detonation: • Effectiveness of risk communication • Short- and long-term mental health • Efficacy of nonmedical protective actions such as sheltering in place and evacuation Brooke Buddemeier gave the first presentation, a condensed version of his June workshop presentation on fallout effects based on a simulation model of a 10-kt IND detonation in Washington, DC, near the White House.
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From page 98... ...
3. The scale and scope of planning is not adequate for the impact of an IND event.
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From page 99... ...
Redlener concluded that improving preparedness for an IND event will require White House leadership, congressional buy-in, and public acceptance. Reuben Varghese described public health emergency response planning in Arlington, Virginia, a suburb adjoining Washington, DC, and part of the National Capital Region.
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From page 100... ...
models, which are designed primarily for field use by emergency responders to incidents involving the release of radioactive materials, such as would occur in a nuclear power plant accident. Thomas Ahrens described the roles and capabilities of the California Department of Public Health in an IND event.
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From page 101... ...
The fire department would be responsible for life safety and public decontamination operations under CIMS. In a radiological or IND event, under the city's Radiation Emergency Operations Plan, NYCDOH would be responsible for medical and mental health activities, environmental mitigation, health risk assessment, and public health
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From page 102... ...
Prud'homme listed some gaps, in addition to the lack of fully coordinated regional response capability in the New York metropolitan area that need to be addressed by local and regional efforts: • Lack of guidance for choosing a sheltering-in-place versus evacua tion response to an IND or other radiological event • Lack of open-source information on what conditions will be like after an IND detonation, which is needed for realistic response planning • The need for better systems for real-time data collection and interpretation • The need for a robust tiered communications system • The need for mitigation and recovery plans for radiological con tamination in an urban environment Cass Kaufman said that Los Angeles County, like New York City, is planning to use the multiagency radiation response plan it has developed as the basis of a nuclear response plan, while recognizing that a nuclear detonation will have some unique aspects. In a radiological incident, the PAG limits are an accumulated dose of 50 rem (500 mSv)
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From page 103... ...
This would help define the radioactive zone on the map. The same response would be taken for an IND event, except that the staff members might have to drive out to find the 100 millirem per hour perimeter, depending on where they were when the device went off.
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From page 104... ...
Meanwhile, Los Angeles will be conducting flyovers to map the areas and levels of radiation, to determine when and where it is safe to evacuate people. Outside the close-in area, Los Angeles County will use the EPA PAGs, which call for evacuation if the 4-day dose is expected to be 1 rem (10 mSv)
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From page 105... ...
This implies the need for the identification and preparation of local subject matter specialists who can put out the messages. Several participants had been involved in workshops on messaging for an IND event held by HSI in four cities during 2008, which examined messages such as "go in, stay in, tune in," but the results had not yet been published.51 The Conference of Radiation Control Program Directors (CRCPD)
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From page 106... ...
Los Angeles County's playbook, for example, calls for registration at ESF-6 shelters. This would probably be piggybacked on their point 53 According to González (2005)
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From page 107... ...
The workshop brought up some important decisions that must be resolved, such as radiation exposure limits for emergency responders and the public and also the criteria for telling the populace to shelter where they are or to evacuate (discussed below)
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From page 108... ...
He added that the number injured by prompt effects in New York City would be larger, about 400,000. In January 2009, the Homeland Security Council issued Planning Guidance for Response to a Nuclear Detonation, which provides information about the detonation effects of a 10-kt IND in an urban environment and advice on effective response strategies for state and local responders to use (EOP, 2009)
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From page 109... ...
• What the triage criteria and process should be, given the mismatch between medical needs and resources: HHS is developing a sys tem, but it is not clear what it will be or how it will be legitimated among providers and the public. • What the radiation exposure levels for responders should be, and who should apply them: Should each state or locality decide for its people, or should there be national consensus standards?
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From page 110... ...
However, none have yet been licensed for the treatment of radiation injury and current federal investment for the development of such products is limited in comparison with that for biodefense countermeasures. Also, radiation countermeasures are not going to help people injured by the blast and burn effects if they do not receive trauma care, which poses a great challenge for the reasons mentioned throughout the workshop and described above (e.g., lack of health care facilities, especially for burn patients and other patients needing specialized intensive care; limited assets for moving patients to existing health care facilities, regionally and nationally; problems with the resupply of health care facilities that have one-day inventories of drugs and other supplies)
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From page 111... ...
2008. Medical response to a radiologic/nuclear event: Integrated plan from the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services.
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From page 112... ...
2009. Planning guidance for response to a nuclear detonation.
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From page 113... ...
2007. Radioactive fallout from terrorist nuclear detonations.
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From page 114... ...
2008. Radiologic and nuclear events: Contingency planning for hematologists/oncologists.
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Key Terms
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