Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report

INTRODUCTION

A nuclear attack on a large U.S. city by terrorists—even with a low-yield improvised nuclear device (IND) of 10 kilotons (kt) or less—would cause a large number of deaths and severe injuries. 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) that would be deposited on the ground for many miles downwind of the detonation point. The heaviest and therefore most dangerous particles of fallout would be on the ground for nearly 10 miles downwind within minutes. The number of casualties from this secondary source could also be of great magnitude. However, the count could be reduced substantially if individuals swiftly took appropriate steps to protect themselves.

Of greatest concern is that, beyond all of the immediate deaths, the large number of injured from an IND detonation would be overwhelming for local emergency response and health care systems to rescue, evacuate, and treat, even assuming that these systems and their personnel were not themselves incapacitated by the initial impact of the explosion. Yet to survive in the long term, many people would need immediate treatment, particularly for severe burns and traumatic injuries. In addition, many of the initial survivors would receive high doses of radiation from the detonation or the subsequent fallout. They should be identified rapidly and directed to



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Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report INTRODUCTION A nuclear attack on a large U.S. city by terrorists—even with a low- yield improvised nuclear device (IND) of 10 kilotons (kt) or less—would cause a large number of deaths and severe injuries. 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) that would be deposited on the ground for many miles downwind of the detonation point. The heaviest and therefore most dangerous particles of fallout would be on the ground for nearly 10 miles downwind within min- utes. The number of casualties from this secondary source could also be of great magnitude. However, the count could be reduced substantially if individuals swiftly took appropriate steps to protect themselves. Of greatest concern is that, beyond all of the immediate deaths, the large number of injured from an IND detonation would be overwhelming for local emergency response and health care systems to rescue, evacuate, and treat, even assuming that these systems and their personnel were not themselves incapacitated by the initial impact of the explosion. Yet to sur- vive in the long term, many people would need immediate treatment, par- ticularly for severe burns and traumatic injuries. In addition, many of the initial survivors would receive high doses of radiation from the detonation or the subsequent fallout. They should be identified rapidly and directed to 

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 MEDICAl PREPAREDNESS FOR A TERRORIST NuClEAR EVENT facilities for the intensive supportive care that they would need to achieve long-term survival when they eventually became ill with acute radiation syndrome (ARS) during the following days and weeks. Terrorist groups have indicated an interest in using weapons of mass destruction (WMDs), including nuclear weapons, against the United States, although there is no evidence to date to confirm that any particular group possesses nuclear weapons. Considering the inherent difficulties, it is not known whether such a group actually could develop the capacity to carry out such an attack in the near future, and there is a range of views among experts on the extent of the threat (Levi, 2007; Commission on the Preven- tion of Weapons of Mass Destruction Proliferation and Terrorism, 2008). Gaining access to sufficient quantities of weapons-grade nuclear material is the highest hurdle facing would-be nuclear terrorists, and numerous other hurdles would have to be overcome before a weapon devised from such material could be used. For example, terrorist groups would require the capacity to manufacture a device that would detonate when (and only when) they wanted. They also would have to transport the device into or within the United States and move it to the targeted location without being detected. The United States has made preventing such an attack a high prior- ity and has a number of programs in place to (1) deny terrorists access to nuclear materials, (2) deter other nations from helping terrorists mount a nuclear attack, and (3) intercept any attack before it can succeed. Still, since no individual preventive measure or even a set of such measures is fail-proof, the question remains: What if prevention efforts fail? Over the past several years, the U.S. government has made increased efforts to address this question. In 2004-2005, the Department of Homeland Security (DHS) drafted 15 scenarios to be used in conjunction with planning responses to catastrophic events under the National Response Framework (NRF). The scenarios were chosen to “highlight a plausible range of major events such as terrorist attacks, major disasters, and other emergencies, that pose the greatest risk to the Nation.”1 Relevant to the current dis- cussion, Scenario 1 involves the detonation of a 10-kt IND in the central business district of a large city. 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). The planning scenarios themselves are for official use only; thus, the content of Scenario 1 was not referred to in the workshop, although Brooke Buddemeier’s presentation contained details on the health effects of the 10-kt detonation in Scenario 1 that are publicly available.

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 WORKSHOP REPORT immediate response and short-term recovery activities for incidents involv- ing release of radioactive materials,” including IND attacks.2 Congressional committees on homeland security have begun to put more emphasis on the nation’s capacity to respond to a nuclear event if prevention fails. The conference report on Public Law (P.L.) 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 out- comes; 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.3 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) INDs. The six Tier 1 UASI areas are New York City/Northern New Jersey,4  National Capital Region, Los Angeles/Long Beach, San Francisco Bay Area, Houston, and Chicago. The same legislation also directed DHS to have the National Academy of Sciences assess the current level of medical readiness to respond to a nuclear detonation in Tier 1 UASI cities. In response to the congressional mandate, DHS contracted with the Institute of Medicine (IOM) of the National Academies to • establish a committee of experts in emergency medical response and treatment, medical and public health preparedness, health sci- ences research, and nuclear medicine; 2 The Nuclear/Radiological Incident Annex is at http://www.fema.gov/pdf/emergency/nrf/ nrp_nuclearradiologicalincidentannex.pdf (accessed June 23, 2009). The annex was issued in 2004 and updated in 2008. It assigns federal agency responsibilities in the event of a release of radiation. DHS would be the lead, or “coordinating agency,” in responding to a deliberate attack, such as a terrorist IND, and would be supported by other agencies. In other situations the coordinating agency might be the Department of Energy, the Department of Defense, the Nuclear Regulatory Commission, the National Aeronautics and Space Administration, the Environmental Protection Agency, or the Coast Guard, depending on ownership, cus- tody, origin, or location of the radioactive materials in question. Under another NRF annex (Emergency Support Function #8, “Public Health and Medical Services”), the Department of Health and Human Services would lead the public health and medical response, with the support of other agencies with medical assets, in an IND response. See Topic 6, “Federal and State Medical Resources for Responding to an IND Event,” for a summary of HHS’s plans and assets for an IND event. 3 The conference report is at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=110_ cong_public_laws&docid=f:publ028.110.pdf (accessed June 23, 2009). 4 After the workshop, the New York City/Northern New Jersey area was split in two, to form seven Tier 1 UASI areas. The Northern New Jersey area was renamed Jersey City/Newark.

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 MEDICAl PREPAREDNESS FOR A TERRORIST NuClEAR EVENT • conduct a workshop planned by the committee on medical pre- paredness for a nuclear detonation of up to 10 kt; and • prepare a report on the workshop presentations and discussions. Specifically, DHS asked for the workshop and workshop report to 1. review and summarize the overall emergency response activities and available health care capacity (including shelter, evacuation, decontamination, and medical infrastructure interdependencies) to treat the affected population; 2. examine the capacity and identify gaps in the capability of the federal, state, and local authorities to deliver available medical countermeasures in a timely enough way to be effective; 3. review and summarize available treatments for pertinent radiation illnesses, including the efficacy of medical countermeasures; and 4. 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. Classified information and sensitive information marked “For Official Use Only” was not presented or discussed at the workshop or used in this report. Because official estimates of the likelihood of a successful attack on the United States by terrorists using an IND are not public information, this question was not addressed at the workshop. The scope of the workshop was limited to medical public health preparedness if such an event were to occur. Thus, the workshop did not address the priority that emergency preparedness planners should give to responding to the threat of an IND or how resources should be allocated among different threats. IOM formed a committee with the appropriate expertise and experi- ence to plan and conduct the workshop. The committee held a planning meeting in April 2008. The workshop was held in two parts, June and August 2008. The agendas of the two workshop sessions are found in Appendix A, the list of attendees of the workshop sessions in Appendix B, short biographies of speakers and panelists at the workshop in Appendix C, and short biographies of the committee members, consultant, and staff in Appendix D. The role of the committee was to plan the workshop by deciding on the workshop topics, identifying experts on those topics to speak, developing questions for the speakers to address, and authoring a report of the work- shop discussions. Committee members also moderated the presentations

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 WORKSHOP REPORT and the question-and-answer period that followed each speaker or set of speakers on a specific topic. This publication is a report provided by the committee to document the workshop discussions. It is not a consensus document expressing committee findings or recommendations. Rather, it summarizes the views expressed by the workshop participants and committee members in their individual capacities. 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 manage- able. These assumptions in turn helped shape the topics addressed in the workshop. Assumptions The assumptions adopted for the purpose of workshop discussions were as follows: 1. The yield of the IND that workshop participants needed to address would be equivalent to 10 kt of TNT (trinitrotoluene). This is somewhat less than the 16- and 21-kt yields of the Hiroshima and Nagasaki bombs, respectively.5 However, it corresponds to the highest yield that Congress directed DHS to use in modeling the effects of nuclear attacks on the Tier 1 UASI cities in P.L. 110-28, and it is also the same as the yield used in the IND planning sce- nario under the NRF. 2. The attack would be a surprise, with the intent of maximizing the number of casualties and minimizing the chance that the bomb would be found and disarmed before it could be set off and the bombers would be caught. 3. The terrorists would detonate the IND in the central business dis- trict or in another densely populated area to maximize the number of casualties. 4. The attack would occur during a workday to maximize the number of casualties, although the terrorist could choose the middle of the 5 The yields were most recently estimated as being between 14 and 18 kt at Hiroshima and between 19 and 23 kt at Nagasaki, each at a 99 percent confidence limit (RERF, 2002:51-52).

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 MEDICAl PREPAREDNESS FOR A TERRORIST NuClEAR EVENT night instead, to exploit vulnerability and minimize the chances of interception and capture. 5. The IND would be detonated at or near ground level. This differs from the bombings of Hiroshima and Nagasaki, where the bombs were detonated at altitudes of approximately 1,970 and 1,652 feet, respectively (RERF, 2002:48, 51). Compared with an airburst, the blast, thermal radiation, and prompt nuclear radiation impacts of a ground-level detonation would affect a smaller area, but radio- active fallout (which was negligible at Hiroshima and minimal at Nagasaki) would be considerable and would affect a very large area (Glasstone, 1962:633-634). 6. The workshop would focus on the acute medical effects of the explosion and the resulting fallout. These would include blast injuries, burns, ARS, and combinations of these effects. Although decontamination requirements and the long-term effects of radia- tion exposure on health, particularly cancer, are also matters of serious medical concern, they were not a focus of this workshop. 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) and to minimize long-term effects. 8. Although the scope of the workshop would be national prepared- ness, it was recognized and assumed that the initial response would be largely local and regional and that it could take as long as a week before substantial state and federal resources could arrive. This assumption was based on the realization that no city or metro- politan area would be able to respond to a nuclear event alone and that the preparations for such an event would also have to depend on state and federal government involvement and support. Topics To respond to the statement of tasks provided by DHS and guided by the assumptions listed above, the committee selected the topics to be addressed at the workshop, which were reflected in the agenda (Appen- dix A). The topics were the following: 1. Effects of a 10-kt IND detonation on a. human health and b. the regional health care system 2. State-of-the-art medical care for two mostly distinct groups, namely victims of a. the immediate effects of a nuclear detonation (i.e., injuries from blast, heat, and prompt radiation, singly and in combination) and

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 WORKSHOP REPORT b. radiation from the fallout caused by a ground burst 3. Expected benefit of radiation countermeasures 4. Potential protective actions and interventions to reduce radiation injury to a. first responders and b. the population under the fallout plume 5. Risk communication, public reactions, and psychological conse- quences of an IND event 6. Federal and state medical resources for responding to an IND event 7. Current preparedness for responding to the medical needs of those injured by the immediate effects of an IND detonation, including the capacity a. to reach, triage, and stabilize those injured by the detonation safely; b. to evacuate casualties to regional treatment facilities; c. of the metropolitan region’s medical system to treat casualties; and d. to evacuate serious casualties to appropriate treatment facilities 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. With an IND detonation, he noted, there would be an overwhelming number of casualties with physical trauma and thermal burns with radiation injury, and severely damaged infrastructure. Initially, the pre- planned medical response would not be able to match the medical needs. In that vacuum, spontaneous individual responses would be likely from local medically trained and untrained personnel who would step forward to aug- ment the initial emergency medical response (this was seen, for example, at Hiroshima). Even with volunteers, in an overwhelming mass casualty scenario there would be austere medical care rather than ideal standard-of-care practice. Flynn questioned whether those who volunteer to augment the initial emer- gency medical response would have access to enough first-aid and basic medical supplies.

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 MEDICAl PREPAREDNESS FOR A TERRORIST NuClEAR EVENT He indicated that the anatomy of a nuclear detonation can be dissected into blast, thermal, and radiation effects, each of which can cause signifi- cant injury. Two types of blast forces occur simultaneously in the shock front of the nuclear detonation: (1) static overpressure effects measured in pounds per square inch (psi) over ambient pressure and (2) dynamic pressure effects (i.e., wind), measured in miles per hour (mph). Overpressure can cause eardrum rupture at a threshold of 5 psi and severe lung injury at 20 to 30 psi. However, blast winds are much stronger than hurricane winds, and can cause fragmentation and collapse of buildings and other objects, therefore creating flying debris (missiles) and projecting human bodies into the air, resulting in both penetrating and blunt trauma. The blast winds are significant because, for example, although 15 psi might rupture eardrums, the associated blast winds would be well over 300 mph and inflict seri- ous injury and death (Glasstone and Dolan, 1977:Table 12.38; Alt et al., 1989:7; AFRRI, 2003:33-36). Thermal radiation injury caused by the intense heat of the expanding fireball and thermal infrared radiation would result in first-, second-, and third-degree burns. The extremely bright flash of light from the detonation would cause a spectrum of blindness effects, ranging from temporary flash blindness to permanent total blindness, depending on the distance from and the visual orientation at the moment the nuclear device exploded. Nuclear radiation injury would be caused either by the prompt radia- tion released immediately on detonation in the proximal blast zone or, if the detonation occurred at ground level, by exposure to radioactive fallout. 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 conse- quences 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. Initial primary triage of combined injury patients should be based on conventional criteria of mechanical trauma and burns, because they are the primary cause of death in the first few days. Removal of significant radiation contamination would occur simultane- ously with the primary triage process. As data on the radiation dose became available, a secondary triage evaluation, now based on likely radiation injury, would be conducted after the first few days in such a mass casualty scenario. After this introduction, Flynn introduced the two subject matter experts who spoke during this session. Brooke Buddemeier, a certified health physi- cist at Lawrence Livermore National Laboratory, reviewed the potential effects on the population in the immediate vicinity of the detonation and on the population in the downwind area covered with radioactive fallout. Cham Dallas, a toxicologist, chair of the Department of Health Policy and

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 WORKSHOP REPORT Management and director of the Institute for Health Management and Mass Destruction Defense at the University of Georgia, then focused on the effects that a nuclear explosion would have on the capacity of the health care system in several of the Tier 1 UASI areas. Health Effects Introduction6 If a terrorist were to explode a 10-kt-equivalent IND at or near the center of a Tier 1 UASI city, at or near ground level, without warning and during a workday, the number of casualties needing immediate medical care would be very large. 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). It is not possible to predict the exact numbers of injured persons in such an event because, fortunately, there has never been a ground-level nuclear explosion in any city for comparison. As a result, there is no applicable experience to provide the insight and essential data required to formulate a detailed projection. Instead, models extrapolated from Hiroshima, Nagasaki, and nuclear bomb tests on Pacific atolls and in the Nevada desert more than half a century ago have been used to make estimates of the number of casual- ties. Clearly, these estimates are very rough for a number of reasons: • As already noted, the Hiroshima and Nagasaki bombs that exploded were airbursts and therefore produced much less fallout than a ground-level detonation would. • Atmospheric nuclear tests in Nevada had yields less than 100 kt, but most were detonated on top of steel towers 100 to 700 feet high. The few true surface shots were 1 kt or less “so that they pro- vided relatively little useful information concerning the effects to be expected from weapons of higher energy” (Glasstone, 1977:419- 420). The surface bursts in the Pacific Ocean tests drew large amounts of water into the cloud “so that the fallout was probably quite different from what would have been associated with a true land surface burst” (Glasstone, 1977:420). • The test detonations were conducted in open terrain or ocean set- tings and not in the same topographical and structural circumstances or population densities of the Tier 1 cities being evaluated. • The factors used to adjust for the moderating effects of buildings and local topography have been primarily ad hoc but can affect the results by factors of 2 or 3. 6 This introduction to health effects was drafted by the committee.

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0 MEDICAl PREPAREDNESS FOR A TERRORIST NuClEAR EVENT FIGURE 1 Sources of injury from a 10-kt IND: approximate blast, thermal, and prompt radiation effects around—and fallout effects downwind from—the detona- Figure 1 tion point. R01441 SOURCE: Reprinted, with permission, from Lawrence Livermore National Laboratory, bitmapped, fixed image, color Laboratory. 2009. Copyright 2008 by Lawrence Livermore National scaled for landscape above, scaled for por trait below • Most models have calculated blast, burn, and radiation injuries separately and have not tried to determine the extent of combined injuries (i.e., estimates of blast, burn, and radiation injuries might count the same person as injured or killed two or three times).7 Efforts are under way to produce improved human casualty esti- mates, but the work is in the early stages and the issue needs fur- ther study (see Box 1 and footnote 13). 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), massive infrastructure damage, and 7 An exception is a U.S. Army textbook, which estimates the percentages of the injured in a nuclear war by type of injury or combination of injuries (e.g., 40 percent from burns and irradiation combined and 20 percent from trauma, burns, and radiation combined) (Alt et al., 1989:Table 1-1).

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 WORKSHOP REPORT BOX 1 Modeling the Effects of INDs in Modern U.S. Cities and Implications for Response and Recovery Plans The conference report on P.L. 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. The modeling results were used to identify key drivers in response planning and to assess and refine effective response strategies. A preliminary report on sheltering and evacuation strategies indicated that sheltering immediately after a detonation for a period of time is critical in reducing exposure to fallout, followed by informed evacuation (“informed” means that the location and intensity of the fallout area can be determined and communicated soon after the detonation) (Law et al., 2008). A summary report of the modeling and response work is being prepared (Buddemeier and Dillon, forthcoming). It will provide guidance for response planning by summarizing the key factors to be considered in (1) developing a public protection strategy; (2) setting first responder priorities for protecting response personnel, assessing the regional situation, and protecting the public; and (3) avoiding common misperceptions about nuclear weapons and identifying critical issues in planning responses to an IND. The modeling and response analyses also informed the effort by the Homeland Security Institute to develop a communications strategy for respond- ing to a nuclear detonation in a U.S. city, also mandated by P.L. 110-28 (see Box 5 for an overview of that activity). thousands of square kilometers of contaminated land.”8 That government estimate of effects from an IND detonation is very general, but it indicates that there would likely be more than 100,000 survivors with injuries that would have to be treated. Although this detail is not mentioned in the annex, it can be interpreted that many of the 100,000 fatalities might be those who live for weeks or possibly several months before succumbing to ARS, as described in the next section: Topic 2, “Medical Care of Victims of the Immediate and Fallout Effects of a 10-kt IND.” Several nonfederal experts have developed models of the effects that a nuclear explosion of approximately 10-kt yield would have in several U.S. 8 See footnote 2 for a brief overview of the Nuclear/Radiological Incident Annex and its URL.

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0 MEDICAl PREPAREDNESS FOR A TERRORIST NuClEAR EVENT initially and be distributed by NYSDOH, and the department would advise on the use of medical countermeasures. In May and June 2009 the New York State Capital District area— Albany and Rensselaer counties—will host a full-scale FRMAC response exercise involving an RDD. It will begin with a 2-day tabletop exercise to simulate the first 48 hours (mostly local and state activities since the sce- nario assumes that federal assistance will not arrive for 2 or 3 days) and will be followed by a 3-day full-scale exercise including federal agencies. Discussion of Preparedness to Prevent and Treat the Delayed Casualties of an IND Detonation The discussion addressed a number of areas in which preparedness policies and procedures are not clear. Sheltering in Place or Evacuation This question was posed: Who will decide to recommend sheltering or evacuation and on what basis? Currently, each area is deciding what to do. In Los Angeles County, for example, the initial message to those within a half-mile or mile of the detonation point will be to shelter in place because levels of radioactivity outdoors will be too high for them or rescuers to be outdoors for a day or two. 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) or more. Since this would involve a large number of people and result in significant traffic congestion, the county will attempt to have people shelter in place for several days until it can arrange for buses. New York City would also use the PAGs, but it sees the problem to be lack of information on which to estimate the dose levels. This discussion of sheltering and evacuation policies was intertwined with the public messaging topic, which is summarized below. Pre-Event and Intra-Event Messaging A participant posed the issue as follows: “If you don’t get public mes- saging correct in the first 12 or 24 hours in a post-detonation environment, you are going to wind up with another 100,000 or 200,000 people stuck on the roads who are now going to become fallout victims.” The actual numbers would depend on circumstances, but whatever the number, auto- mobiles would provide little shielding to the passengers inside from fallout on the ground around them.

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0 WORKSHOP REPORT Others pointed out that messaging during an event would probably have little impact without some pre-event education that was understand- able to people. For example, NYSDOH found in preparing training courses for local health departments that the phrase “shelter in place” was not understood by most people. Another factor identified was the need for the information to come from a credible source. CDC has found in its research on crisis and risk commu- nication that the more local the source, the more credible it is for the public. 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 mes- sages such as “go in, stay in, tune in,” but the results had not yet been pub- lished.51 The Conference of Radiation Control Program Directors (CRCPD) is also working on messaging, beginning with a comprehensive review of messages that have been developed by various groups and localities.52 CDC also found that the public and clinicians need different messages. A participant suggested having emergency preparedness be part of con- tinuing education requirements for clinicians. At least one state requires a certain number of hours of emergency preparedness education. Decontamination Criteria and Policies Another area of extended discussion was how to deal with radiation contamination of people, especially uninjured people needing food and shelter and medical care for chronic conditions. The Red Cross, the lead for ESF-6, the “Mass Care, Housing, and Human Services” annex to the NRF, has a zero-contamination policy for entry into shelters. This poses a major problem because many people will be sufficiently contaminated to trigger portal monitor alarms, and it will not be possible to decontaminate hundreds of thousand of people in 12 hours. Many contaminated individu- als will have chronic medical conditions that may be exacerbated if they do not receive shelter, food, and medical care. There were suggestions that removal of clothing and washing of face and hands would be adequate even if it did not provide 100 percent decontamination and that there could be agreement on a low but nonzero level of contamination at which to set the portal monitor alarms. Health care providers who treated victims of the Chernobyl reactor 51 The HSI report was published in March 2009 (Hampton et al., 2009). See Box 5 for a brief summary. 52 In December 2008, CRCPD published a report on keys to successful radiological response (CRCPD, 2008).

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0 MEDICAl PREPAREDNESS FOR A TERRORIST NuClEAR EVENT accident received at most 1 rad (1 cGy). Even the rescuers at Chernobyl breathing the dust received less than 10 percent of their dose from internal contamination. Pre- and intra-event messaging would be important in allaying public fears that contamination would be a major hazard and lessening the fears of health care providers that treating trauma patients would put them at risk of being contaminated. Identifying the Acutely Irradiated An IND explosion could irradiate upwards of 100,000 people to sev- eral hundred rad (cGy) or more. Two hundred rad (cGy) is the fatality threshold at which about 5 percent of those exposed would die without treatment. Currently, as discussed earlier in this report, dose assessment for initial field triage purposes is assessed by performing an evaluation that includes determining where the person was at the time of detonation and estimating the time from irradiation until he or she vomited as well as other, less reliable symptoms such as erythema. At the hospitals, laboratory tests (e.g., serial complete blood counts) would be useful but the capacity to conduct laboratory tests would be severely limited relative to demand. The problem of identifying and transporting people with radiation injuries would be complicated because many of them would be in areas of heavy fallout and infrastructure destruction where for several days after the explosion it would be dangerous and difficult for EMS to operate. Addressing long-Term Effects This topic was not a focus of the workshop, but it was touched on a number of times, in part because it involves activities that should begin immediately after an IND is detonated. A large number of people, upwards of one million, would likely have been in areas where the 4-day fallout dose was 1 rem (10 mSv) or more. Although doses of 1 to 5 rem (10 to 40 mSv) are estimated to increase the long-term cancer rate slightly, the absolute number of people potentially affected by such a low dose could be several thousand.53 Because these people would not be acutely affected, the plans would be to receive and maintain them in shelters until it is safe for them to return to their homes. Los Angeles County’s playbook, for example, calls for registra- tion at ESF-6 shelters. This would probably be piggybacked on their point 53 According to González (2005), each mSv would increase the probability of cancer in the long term by 0.005 percent. Assuming the average dose in the area exposed to between 10 and 50 mSv is 30 mSv, the probability would be 0.15 percent (0.0005 times 30), which would affect approximately 1,500 of a population of one million.

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0 WORKSHOP REPORT of dispensing database by adding information to the database, especially details about where the person was at the time of detonation and time to vomiting, in order to estimate the person’s dose. Administering Countermeasures The question posed was about the criteria for administering decorpo- rating and blocking agents such as DTPA. With respect to the decorporating and blocking agents, a major problem is determining how much internal contamination someone has experienced. Another question was about the adequacy of the supply of cytokines such as filgrastim. Hospitals would only have a small supply on hand for treating oncology and hematology patients. The Public Health Emergency Medical Countermeasures Enterprise has a requirement for 200,000 treat- ment courses of a medical countermeasure to mitigate or treat the neutro- penia associated with ARS. Currently, SNS includes a modest quantity of filgrastim in its vendor-managed inventory system. HHS is currently seek- ing to increase its stockpile of medical countermeasures for hematopoietic syndrome and radiation-induced neutropenia. WRAP-UP AND FINAL THOUGHTS Committee chair Georges Benjamin concluded the workshop by sum- marizing the main points he had heard during the presentations and dis- cussions. First, the detonation of an IND would be a national catastrophe of unprecedented proportions because of the large number of casualties, reinforced by the social, economic, and psychological impacts. Local and state responses would be overwhelmed immediately, and it would be several days or a week before federal and other resources could be fully mobilized. HHS has developed a playbook outlining how the federal medical response to an IND detonation would evolve and unfold and intends to publish this on the Internet. Second, it was apparent from the presentations that there are many emergency preparedness efforts going on at multiple levels, and the degree of planning varies among them. Generally, large urban areas and their states have begun to prepare their responses to a radiological event such as an RDD but are only beginning to think about what they should do to prepare for a possible IND detonation. 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). Third, many federal agencies are poised to help, but there is a lack of awareness at the local level about what assets would be available and the

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0 MEDICAl PREPAREDNESS FOR A TERRORIST NuClEAR EVENT process.54 More planning and exercising for an IND detonation contingency is needed at the local level if local and state planners are to understand how these various pieces would fit together in an actual event. Fourth, in addition to the lack of knowledge of federal plans and resources for responding to an IND event, localities and states generally lack awareness of the number and mix of casualties that would occur in plausible detonation scenarios. There is currently little open-source infor- mation on the conceivable conditions following an IND detonation in a modern U.S. city. The information provided by Brooke Buddemeier in his presentation at the June workshop is all that is public, and it did not include estimates of the numbers of casualties by type of injury except in the most general terms (i.e., “hundreds of thousands of casualties can occur from the prompt effects in the first few minutes within a few miles of detonation site” and “hundreds of thousands of acute casualties from radioactive fallout can occur within 15 km downwind”). This makes it difficult for localities and states to plan their responses.55 Fifth, there are significant limitations on the effectiveness of a response. Current supplies of specific (e.g., cytokines) and nonspecific (e.g., blood products) medical countermeasures are not matched to the projected require- ments of an IND detonation, and the logistical challenges that would have to be overcome in order to administer these countermeasures when they are needed are substantial. There will not be enough vehicles and airplanes to extricate victims and move them to treatment facilities. Sixth, the nation is not prepared to respond to the medical and public health consequences of an IND detonation, but it is not clear what “pre- pared” means. Preparedness is a process, not a point in time, and it is not clear what the goal should be. Determining such a goal would help in mea- suring and evaluating progress toward preparedness. 54 As footnoted earlier, HHS’s nuclear detonation playbook, which would lay out the various roles and responsibilities of the federal agencies in more detail, has not yet (as of June 23, 2009) been released. 55 Some additional information has been released since the workshops were held, cited in footnotes 13 and 16 and Box 1. Buddemeier (2008) has estimated the unduplicated number of injured from all prompt effects (blast, thermal, and radiation) in his Washington, DC, scenario as 250,000, divided into those who (1) would recover without advanced medical aid, (2) would succumb to fatal doses of radiation or combinations of injuries in the coming weeks and months, and (3) would most benefit from advanced medical aid. 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). Law et al. (2008) analyzed alternative sheltering and evacuation strategies in the fallout area, finding that sheltering for a period of time immediately after a detonation, followed by delayed evacuation when radiation levels have declined, is generally the best strategy.

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0 WORKSHOP REPORT Seventh, many important strategic decisions have to be made at the national (i.e., combined local, state, and federal) level: • How to inform and engage the public in the process of deciding what responses would be realistic and appropriate. • 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? • Whether to tell the public to shelter in place or evacuate, and on what criteria to base such a decision: For reasons discussed during the workshop (e.g., the speed of the arrival of fallout and the rela- tively effective protection that can be provided by buildings versus the probability of gridlock), the default policy probably should be, “Shelter in place until we let you know it is safe enough to evacu- ate,” but no one has stated this officially. Part of the problem is that this or any other blanket policy will not be the best policy for every situation, but the capacity to provide more nuanced advice probably does not exist at this time. No blanket policy is perfect, but the capacity to provide tailored advice during an event is and will continue to be quite limited. • To what extent plume models should form the basis of decisions to recommend that people should shelter or evacuate: There was evidence presented at the workshop that the footprint of the fallout might well be patchy rather than the sharply defined cigar or fan shape provided by plume models, because the winds at different levels might be going in different directions and shifting at the same time. • How long-term medical effects should be handled: This was not addressed at the workshop, but steps must be taken soon after the event to identify people exposed to 1 rem (10 mSv) or more, inform them of the long-term risks of cancer, and implement registries to keep track of them. There will also be long-term mental health and behavioral effects that will need to be monitored. DoD has been developing instruments and procedures for military personnel serving in Iraq and Afghanistan that might be transferable into the civilian setting. • How to manage public and health care professional concerns and fear: There is no clear strategy for communicating with people and keeping them informed, especially vulnerable populations who have fewer resources to help them make it through a devastating event.

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0 MEDICAl PREPAREDNESS FOR A TERRORIST NuClEAR EVENT Eighth, there are few medical countermeasures available for victims of radiation exposure, and more are greatly needed. Current licensed coun- termeasures are limited to decorporation and blocking agents, but internal contamination with radionuclides will not be a significant determinant of near-term morbidity and mortality in an IND scenario. Radioiodine is not likely to be a major fission product of an IND, and in any case, KI works best when taken before exposure and has little effect unless it is applied within a day or two after exposure, which will be difficult to accomplish. In any event, ingestion is not likely to be a major problem in the days after an IND detonation, although eventually it will become one as people began to ingest contaminated food and water. The standard treatment for ARS includes cytokines, antibiotics, and other supportive care. New countermeasures are under development as part of a concerted federal effort, with some products in comparatively late stages of development or licensed for other indications. 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 nation- ally; problems with the resupply of health care facilities that have one-day inventories of drugs and other supplies). Finally, while no preparations could fully mitigate the impacts of a nuclear detonation in the middle of a major U.S. city, the workshop dis- cussions touched on a number of ways that governments at all levels have begun to improve their capacity to respond to such an event, especially by increasing joint information sharing and response planning on a regional basis. Determining how much priority to give such efforts, considering the more likely threats of the occurrence of events such as earthquakes, hur- ricanes, and other forms of terrorism, was beyond the committee’s charge. However, many of these efforts would also help improve the nation’s capac- ity to respond to other types of mass casualty events. REFERENCES Abramson, D. M., S. S. Morse, A. L. Garrett, and I. Redlener. 2007. Public health disaster research: Surveying the field, defining its future. Disaster Medicine and Public Health Preparedness 1(1):57-62.

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