Assessing Medical Preparedness to Respond to a Terrorist Nuclear Event: Workshop Report (2009)

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ASSESSING MEDICAL PREPAREDNESS TO RESPOND TO A TERRORIST NUCLEAR EVENT W O R K S H O P R E P ORT Committee on Medical Preparedness for a Terrorist Nuclear Event Georges C. Benjamin, Michael McGeary, and Susan R. McCutchen, Editors Board on Health Sciences Policy THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu 

THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This study was supported by a contract between the National Academy of Sciences and the U.S. Department of Homeland Security (Contract HSHQDC-08-C-00014). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-13088-2 International Standard Book Number-10: 0-309-13088-3 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334- 3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. COVER: The cover depicts a schematic model of the effects of detonating a 10-kiloton (kt) nuclear device at ground level in the central business district of a large metropolitan area. The circles around ground zero represent areas of extensive immediate damage from the blast (red), thermal (orange), and radiation (yellow) effects of the detonation. For illustrative purposes, the circles are not drawn to scale (in a 10-kt detonation, they would be nearly overlapping). The long elliptical contour lines emanating from ground zero represent the area where radioactive fallout would settle soon after a detonation, after being carried by atmospheric winds. The red ellipse represents the area in which the short exposure of anyone outdoors immediately after the detonation would probably be lethal. The orange and yellow ellipses represent areas of progressively less radiation. The H’s are hospitals and represent the likelihood that some hospitals, which tend to concentrate in the downtown of most central cities, would likely be affected negatively by a 10-kt nuclear detonation—some by the immediate effects, others by the fallout, and some by both. Suggested citation: IOM (Institute of Medicine). 2009. Assessing medical preparedness to respond to a terrorist nuclear event: Workshop report. Washington, DC: The National Academies Press. 

“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health. 

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general wel- fare. Upon the authority of the charter granted to it by the Congress in 1863, the ­ Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of S ­ ciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The ­Institute acts under the responsibility given to the National Academy of Sciences by its con- gressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of ­Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org 

COMMITTEE ON MEDICAL PREPAREDNESS FOR A TERRORIST NUCLEAR EVENT GEORGES C. BENJAMIN (Chair), American Public Health Association, Washington, DC gEORGE J. ANNAS, Department of Health Law, Bioethics and Human Rights, Boston University School of Public Health, Boston, MA DONNA F. BARBISCH, Global Deterrence Alternatives, LLC, Washington, DC frederick m. burkle, jr., Center for Refugee and Disaster Studies, Johns Hopkins University Medical Institutions and Harvard Humanitarian Initiative, Kailua, HI COLLEEN CONWAY-WELCH, Vanderbilt University School of Nursing, Nashville, TN DANIEL F. FLYNN, Caritas Holy Family Hospital and Medical Center, Methuen, MA RICHARD J. HATCHETT, Radiation Countermeasures Research and Emergency Preparedness, National Institute of Allergy and Infectious Diseases, Bethesda, MD FRED A. METTLER, JR., Radiology and Nuclear Medicine, New Mexico Federal Regional Medical Center, and Department of Radiology, University of New Mexico School of Medicine, Albuquerque, NM JUDITH A. MONROE, Indiana State Department of Health, Indianapolis, IN PAUL E. PEPE, University of Texas Southwestern Medical Center at Dallas; City of Dallas Medical Emergency Services for Public Safety, Public Health and Homeland Security; Dallas Metropolitan Medical Response System; and Metropolitan Biotel System, Dallas, TX tHOMAS M. SEED, Consultant, Tech Micro Services, Bethesda, MD JAMES M. TIEN, College of Engineering, University of Miami, Coral Gables, FL ROBERT J. URSANO, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD Study Staff MICHAEL McGEARY, Study Director william f. stephens, Consultant SUSAN R. McCUTCHEN, Senior Program Associate Andrew Pope, Director, Board on Health Sciences Policy  



Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Herbert L. Abrams, Department of Radiology, Professor Emeritus, Stanford University Brooke Buddemeier, Global Security Directorate, Lawrence Livermore National Laboratory Michael L. Freeman, Vanderbilt University School of Medicine Dan Hanfling, Emergency Management and Disaster Medicine, Inova Health System Nathaniel Hupert, Weill Cornell Medical College Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the report before its release. The review of this report was overseen by Ms. Hellen Gelband, Resources for the Future. Appointed by the Institute of Medicine, vii 

viii REVIEWERS she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. 

Preface The 20th century brought us the birth of the atomic age, with Albert Einstein’s understanding that E = MC2 in 1905, Ernest Rutherford’s theory of the structure of the atom in 1911, and the first sustained nuclear reac- tion in Chicago in 1942. While it brought the promise of a robust use of nuclear technologies for peaceful purposes, it also brought the reality of nuclear weapons in 1945. Those initial weapons were large, heavy, and complex to make and use. Moreover, only nations had nuclear weapons, not individuals or groups. Since then, nuclear weapons technology has con­ tinued to advance, producing smaller, lighter, and more potent weapons. In addition to that technological advance, terrorists are working diligently to obtain those devices. Today, the development and detonation of a compact and portable nuclear device by a small group of terrorists is a potential threat.1 Such an improvised nuclear device (IND) could be small enough to transport in a vehicle and could produce an explosion equal in yield to 10 kilotons (kt) of TNT (trinitrotoluene).2 Like other nuclear weapons, an IND detonation would result in sub- stantial structural and environmental destruction from blast, heat, and radiation effects. That destruction would impose a significant additional burden on the normal disaster emergency medical response because of the extent of physical destruction, the presence of dangerous levels of radia- tion, and the potential loss of critical medical infrastructure in surrounding areas. Numerous operational and logistical problems with delivering sup- plies, transporting patients, and emergency communications would further complicate the response. ix 

 PREFACE The medical impacts of those injuries are likely to be catastrophic, both for people in the immediate area and for those in a radius of up to several miles. Survivability is related to a combination of the degree and type of injury and the degree of exposure to radiation in both the short and intermediate terms. Those effects have both medium- and long-term health consequences for victims and emergency response personnel. Under any scenario envisioned from the release of an IND, we will have a significant medical disaster with thousands of casualties. The immediate requirement for a large number of specialized beds for burns, broken limbs, head inju- ries, crushed lungs, eye injuries, and other types of trauma will overwhelm the current health system, which is already overtaxed.3 The number and variety of casualties, the lack of adequate emergent health care infrastruc- ture in many areas (including burn and trauma beds, respirators, supplies, and trained staff), and the long-term disruption to routine emergent and urgent health care services represent a significant planning challenge. In addition to the devastation around ground zero from blast, thermal, and prompt radiation effects, a ground-level detonation would create a substantial amount of fallout that would be deposited for miles downwind. Radiation from the fallout would cause death and injury to people exposed to it, especially those outdoors in the first 10-15 miles downwind during the first few hours, but efforts to prepare the public to take the appropriate steps to protect themselves from fallout are almost nonexistent. Disasters also have serious psychological impacts on people who are involved in them.4 In general, we are not well prepared to help victims cope with the psychological effects of disasters, and terrorist nuclear events are no exception. The United States has been struggling for some time to address and plan for the threat of nuclear terrorism and other weapons of mass destruction (WMDs) that terrorists might obtain and use. One of the earliest medical preparedness efforts, the Metropolitan Medical Response System Program, was started in 1995, but it has remained underfunded and its potential has been largely unfulfilled.5 A range of public health efforts have been taken to prepare for the appearance of pandemic influenza, smallpox, anthrax, and other infectious disease threats. Those efforts have put some systems and some resources in place, such as the National Disaster Medical System, to respond to infectious and other health emergencies, but as Hurricane Katrina showed, they are not adequate to overcome a substantial loss of critical medical and response infrastructure. There are, of course, a number of public and nonpublic efforts by a variety of federal, state, and local agencies to prevent, mitigate, and respond to the threat of an IND. The latest effort, the Urban Area Security Initia- tive (UASI), is providing funds to 45 urban areas to improve preparedness for WMDs, including an IND detonation. The Department of Homeland 

PREFACE xi Security, as directed by Congress, asked the Institute of Medicine (IOM) to conduct a workshop to better understand the state of preparedness for an IND detonation in the six UASI cities designated as “Tier 1.” Public health practitioners are usually asked to figure out how to prevent bad things from happening and to preserve our health. The basic assumption for this workshop, however, was to assume: What if? Specifically, what if the efforts by law enforcement and other security officials failed to prevent the detonation of a 10-kt nuclear device in a central city? The committee’s task was basically to ask: Where are we today, and what are the gaps should the unthinkable happen? The committee fulfilled that task. This report provides a frightening but candid look into our level of pre- paredness today. It was an informative process; one that did much to con­firm that we are not yet prepared for a nuclear event. In fact, in many ways, we are still in the infancy of our planning and response efforts. The workshop identified several key areas in which we might begin to focus our national efforts in a way that will improve the overall level of preparedness. The workshop committee members were a group of some of the most intelligent and wisest people in the areas of emergency preparedness and nuclear response. In addition, the many panel members who contributed to the workshop brought a great deal of technical knowledge and practical reality to the discussion. That contribution was of particular value concern- ing the status of preparedness of the Tier 1 UASI cities. In closing, I would like to thank the IOM staff who supported this committee’s work, and the committee members with whom I had the plea- sure to work. The workshops were complicated, the deadlines tight, and the material complex. The staff did a terrific job, and I was honored to have the opportunity to work with them. Georges C. Benjamin, M.D., Chair Committee on Medical Preparedness for a Terrorist Nuclear Event Endnotes 1.  Allison, G. 2004. Nuclear terrorism: The ultimate preventable catastrophe. New York: Times Books, Henry Holt and Company; Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism. 2008. World at risk: The report of the Commission on the Prevention of WMD Proliferation and Terrorism. New York: Vintage Books; State- ment for the Record of Charles E. Allen, Under Secretary for Intelligence and Analysis, U.S. Department of Homeland Security, Before the Senate Committee on Homeland Security and Governmental Affairs, Hearing on Nuclear terrorism: Assessing the threat to the homeland, April 2, 2008. 2.  Bunn, M. 2008. The risk of nuclear terrorism—and next steps to reduce the danger. P ­ repared testimony for the Senate Committee on Homeland Security and Governmental A ­ ffairs, Hearing on Nuclear terrorism: Assessing the threat to the homeland, April 2, 2008. 

xii PREFACE 3.  IOM (Institute of Medicine). 2007. Hospital-based emergency care: At the breaking point. Washington, DC: The National Academies Press. 4.  IOM. 2003. Preparing for the psychological consequences of terrorism: A public health strategy. Washington, DC: The National Academies Press. 5.  IOM. 2002. Preparing for terrorism: Tools for evaluating the Metropolitan Medical ­ esponse System Program. Washington, DC: The National Academies Press. R 

Contents ABBREVIATIONS AND ACRONYMS xvii INTRODUCTION 1 COMMITTEE PROCESS 4 WORKSHOP ASSUMPTIONS AND TOPICS 5 Assumptions, 5 Topics, 6 TOPIC 1: EFFECTS OF A 10-kt IND DETONATION ON HUMAN HEALTH AND THE AREA HEALTH CARE SYSTEM 7 Health Effects, 9 Effects on the Area Health Care System, 20 Discussion of Health Effects and Health Care System Impacts, 23 Summary of 10-kt Detonation Effects, 24 TOPIC 2: MEDICAL CARE OF VICTIMS OF THE IMMEDIATE AND FALLOUT EFFECTS OF A 10-kt IND DETONATION 27 Discussion of Medical Care of Victims of a Nuclear Detonation, 31 TOPIC 3: Expected benefit of radiation countermeasures 32 Discussion of Radiation Countermeasures, 41 xiii 

xiv CONTENTS Topic 4: protective actions and INTERVENTIONS IN THE EVENT OF A 10-kt IND DETONATION 42 Discussion of Protective Actions and Interventions, 47 Summary of Protective Action Guides, 48 TOPIC 5: Risk CommunicatIOn, Public reactions, and psychological consequences IN THE EVENT of a 10-kt ind detonation 49 Discussion of Risk Communication, Public Reactions, and Psychological Consequences, 60 summary of key points from the june workshop 62 TOPIC 6: Federal and state medical resources FOR RESPONDING TO AN IND EVENT 64 Discussion of Federal and State Medical Resources for Responding to an IND Event, 74 Topic 7: Current Preparedness for responding To the immediate casualties OF AN IND EVENT 76 Panel 1 on Capability to Reach, Triage, and Treat the Injured, 78 Panel 2 on Capacity to Transport Casualties to Local Treatment Facilities, 82 Panel 3 on Preparedness of the Metropolitan Area’s Medical System, 84 Panel 4 on Preparedness to Evacuate Serious Casualties from the Metropolitan Area, 87 General Discussion of Topic 7: Preparedness for Responding to the Immediate Casualties of an IND Event, 94 Topic 8: Current preparedness to prevent and treat the delayed casualties of an ind EVENT 96 Discussion of Preparedness to Prevent and Treat the Delayed Casualties of an IND Detonation, 104 wrap-UP and final thoughts 107 references 110 APPENDIXES A Workshop Agendas 115 B Registered Workshop Attendees 131 C Biographical Sketches of Workshop Speakers and Panelists 138 D Biographical Sketches of Committee Members, Consultant, and Staff 160 

Tables, Figures, and Boxes Tables 1 Estimated Acute Symptom and Death Rates from Radiation as a Function of Short-Term Whole-Body Absorbed Dose, 15 2 Treatment Strategies for Hematopoietic ARS, 37 Figures 1 Sources of injury from a 10-kt IND: approximate blast, thermal, and prompt radiation effects around—and fallout effects down- wind from—the detonation point, 10 2 Protection from exposure to radiation provided by sheltering in ­ different types of structures and various places within those s ­ tructures, 19 Boxes 1 Modeling the Effects of INDs in Modern U.S. Cities and Implica- tions for Response and Recovery Plans, 11 2 Prompt Effects Summary, 13 3 Radiation Unit Equivalencies, 14 4 Fallout Effects Summary, 17 5 Nuclear Incident Communication Planning, 95 xv 



Abbreviations and Acronyms AFRRI Armed Forces Radiobiology Research Institute AMS Aerial Measuring System ARAC Atmospheric Release Advisory Capability ARS acute radiation syndrome ASPR Assistant Secretary for Preparedness and Response (HHS) CBRN chemical, biological, radiological, or nuclear CBRNE chemical, biological, radiological, nuclear, or explosive CDC Centers for Disease Control and Prevention CERFP CBRNE Enhanced Response Force Package cGy centigray CIMS citywide incident management system (New York City) CMOC catastrophic medical operations center (Texas) CMRT Consequence Management Response Team CONOPS concept of operations CRAF Civil Reserve Air Fleet CRCPD Conference of Radiation Control Program Directors CRI Cities Readiness Initiative CST Civil Support Team DC District of Columbia DHS Department of Homeland Security DMAT Disaster Medical Assistance Team (NDMS) DoD Department of Defense DOE Department of Energy xvii 

xviii ABBREVIATIONS AND ACRONYMS DRC Disaster Resource Center DTPA diethylenetriamine pentaacetic acid ED emergency department EMAC Emergency Management Assistance Compact EMEDS Expeditionary Medical Support EMP electromagnetic pulse EMS emergency medical services EMT emergency medical technician EPA Environmental Protection Agency ESAR-VHP Emergency System for Advance Registration of Volunteer Health Professionals ESF-6 Emergency Support Function #6 (NRF) ESF-8 Emergency Support Function #8 (NRF) EUA Emergency Use Authorization FCC federal coordinating center (NDMS) FDA Food and Drug Administration FEMA Federal Emergency Management Agency FRMAC Federal Radiological Monitoring and Assessment Center FY fiscal year GPS global positioning system Gy gray hazmat hazardous materials HHS Department of Health and Human Services HPP Hospital Preparedness Program HSI Homeland Security Institute ICU intensive care unit IND improvised nuclear device IOM Institute of Medicine IRB institutional review board JumpSTART Simple Triage and Rapid Treatment (pediatric) KI potassium iodide kt kiloton(s) LACDPH Los Angeles County Department of Public Health mGy milligray 

ABBREVIATIONS AND ACRONYMS xix MMRS Metropolitan Medical Response System mph miles per hour MRC Medical Reserve Corps mSv millisievert NDMS National Disaster Medical System NIH National Institutes of Health NRAT Nuclear/Radiological Advisory Team NRC Nuclear Regulatory Commission NRF National Response Framework NVHA Northern Virginia Hospital Alliance NYCDOH New York City Department of Health and Mental Hygiene NYSDOH New York State Department of Health OSHA Occupational Safety and Health Administration PAG protective action guide PAG Manual Manual of Protective Action Guides and Protective Actions for Nuclear Events (EPA, 1992) PF protection factor PHEP Public Health Emergency Preparedness P.L. Public Law PPE personal protective equipment psi pounds per square inch PTSD posttraumatic stress disorder QF quality factor R&D research and development rad radiation absorbed dose RAP Radiological Assistance Program RDD radiological dispersal device RDF rapid deployment force REAC/TS Radiation Emergency Assistance Center/Training Site rem roentgen equivalent man REMM Radiation Event Medical Management RHCC regional healthcare coordinating center (Northern Virginia) RITN Radiation Injury Treatment Network RSS receipt, stage, and storage (site) (SNS) RTR Radiation Treatment, Triage, and Transport (system) SFDPH San Francisco Department of Public Health 

xx ABBREVIATIONS AND ACRONYMS SI Système International d’Unités (International System of Units) SNS Strategic National Stockpile SRT Search Response Team START Simple Triage and Rapid Treatment (adult) Sv sievert TOPOFF Top Officials UASI Urban Area Security Initiative U.S. United States USPS United States Postal Service VA Department of Veterans Affairs WMD weapon of mass destruction WMD-CST Weapons of Mass Destruction Civil Support Team