Nationwide Response Issues
After an Improvised
Nuclear Device Attack

Medical and Public Health Considerations
for Neighboring Jurisdictions

Workshop Summary

Forum on Medical and Public Health Preparedness for
Catastrophic Events

Board on Health Sciences Policy

Miriam Davis, Megan Reeve, and Bruce M. Altevogt, Rapporteurs

INSTITUTE OF MEDICINE
                         OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

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Forum on Medical and Public Health Preparedness for Catastrophic Events Board on Health Sciences Policy Miriam Davis, Megan Reeve, and Bruce M. Altevogt, Rapporteurs

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, NW • Washington, DC 20001 NOTICE: The workshop that is the subject of this workshop summary 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 activity was supported by contracts between the National Academy of Sciences and the American College of Emergency Physicians; American Hospital Association; American Medical Association; Association of State and Territorial Health Officials; Centers for Disease Control and Prevention (Contract No. 200-2011-38807, TO #3); Department of Defense (Contract No. HT0011-11-P-0186); Department of Defense, Uniformed Services University of the Health Sciences (Contract No. HT9404-12-1-0022); Department of Health and Human Services’ National Institutes of Health: National Institute of Allergy and Infectious Diseases, National Institute of Environmental Sciences, National Library of Medicine (Contract No. HHSN26300007 [Under Base 1 #HHSN263201200074I]); Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (Contract No. HHSO100201000021P); Department of Homeland Security’s Federal Emergency Manage- ment Agency (Contract No. HSFE20-12-P-0165); Department of Homeland Security, Office of Health Affairs (Contract No. HSHQDC-11-J-002336 [Master Contract # 10000439]); Department of Transportation’s National Highway Traffic Safety Administration (Contract No. DTNH22-10-H-00287); Department of Veterans Affairs (Contract No. 101-G09041); Emer- gency Nurses Association; Food and Drug Administration (Contract No. HHSF22301027T [Under Base Contract DHHS-8598]); Infectious Disease Society of America; Martin, Blanck & Associates; Mayo Clinic; Merck Sharp & Dohme Corp. (Contract No. 2391); National As- sociation of Chain Drug Stores; National Association of County and City Health Officials; National Association of Emergency Medical Technicians; Pharmaceutical Research and Manufactures of America; Target Corporation; Trauma Center Association of America; and United Health Foundation. The views presented in this publication do not necessarily reflect the views of the organizations or agencies that provided support for the activity. International Standard Book Number-13: 978-0-309-28601-5 International Standard Book Number-10: 0-309-28601-8 Additional copies of this workshop summary are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Cover Images: Left: Augustino, Jocelyn. Aerial of local residents making their way home days after Hurricane Ike (2008). Federal Emergency Management Agency Photo Library, http://www.fema.gov/photolibrary/photo_details.do?id=38812. Right: Buddemeier, Brooke. “Medical and public health considerations in the aftermath of nuclear terrorism.” Presentation at the Institute of Medicine workshop Nationwide Response Issues After an Improvised Nuclear Device Attack: Medical and Public Health Considerations for Neighboring Jurisdictions, Washington, DC, January 23-24, 2013. Suggested citation: IOM (Institute of Medicine). 2014. Nationwide response issues after an improvised nuclear device attack: Medical and public health considerations for neighboring jurisdictions: Workshop summary. Washington, DC: The National Academies Press.

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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 welfare. 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 engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences 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 congressional 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. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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NATIONWIDE RESPONSE ISSUES AFTER AN IMPROVISED NUCLEAR DEVICE ATTACK WORKSHOP PLANNING COMMITTEE1 JACK HERRMANN (Co-Chair), National Association of County and City Health Officials, Washington, DC JOHN L. HICK (Co-Chair), Hennepin County Medical Center, Minneapolis, MN GEORGES C. BENJAMIN, American Public Health Association, Washington, DC JAMES S. BLUMENSTOCK, Association of State and Territorial Officials, Arlington, VA JOHN CUELLAR, Office of Health Affairs, Department of Homeland Security, Washington, DC LISA E. GORDON-HAGGERTY, President, LEG, Inc., McLean, VA JAMES R. KISH, Federal Emergency Management Agency, Department of Homeland Security, Washington, DC CHRISTINE KOSMOS, Division of State and Local Readiness, Centers for Disease Control and Prevention, Atlanta, GA GRAYDON LORD, Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC DAVID E. MARCOZZI, Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC SUZET M. MCKINNEY, Chicago Department of Health, IL CHARLES MILLER, Radiation Studies Branch, Centers for Disease Control and Prevention, Atlanta, GA IRWIN REDLENER, National Center for Disaster Preparedness; Mailman School of Public Health, Columbia University, New York, NY RICHARD REED, American Red Cross, Washington, DC MITCH STRIPLING, New York City Department of Health and Mental Hygiene, NY ERIC S. TONER, UPMC Center for Health Security, Baltimore, MD JODY R. WIREMAN, Force Health Protection Division, U.S. Northern Command, Peterson Air Force Base, CO 1 Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. v

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IOM Staff BRUCE M. ALTEVOGT, Project Director MEGAN REEVE, Associate Program Officer ALEX REPACE, Senior Program Assistant vi

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FORUM ON MEDICAL AND PUBLIC HEALTH PREPAREDNESS FOR CATASTROPHIC EVENTS1 ROBERT P. KADLEC (Co-Chair), RPK Consulting, LLC, Alexandria, VA LYNNE R. KIDDER (Co-Chair), The Bipartisan WMD Terrorism Research Center, Washington, DC ALEX J. ADAMS, National Association of Chain Drug Stores, Alexandria, VA ROY L. ALSON, American College of Emergency Physicians, Winston-Salem, NC GEORGES C. BENJAMIN, American Public Health Association, Washington, DC CAPT. D. W. CHEN, Office of the Assistant Secretary of Defense for Health Affairs, Department of Defense, Washington, DC BROOKE COURTNEY, Office of Counterterrorism and Emerging Threats, Food and Drug Administration, Washington, DC JEFFREY S. DUCHIN, Public Health–Seattle & King County and University of Washington BRUCE EVANS, National Association of Emergency Medical Technicians, Upper Pine River Fire Protection District, Bayfield, CO ALEXANDER G. GARZA, Office of Health Affairs, Department of Homeland Security, Washington, DC JULIE L. GERBERDING, Merck Vaccines, Merck & Co., Inc., West Point, PA LEWIS R. GOLDFRANK, New York University School of Medicine, New York DAN HANFLING, INOVA Health System, Falls Church, VA JACK HERRMANN, National Association of County and City Health Officials, Washington, DC JAMES J. JAMES, American Medical Association, Chicago, IL PAUL E. JARRIS, Association of State and Territorial Health Officials, Arlington, VA BRIAN KAMOIE, The White House, Washington, DC LISA G. KAPLOWITZ, Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC 1 Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. vii

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ALI S. KHAN, Centers for Disease Control and Prevention, Atlanta, GA MICHAEL G. KURILLA, National Institute of Allergy and Infectious Diseases, Washington, DC JAYNE LUX, National Business Group on Health, Washington, DC NICOLE MCKOIN, Target Corporation, Minneapolis, MN MARGARET M. MCMAHON, Emergency Nurses Association, Williamstown, NJ AUBREY K. MILLER, National Institute of Environmental Health Sciences, Bethesda, MD MATTHEW MINSON, Texas A&M University, College Station ERIN MULLEN, Pharmaceutical Research and Manufacturers of America, Washington, DC JOHN OSBORN, Mayo Clinic, Rochester, MN ANDREW T. PAVIA, Infectious Diseases Society of America, Salt Lake City, UT STEVEN J. PHILLIPS, National Library of Medicine, Bethesda, MD LEWIS J. RADONOVICH, Department of Veterans Affairs, Washington, DC KENNETH SCHOR, Uniformed Services University of the Health Sciences, Bethesda, MD ROSLYNE SCHULMAN, American Hospital Association, Washington, DC RICHARD SERINO, Federal Emergency Management Agency, Department of Homeland Security, Washington, DC SHARON A. R. STANLEY, American Red Cross, Circleville, OH ERIC S. TONER, UPMC Center for Health Security, Baltimore, MD REED V. TUCKSON, UnitedHealth Group, Minneapolis, MN MARGARET VANAMRINGE, The Joint Commission, Washington, DC CRAIG VANDERWAGEN, Martin, Blanck & Associates, Alexandria, VA JENNIFER WARD, Trauma Center Association of America, Las Cruces, NM GAMUNU WIJETUNGE, National Highway Traffic Safety Administration, Washington, DC viii

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IOM Staff BRUCE M. ALTEVOGT, Forum Director MEGAN REEVE, Associate Program Officer ALEX REPACE, Senior Program Assistant ANDREW M. POPE, Director, Board on Health Sciences Policy ix

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Reviewers This workshop summary has been reviewed in draft form by individ- uals chosen for their diverse perspectives and technical expertise, in ac- cordance 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 workshop summary as sound as possible and to en- sure that the workshop summary meets institutional standards for objec- tivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integri- ty of the process. We wish to thank the following individuals for their review of this workshop summary: Timothy Cooper, Delaware Division of Public Health Steven Englender, City of Cincinnati Department of Health Onora Lien, Northwest Healthcare Response Network Ruth McBurney, Conference of Radiation Control Program Directors Monica Schoch-Spana, UPMC Center for Health Security Tammy Taylor, Los Alamos National Laboratories Although the reviewers listed above have provided many construc- tive comments and suggestions, they did not see the final draft of the workshop summary before its release. The review of this workshop summary was overseen by Hellen Gelband, Center for Disease Dynamics, Economics and Policy. Appointed by the Institute of Medicine, she was responsible for making certain that an independent examination of this workshop summary was carried out in accordance with institutional procedures and that all review comments were carefully considered. Re- xi

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xii REVIEWERS sponsibility for the final content of this workshop summary rests entirely with the rapporteurs and the institution.

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Contents 1 INTRODUCTION 1 Background, 1 Overview of Key Messages, 2 Organization of the Report, 6 2 PUBLIC HEALTH AND LOGISTICAL CONSIDERATIONS 9 Differences in Nuclear Events, 10 Response Protocols, 12 Public Health Impact on Outlying Communities, 15 Summary, 17 3 FEDERAL PROGRAMS AND PERSPECTIVES 19 Office of the Assistant Secretary for Preparedness and Response, 20 Centers for Disease Control and Prevention, 22 Federal Emergency Management Agency, 23 U.S. Northern Command and Other Military Forces, 23 Summary, 25 4 LOCAL, STATE, AND REGIONAL PERSPECTIVES AND PROGRAMS 27 Planning for an IND Attack: A Case Study, 28 Efforts in a Large Metropolitan Region, 30 Efforts in an Outlying Community, 31 New York City Emergency Medical Services, 32 Summary, 34 xiii

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xiv CONTENTS 5 CHALLENGES TO COMMAND AND CONTROL 35 Establishing Functions After an IND Attack, 36 FEMA Perspective, 40 State Involvement, 41 Perspective from the Office of the Assistant Secretary for Preparedness and Response, 42 Summary, 45 6 RISK COMMUNICATION AND EDUCATION 47 Learning from Focus Groups, 48 Lessons from Nuclear Reactor Accidents, 50 Risk Communication Efforts at FEMA, 53 The Role of Public Information Officers, 54 Summary, 54 7 MONITORING AND MASS CARE IN OUTLYING COMMUNITIES 57 The Need for Reception Centers and Population Monitoring, 58 Building Capacity for Community Reception Centers, 60 Family Assistance in Outlying Communities, 64 National Networks to Assist in Victim Transport and Care, 65 Summary, 70 8 REORIENTING AND AUGMENTING PROFESSIONAL APPROACHES 71 Adding Systems to Planning, 72 Mental Health Implications of an IND, 75 Health and Safety of Emergency Responders, 76 Summary, 79 9 ROLES OF REGIONAL HEALTH CARE COALITIONS IN PLANNING AND RESPONSE 81 Improving Hospital Preparedness, 82 National Capital Region Health Care Coalitions, 84 Roles for Outlying Communities, 85 Exercising an IND Incident as a Regional Coalition, 88 Summary, 90

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CONTENTS xv APPENDIXES A References 93 B Abbreviations and Acronyms 99 C Workshop Agenda 103 D Biographical Sketches of Speakers and Panelists 115 E Resource List 143 F List of Speakers and Registered Attendees 149 G Day 30: The Impact of Mass Evacuations on Host Communities Following Nuclear Terrorism 161 H Implications of an Improvised Nuclear Device Detonation on Command and Control for Surrounding Regions at the Local, State, and Federal Levels 191 I Role of Regional Health Care Coalitions in Managing and Coordinating Disaster Response 213

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