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Introduction1

Our nation faces the distinct possibility of a catastrophic terrorist attack using an improvised nuclear device (IND), according to international and U.S. intelligence (Jenkins, 2008). Detonation of an IND in a major U.S. city would result in tens of thousands to hundreds of thousands of victims and would overwhelm public health, emergency response, and health care systems, not to mention creating unprecedented social and economic challenges. Although preparing for an IND may seem futile at first glance, thousands of lives can be saved by informed planning and decision making prior to and following an attack.

BACKGROUND

In 2009 the Institute of Medicine published the proceedings of a workshop assessing the public health and medical preparedness for responding to an IND detonation (IOM, 2009). Since that time, multiple federal and other publications have added layers of detail to this conceptual framework, resulting in a significant body of literature and guidance. Many of these materials can be found in the resource list located in Appendix E. However, there has been only a limited planning effort at the local level, as much of the federal guidance has not been translated into action for states, cities, and counties. According to an informal survey of

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1This report has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. The planning committee’s role was limited to planning and convening the workshop. The views contained in the report are those of individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the Institute of Medicine.



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1 Introduction1 Our nation faces the distinct possibility of a catastrophic terrorist at- tack using an improvised nuclear device (IND), according to internation- al and U.S. intelligence (Jenkins, 2008). Detonation of an IND in a major U.S. city would result in tens of thousands to hundreds of thousands of victims and would overwhelm public health, emergency response, and health care systems, not to mention creating unprecedented social and economic challenges. Although preparing for an IND may seem futile at first glance, thousands of lives can be saved by informed planning and decision making prior to and following an attack. BACKGROUND In 2009 the Institute of Medicine published the proceedings of a workshop assessing the public health and medical preparedness for re- sponding to an IND detonation (IOM, 2009). Since that time, multiple federal and other publications have added layers of detail to this concep- tual framework, resulting in a significant body of literature and guidance. Many of these materials can be found in the resource list located in Ap- pendix E. However, there has been only a limited planning effort at the local level, as much of the federal guidance has not been translated into action for states, cities, and counties. According to an informal survey of 1 This report has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. The planning committee’s role was limited to planning and convening the workshop. The views contained in the report are those of individual workshop participants and do not necessarily represent the views of all workshop partici- pants, the planning committee, or the Institute of Medicine. 1

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2 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK community preparedness by the National Association of City and County Health Officials (NACCHO), planning for a radiation incident ranked lowest in priority among other hazards by 2,800 local health departments. Meeting Objectives and Statement of Task In partnership with NACCHO, this workshop, held on January 23– 24, 2013, focused on key response requirements faced by public health and health care systems in response to an IND detonation (see Box 1-1). Especially included were the planning needs of state and local jurisdic- tions outlying the detonation site. The specific meeting objectives were as follows: Understand the differences between types of radiation incidents and implications of an IND attack on outlying communities. Highlight current planning efforts at the federal, state, and local level as well as challenges to the implementation of operational plans. Examine gaps in planning efforts and possible challenges and solutions. Identify considerations for public health reception centers: o How will public health and health care interface with func- tions and staffing? o How will radiological assessments and triage be handled? Discuss the possibilities and benefits of integration of disaster transport systems. Explore roles of regional health care coalitions in coordination of health care response. OVERVIEW OF KEY MESSAGES Although facing and planning for an improvised nuclear device at- tack continues to be a daunting task, many participants and speakers highlighted the amount of work and progress that has already been made across the country through dedicated “all-hazards preparedness” plan- ning at the federal, state, and local level and by interagency workgroups.

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INTRODUCTION 3 BOX 1-1 Medical and Public Health Preparedness for an Improvised Nuclear Device Incident: A Workshop Statement of Work An ad hoc committee will organize a public workshop that will examine public health and medical preparedness to respond to an improvised nuclear device (IND) incident. The committee will develop the workshop agenda, se- lect and invite speakers and discussants, and moderate the discussions. Specifically, the topics to be addressed at the workshop will include the fol- lowing: How state and local health department planning is informed through threat intelligence and risk assessments. How an “informed” evacuation would be coordinated after a period of sheltering in place. o How to effectively communicate to the public the importance of sheltering in place immediately following a no-notice detonation (including coping with societal elements such as family member separation). Strategies to assess radiation exposure and triage patients. Opportunities to integrate the Radiation Injury Treatment Network with the National Disaster Medical System and the national health care “system” so as to be able to provide care to tens or hundreds of thousands. Discuss re-entry and recovery considerations related to potential con- tamination concerns, including the necessary public health monitor- ing, that will inform what medical and public health assets and critical infrastructure will be available. An individually authored workshop summary will be prepared based on the information gathered and the discussions held during the workshop. Irwin Redlener of the National Center for Disaster Preparedness at the Mailman School of Public Health at Columbia University, stated that, if such an attack occurs, it will be nothing like any disaster or emergency the United States has experienced before, but many individual lessons learned from natural disasters the country has experienced can help to inform planning for an incident of this magnitude. Carrying those lessons forward, in addition to the ever-increasing amount of federal guidance available, and making important connections between systems and or- ganizations could lead to a much more successful response to an IND detonation than if no planning were done at all. The following themes

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4 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK were identified by various participants throughout the workshop as areas that, given more attention, could positively influence state and local planning progress: High-level political support and direction to supplement availa- ble guidance Translation of federal guidance into actionable local tools “Socializing” preparedness—getting the public to take personal responsibility for being prepared—to increase resiliency and de- crease public dependency on already taxed services Need for education of first responders, local leadership, and health care providers on types of radiation attacks and different vulnerabilities Coordinating transport systems: Radiation Injury Treatment Network, National Disaster Medical System, Civil Reserve Air Fleet, and regional/local transports Robust risk communication, including pre-event messaging if possible Expanding health care coalitions to include a wider, more di- verse range of partners Integration of public health and medical services into command and control infrastructure, emergency operations centers, and unified command Core capabilities that receiving communities should focus on re- lated to an IND—and corresponding commonalities with the Public Health Emergency Preparedness/Hospital Preparedness Program agreements An IND detonation would be a terribly traumatic event, but positive messages were heard during the workshop, and steps in the right direc- tion have already been taken. The health and medical system is moving forward toward a coalition model of cooperation during responses, which will be critical. Shelter-in-place and other initial-action educational mes- sages for the public have been developed; now, authorities need to dedi- cate plans to ensure that the messages are heard and understood. Many tools and strategies already tested in jurisdictions (reception centers, vac- cination sites, and alternate care sites) are the same ones that will allow communities to successfully support victims of an IND event. However, specific guidance and the education of key personnel are critical to as- sure that responders are able to provide assessments and care required by

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INTRODUCTION 5 victims of radiation. Much work has already been done, but many speak- ers and discussants voiced concern that it is time to build on the existing “all-hazards capabilities” that communities have built during the past decade and make them as robust and scalable as possible to respond to a radiological emergency such as an IND attack. Themes and Opportunities Although it is generally accepted that larger U.S. cities likely repre- sent the highest-risk targets for an IND terrorist attack, the ripples from an IND detonation would overwhelm the surrounding communities and spread nationwide. Thus, this workshop set out to bring under examina- tion, as part of the focus of planning, the effects of an IND attack on out- lying communities. This encompasses neighboring jurisdictions as well as regional and national receiving sites. Having these communities be prepared for the influx of evacuees demanding medical care and services might greatly alleviate the overall severity of the disaster. Because there has not yet been an IND incident in the United States, the closest approx- imation to the widespread displacement that might be seen after an IND attack, however understated, comes from the migration patterns follow- ing Hurricane Katrina in 2005. Less than 1 month after the hurricane, the Federal Emergency Management Agency had received 1.36 million indi- vidual assistance applications from Katrina victims in all 50 states. Forty-six percent of applications were received from within 100 miles of New Orleans, while 53 percent were from 100 to 3,000 miles away from New Orleans (New York Times, 2005). Being unaffected physically, outlying communities are likely to be in the best position to save lives following an IND attack. However, these communities will experience an unparalleled number of evacuees who will need emergency medical care for blast, burn, and radiation injuries; screening for contamination and acute radiation syndrome; and provision of radiation countermeasures, shelter resources, and mental health and material support. Yet, most outlying communities have not considered the potential burden they may experience and so have not undertaken planning for an IND detonation in a nearby city, making them drastically underprepared. The influx of tens of thousands of displaced victims will require dedicated command, control, and resource capabilities from across the region and nation to ensure a successful response.

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6 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK Outlying communities face numerous barriers in planning for an IND attack, as Jack Herrmann of NACCHO noted in his introductory remarks. He also went on to highlight three main issues that should be considered, that various speakers and participants also emphasized throughout the 2- day workshop: At a basic level, there is an issue of translation, in that much of the federal guidance has not been easily implemented at the local level. The amount of resources that communities would need to bring to bear in such an event is extremely large. No community has modeled the resources required to screen and administer counter- measures and health care to a large displaced population. An ever-present issue, time, remains a factor because most pub- lic health officials are struggling to meet their current public health responsibilities and therefore are unable to prioritize the complex and multidisciplinary planning required to respond to an IND detonation when they may not even be the direct target. ORGANIZATION OF THE REPORT The report that follows summarizes the presentations by expert pan- elists and open discussions that took place during the workshop. The three papers that were commissioned for this workshop can be found in the appendixes, along with a resource list of available federal and collab- orative tools and websites to assist state and local planners. The begin- ning of each chapter features highlighted key points from individual speakers and can serve as a collection of recurring messages expressed during discussions throughout the workshop. Chapter 2 provides background and distinguishes IND incident from other radiological emergencies as well as expected public health issues. Chapter 3 presents existing perspectives and programs from federal agencies that play a role and describes their capabilities. The roles of re- gional planning, whether through municipalities or health care coalitions, and the work that advanced cities have already done, are examined in Chapters 4 and 9. Chapter 5 considers the important challenges to com- mand and control as well as the infrastructure and agreements that can assist in alleviating problems. Chapter 6 focuses on important risk com- munication and the education of the public and first responders. Monitor-

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INTRODUCTION 7 ing and health care services that would be provided in outlying commu- nities, including community reception centers, triaging, and addressing the mental and physical health of responders and volunteers, are dis- cussed in Chapters 7 and 8.

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