Nationwide Response Issues After an Improvised Nuclear Device Attack: Medical and Public Health Considerations for Neighboring Jurisdictions: Workshop Summary (2014)

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3 Federal Programs and Perspectives Key Points Made by Individual Speakers x The Office of the Assistant Secretary for Preparedness and Response (ASPR) is the lead U.S. Department of Health and Human Services agency responding to any public health or medical disaster, including an improvised nuclear device (IND) detonation. ASPR’s mission is to plan for all health hazards, to augment state and local capabilities when requested, and to coordinate all civilian and federal medical and public health responders. x The Centers for Disease Control and Prevention helps state and local governments to develop formal plans for preparedness to an IND at- tack, including developing radiological toolkits for local public health departments and clinicians, building radiation volunteer corps, and in- cluding acute radiation syndrome––specific countermeasures in the Strategic National Stockpile. x In preparing for an IND attack, the Federal Emergency Management Agency can also assist communities in conducting a threat and haz- ard identification and risk assessment as well as help to coordinate urban search and rescue and plume modeling after an attack. x More than 18,000 military responders could be summoned to the site of an IND attack. The forces would come from several existing com- mands overseen by governors (through their state National Guard) or by the U.S. Northern Command. One of the objectives of this workshop was to spend time under- standing why the gaps in state and local planning efforts for an impro- vised nuclear device (IND) have remained, even though a wealth of federal guidance exists. To assist with this charge, four federal agencies that have done a significant amount of work in the area of IND attack planning gave attendees a synopsis of their efforts and the resources they 19 

20 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK would be able to provide after an incident occurred. The agencies includ- ed the Office of the Assistant Secretary for Preparedness and Response (ASPR), the Centers for Disease Control and Prevention (CDC), the Fed- eral Emergency Management Agency (FEMA), and the Department of De- fense (DOD) via the U.S. Northern Command (USNORTHCOM). OFFICE OF THE ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE George Korch of ASPR described his office as being strategically situated within the U.S. Department of Health and Human Services (HHS) to respond to an IND attack or any other public health emergency. Its mission is to plan for all health hazards, to augment state and local capabilities when requested, and to coordinate all civilian and federal medical and public health responders. The federal assets that ASPR delivers include self-sustaining medical teams for triage, transportation, decontamination, mental health care, medical care, and mortuary duty. Other assets include medical counter- measures available through the CDC, such as hematopoietic, gastrointes- tinal, decorporation,1 and thermal burns therapies; biodosimetry and diagnostics; therapeutics; and supportive therapies. ASPR can help to prepare disaster waivers to suspend nonessential tasks, and it can help facilitate sign-off by the Secretary of HHS for the declaration of a public health emergency. ASPR oversees the National Disaster Medical System (NDMS) whose three-part mission is to (1) provide medical response to a disaster area in the form of personnel, teams and individuals, supplies, and equipment; (2) assist in patient movement from a disaster site to unaf- fected areas of the nation; and (3) provide definitive medical care at par- ticipating hospitals in unaffected areas. NDMS includes approximately 8,000 medical professionals who can be summoned for rapid response and who are organized into units referred to as disaster medical assis- tance teams (DMATs). DMATs include not only medical professionals but also logistical and administrative staff. Another source of medical professionals is the Public Health Service’s Commissioned Corps, with at least 4,200 deployable personnel. 1 Removal of radioactive isotopes from the body. 

FEDERAL PROGRAMS AND PERSPECTIVES 21 Countermeasures and Biodosimetry Another key function of ASPR is to assist in the efforts of the CDC to procure medical countermeasures for the Strategic National Stockpile (SNS), a cache of medications and medical countermeasures that can be delivered to the site of the disaster or stored nearby. If a medical coun- termeasure or device does not yet exist, ASPR funds research and devel- opment through its Office of Biomedical Advanced Research and Development Authority (BARDA). It already has under development, in partnership with pharmaceutical companies, several hematopoietic and gastrointestinal countermeasures, lung and skin countermeasures, and decorporation agents. One of the most pressing needs after an IND attack will be to deter- mine which patients are most heavily exposed and thus need immediate care. That is the goal of biodosimetry, which includes any technique used to determine radiation dose using the assessment of an individual’s bio- logical data (NCRP, 2010). According to speaker Rodney Wallace of BARDA, two of the existing biodosimetry methods are too time- consuming or too complex to be effective for dealing with mass casual- ties in the field. Wallace reported that the biodosimetry program is in the process of developing two generic types of devices for assessing radiation exposure: point-of-care devices and high-throughput devices. The point-of-care devices are designed for ease of use and rapid sampling (less than 30 minutes) in the field and should have the capacity for processing 1 mil- lion samples in 6 days. These point-of-care devices are designed to dis- tinguish between heavily exposed and moderately exposed patients, using 2 Gray (Gy) as the line of demarcation: Doses higher than 2 Gy need immediate treatment, whereas lower dose exposures need not be treated for several weeks. High-throughput devices are highly sensitive, high-volume devices being designed to be used in hospitals and other fixed facilities and to provide a rapid turnaround time of no more than 24 hours per sample. They will be able to measure exposures of from 0.5 to 10 Gy, and they are expected to process 400,000 samples over several weeks. The operators of high-throughput devices will need training. Wallace noted that 11 dosimetry projects have been funded, but none are near completion and it will be a few more years before the products are operational. 

22 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK CENTERS FOR DISEASE CONTROL AND PREVENTION The CDC’s radiation expertise is housed in the Radiation Studies Branch of its National Center for Environmental Health. The branch, as described by Robert Whitcomb, lead physical scientist, strives to leverage national, state, and local resources for the purpose of planning for a radio- logical event. Realizing that radiation control programs are often separate from public health programs at the local level, several years ago the branch facilitated the creation of the National Alliance for Radiation Readiness (NARR). NARR is a forum for sharing and evaluating practices, resources, and tools related to radiological readiness. The CDC and NARR are help- ing state and local governments develop formal plans for emergency pre- paredness for an IND attack, as most existing plans deal with nuclear reactor releases or a radiological dispersion device (RDD) attack. The CDC’s Radiation Studies Branch conducts several other activi- ties concerning radiological events. It has developed toolkits for use by local public health departments and clinicians. One toolkit is for “just-in- time training” for hospital clinicians, and another is for population moni- toring guidelines. The latter was first published in 2007 and is currently being revised. It covers community reception centers, virtual reception centers, decontamination, and essential medical care. The Radiation Studies Branch is also working on the creation of a volunteer program for radiological incidents that is similar to the Medical Reserve Corps, a nationwide list of professionals to summon in the event of any type of health emergency. The CDC’s Radiation Studies Branch also provides expertise to other CDC programs, most notably the program that manages the SNS of medical countermeasures to distribute in times of health emergencies. Whitcomb described one of the agents in the SNS as the cytokine Neupogen, a drug used to treat neutropenia, which is one of the manifes- tations of acute radiation syndrome. Neupogen is an analogue of granu- locyte colony–stimulating factor that induces proliferation and differen- tiation of neutrophils, the most abundant type of white blood cell. The Radiation Studies Branch is expecting to help state and local govern- ments develop plans for Neupogen’s use in radiation incidents. Finally, the Radiation Studies Branch plans to help communities conduct a threat risk assessment with regard to IND events. The focus will be not only on cities, but also on outlying communities that would 

FEDERAL PROGRAMS AND PERSPECTIVES 23 be coping with large numbers of displaced persons who need decontami- nation, medical countermeasures, and long-term follow-up. FEDERAL EMERGENCY MANAGEMENT AGENCY Robert Farmer, director of the operations division of FEMA, gave a broad overview of FEMA’s role in an IND attack or any other disaster. Since 2008 FEMA’s role has been spelled out in the Department of Homeland Security’s (DHS’s) National Response Framework (NRF) (DHS, 2008). The purpose of the NRF is to lay out guiding principles for all response partners to use in preparing for—and providing a unified response to—national disasters and emergencies. The NRF is a generic framework for any type of emergency or disas- ter. If a state or local agency is expressly concerned about an IND inci- dent, then FEMA, under a new policy, would encourage and assist the agency to prepare a threat and hazard identification and risk assessment (THIRA). The preparation of a THIRA is a five-step process: (1) assess threats and hazards; (2) assess the vulnerability of the community to those threats and hazards; (3) estimate the consequences of the direct hazard; (4) establish capability targets; and (5) set an informed founda- tion for prevention, protection, mitigation, response, and recovery. According to Farmer, other resources that FEMA or its interagency partners can bring to bear in the event of an IND detonation include x Urban search and rescue: It can operate in the moderate dam- age zone to rescue people from collapsed buildings. DOD has special teams capable of working in a heavily contaminated environment. x Plume modeling: DHS has an Interagency Modeling Atmos- pheric Assessment Center that maps out the geographic area af- fected by the release of radiation, among other hazards. U.S. NORTHERN COMMAND AND OTHER MILITARY FORCES USNORTHCOM is the operational command of the U.S. military re- sponsible for homeland defense and providing defense support of civilian authorities (DSCA), said Jody Wireman, Force Health Protection Direc- 

24 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK tor at USNORTHCOM. Wireman reported that more than 18,000 mili- tary responders could initially be summoned and time-phased to the site of an IND attack, with additional forces available to be requested, if needed. These initial response forces would come from several existing units overseen by governors (through their state National Guard) and active duty and reserve forces via USNORTHCOM. The troops have a variety of capabilities, from detection and analysis of the radiological threats and exposures to emergency medical care, command and control, decontamination, engineering, rescue operations, and medical transport and evacuation. More specifically, National Guard forces attending to a national dis- aster site can be drawn from three distinct types of units: civil support teams (CSTs; approximately one per state or territory); chemical, biolog- ical, radiological, and nuclear (CBRN) enhanced response force packag- es (CERFPs; 17 units across the United States); and homeland response forces (HRFs; one per FEMA region). The system is tiered, with CSTs able to respond to a scene within a few hours to assist, and the CERFPs and HRFs needing a few more hours to respond but bringing with them a wider medical skillset and more capabilities. Within a few days, USNORTHCOM forces will respond to the event with a still larger array of capabilities. There are two USNORTHCOM response units that will integrate with the above National Guard forces and support DSCA mis- sion assignments: the Defense CBRN Response Force (DCRF; approxi- mately 5,000 personnel) and two Command and Control CBRN Response Elements (C2CRE; approximately 3,000 personnel). The C2CRE(s) could be utilized for command and control or augmented to form additional DCRFs for an event. This new 18,000-member response force concept integrates National Guard and USNORTHCOM forces into plans and exercises. It improves on previous concepts for DOD DSCA responses that were not integrated and slower to respond. In addition, future plans and concepts aim to cap- ture active duty, National Guard, and Reserve forces that may be availa- ble, but are not part of the above-identified 18,000-member forces, thereby integrating all available DOD forces into the planning process. Wireman explained that the determination of where military forces would be sent to support medical and public health requirements is ex- pected to be done through coordination with the HHS Assistant Secretary for Preparedness and Response and other federal leads for medical and public/worker health requirements. The development and refinement of region-specific IND plans is the approach that can best identify where 

FEDERAL PROGRAMS AND PERSPECTIVES 25 response assets (to include DOD forces) should be sent and best assist the DOD in determining whether the current force structure would be efficient and effective for an IND response. These regional FEMA plans are developed through local, state, and federal participants. He said it is important that both response areas and outlying communities be involved in the regional planning to ensure the determination of requirements, to evaluate asset availability, and to identify whether gaps in resources need to be addressed. SUMMARY Before, during, and after an IND attack, numerous federal agencies will play active roles. ASPR has wide-ranging roles, from oversight of NDMS to directing hospital preparedness and research on new methods to assess a person’s radiation dose. The CDC and NARR are helping state and local agencies develop plans for emergency preparedness for an IND attack. The CDC is also helping cities and outlying communities conduct a formal threat risk assessment regarding an IND. FEMA mar- shals resources and provides a unified response to all hazards, including a potential IND incident. USNORTHCOM is the DOD agency responsi- ble for providing civilian authorities with homeland defense and civil support, and it estimates that more than 18,000 military responders could be sent to an IND site to carry out roles that vary from detection and analysis of the radiological threat to command and control, decontamina- tion, and medical evacuation.