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

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2 Public Health and Logistical Considerations Key Points Made by Individual Speakers x For those who survive an improvised nuclear device (IND) blast, the most immediate danger is from radioactive fallout, which emits radia- tion of sufficient energy to penetrate into cars, certain types of shelter, and skin. The danger from fallout is greatest during the first 24 hours post-detonation. x Sheltering in place during the first 24 hours is the policy promulgated by Federal Emergency Management Agency. No evacuations are swift and accurate enough to surpass the widening path of radioac- tive fallout, which drifts outward according to wind direction and speed, and other environmental conditions. Sheltering in place saves lives. x Public health officials use a zoned approach to emergency response. This approach precludes entering the most heavily damaged areas, where survival is highly unlikely, and instead concentrates the re- sponse to a moderate damage zone, which has the highest number of victims who can survive. x Outlying communities are in the best position to save lives and re- duce morbidity. Pre-planning is necessary to ensure an adequate supply of medical countermeasures and health services. Outlying communities will have to shelter and feed evacuees and maintain public safety and order, particularly in hospitals and shelters. x No current national system is capable of handling and tracking down displaced persons and reuniting families across states and regions. x Political support is needed to initiate and sustain planning for an IND attack, taking into account planners’ competing priorities, the magni- tude of the task, the diversity of agencies providing services, the ex- treme resource needs, and the uncharted terrain. 9 

10 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK To set the stage for this workshop and continue to build on the work and summary previously published by the Institute of Medicine (IOM, 2009), the session began with introductory and distinguishing character- istics of an improvised nuclear device (IND) attack. Because many at- tendees and other relevant planners often work with radiological dispersal devices and nuclear power plant leaks, it was important to clearly separate the important fundamental differences in impact that an IND attack would have on response and operations. In addition, the first white paper of the workshop (see Appendix G) was presented to paint a vivid picture of an affected community and the corresponding public health needs and issues that would arise 30 days after an incident. DIFFERENCES IN NUCLEAR EVENTS An IND is a nuclear weapon bought illicitly, stolen from a nuclear state, or fabricated by a terrorist group from illegally obtained nuclear weapons material (e.g., plutonium or highly enriched uranium) (OSTP, 2010). An IND explosion on the ground yields the same physical and health effects as detonating a nuclear weapon in the air, similar to the hydrogen bombs dropped during World War II. An initial conventional explosion produces an imploding shock wave that drives plutonium piec- es inward into a central sphere housing a pellet of beryllium/polonium, creating a “critical mass”—that is, enough fissile material to sustain a nuclear chain reaction—which leads to a nuclear chain reaction that re- leases several million times more energy than could be produced by a chemical reaction proceeding in the same mass of material. An IND is not to be confused with a radiological dispersal device (RDD), informally known as a “dirty bomb.” According to speaker Brooke Buddemeier of the Lawrence Livermore National Laboratory, an RDD is a weapon that combines explosives with radioactive material. The explosion vaporizes or aerosolizes radioactive material, propelling it into the air, but the explosion does not trigger a fission reaction that re- leases the mammoth amounts of energy or fission products that are asso- ciated with a nuclear detonation. The effects of an RDD extend over an area the size of multiple city blocks, whereas the consequences of an IND detonation extend for miles. Buddemeier explained that most of the nuclear hazard of an RDD attack is due to people breathing radioactive dust in the immediate area of the explosion (although there is some ex- ternal radiation), whereas with an IND attack, most of the nuclear hazard 

PUBLIC HEALTH AND LOGISTICAL CONSIDERATIONS 11 is from fallout, which emits radiation of sufficient strength to burn or penetrate the skin and travel into the body cavity to trigger acute radia- tion syndrome. Fallout particles, though, are too large to become a breathing hazard. Fallout is generated, Buddemeier explained, by thousands of tons of debris—from collapsed buildings and other structures destroyed by the blast—combined with radioactive fission products and catapulted up- ward by the extreme heat of detonation. The radioactive debris-filled cloud rapidly ascends through the atmosphere up to 5 miles high for a 10-kiloton (kt) device. Highly radioactive particles coalesce and drop back down to earth as “The real hazard from fallout is the they cool to form fallout. With- direct shine of radiation. It’s not in 10 to 25 miles of the detona- breathing in the particles, they’re too large.” tion, fallout particles are the size of table salt or sand as they fall —Brooke Buddemeier back to earth, contaminating all surfaces, including clothing, skin, and hair. The particles give off penetrating radiation—primarily gamma and beta radiation—that can injure people inside cars or in inadequate shelters (NCRP, 2010). The path of fallout depends on wind direction and speed and other environmental conditions (e.g., terrain and weather). Fallout’s radioactivity decreases with distance and decays rapidly with time, with the greatest danger occurring within the first few hours after the detonation (NCRP, 2010). A ground-level detonation produces more fallout than one exploded above ground, as was the case for the atom bombs dropped on Hiroshima and Nagasaki. Fallout is the primary source of radiation exposure in outlying communities. Buddemeier as- sured attendees that the best method of reducing radiation exposure from fallout is to remove outer clothing and remove particles from hair when entering a safe shelter. Acute Radiation Syndrome Acute radiation syndrome (ARS) is the most immediate health effect of radiation exposure. It appears after whole-body or significant partial- body irradiation of more than 1 Gray (Gy) delivered at a relatively high dose rate (Waselenko et al., 2004). Depending on the dose to which one is exposed, symptoms may manifest within hours or days or, in cases of 

12 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK low doses, weeks or even months. There are three main clusters of symp- toms: gastrointestinal (nausea, vomiting, lack of appetite), hematopoietic (drop in the number of blood cells), and neurovascular (dizziness, head- ache, decreased levels of consciousness). There is also a cutaneous syn- drome that is caused by thermal or radiation burns. The extent, severity, and time course of the symptoms are strictly determined by radiation dose. The greater the dose, the shorter the delay in symptom onset. There are four stages of ARS: (1) a prodromal phase with gastroin- testinal symptoms that lasts minutes to several days; (2) a latent stage in which the patient is asymptomatic for a few hours to a few weeks1; (3) a manifest illness stage (with different clinical presentations, depending on the symptom cluster, but almost always marked by intense immunosup- pression) lasting several weeks; and (4) either recovery or death (CDC, 2013; Waselenko et al., 2004). The early course of ARS can be moni- tored with repeated complete blood counts and absolute lymphocyte counts, from which the dose can be inferred. ARS is treated with anti- biotics, fluids, blood products, and, with higher doses, cytokines and stem cell transplants (Waselenko et al., 2004). According to co-chair John Hick, Hennepin County Medical Center, one of the problems with existing medical guidance is its focus on external contamination from dirty bombs and nuclear reactor releases. In contrast, the focus after an IND attack should be on screening in order to classify a large number of salvageable victims who are in the latent phase of ARS. If those victims receive cytokines in a timely manner, ideally within 24 hours after an otherwise lethal exposure, evidence from animal studies indicates that their lives can be saved (Farese et al., 2001, 2013). However, there is no current guidance on how medical responders should assess and initiate countermeasures, much less how they should conduct blood tests to mon- itor the course of ARS, Hick said. RESPONSE PROTOCOLS In the event of a nuclear detonation, the Federal Emergency Management Agency (FEMA) advises all people within a 50-mile radius to take shelter in the nearest and most protective building or structure and to listen for instructions from authorities (FEMA, 2008). This so-called shelter-in-place recommendation is for the most dangerous period of 1 For doses of 200–500 rad (2–5 Gy), the latency period is typically 3 to 4 weeks (OSTP, 2010). 

PUBLIC HEALTH AND LOGISTICAL CONSIDERATIONS 13 exposure—up to 24 hours post-detonation—and for exposures beginning at 1 roentgen equivalent man (rem). Sheltering in place is the most ra- tional approach because no evacuations are swift enough to stay in front of the widening path of fallout. Shelter-in-place is not the appropriate strategy for dealing with nuclear reactor accidents, in which the radiation exposure comes not from an immediate release but from release over time in “puffs” from the smoke stack. This type of release gives suffi- cient time for evacuation and so has different implications for recom- mended action from FEMA. However, it is important that these differences be made clear to the public ahead of time, as many people will still evacuate even when given shelter advisories, causing more pan- ic and infrastructure overload. Zoned Approach to Emergency Response A relatively new approach to responding to an IND—the “zoned approach”—was formulated in a recent federal government report (OSTP, 2010). The goal of creating a zoned approach is to save lives while minimizing the risks to emergency response workers. The zoned approach, Buddemeier explained, establishes four areas surrounding the site of detonation: the severe damage zone (SDZ), moderate damage zone (MDZ), light damage zone (LDZ), and dangerous fallout zone (DFZ). In the SDZ, which extends out to 0.5 miles for a 10-kt ground detonation, collapsed buildings and major structural damage are ubiqui- tous (see Figure 2-1). The SDZ is so hazardous that first responders are FIGURE 2-1 Zones surrounding nuclear detonation. SOURCE: http://www.remm.nlm.gov/PlanningGuidanceNuclearDetonation.pdf (accessed June 2, 2013). 

14 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK cautioned not to enter until radiation dosages drop with the continued decay of radioactive particles. Most victims in the SDZ cannot survive, whether because of radiation exposure, major trauma from collapsed buildings, or thermal radiation from the extreme heat and light of the expanding fireball (IOM, 2009). In the MDZ, which covers the area 0.5 to 1 mile from a 10-kt ground detonation, he explained, there is signifi- cant damage from collapsing buildings, downed power lines, and over- turned automobiles, but there is not the extent of wholesale devastation that is found in the SDZ. The MDZ has the highest concentration of sur- vivable victims for emergency responders. A survivable victim is gener- ally defined as someone who can survive only with a successful rescue and treatment. First responders face formidable obstacles in the MDZ, including unstable buildings, downed power lines, ruptured gas lines, and hazardous chemicals (OSTP, 2010). In the LDZ, which lies 1 to 3 miles from the detonation, virtually all windows are broken, making glass injuries likely. The structural damage is highly variable and depends upon shock waves from the blast rebound- ing multiple times off of buildings, the terrain, and even the atmosphere. Emergency personnel will encounter victims with mostly superficial wounds and occasional flash burns. Injuries are more serious if the LDZ overlaps with the path of the DFZ, i.e., the plume of fallout, extending up to 25 miles downwind, which has the highest concentration of radiation, corresponding to exposures of more than 10 roentgens/hour. In this zone, fallout can deliver fatal doses of radiation. The location and extent of radiation in the DFZ are affected by wind direction and speed and other environmental conditions. After the contours of the DFZ have been mapped, the following responder activities can be initiated outside its perimeter: establishment of community reception centers and triage sites, extraction of and care for the injured, and fighting fires and controlling hazards. The DFZ is too hazardous for responders unless they have a critical mission and the ability to monitor their exposure, Buddemeier said. In the case of a 10-kt detonation in Washington, DC, Buddemeier said, it is likely that 45,000 people would perish immediately and 100,000 would be at risk of death. An additional 320,000 people would be likely to be seriously injured, and another 175,000 would likely have minor injuries. After the DFZ is mapped and when the first 24 hours have passed, emergency responders can enter the area to triage survivors and evacuate them to outlying communities. Buddemeier concluded his presentation by pointing out that the zoned approach has improved the 

PUBLIC HEALTH AND LOGISTICAL CONSIDERATIONS 15 outlook for overall increased survival following the detonation of an IND. Critical lifesaving actions have been identified and incorporated into planning guidance, which emphasizes early sheltering in place fol- lowed by delayed deliberate evacuation. PUBLIC HEALTH IMPACT ON OUTLYING COMMUNITIES The likely impact of an IND attack on outlying communities was de- scribed in a presentation by Irwin Redlener of the National Center for Disaster Preparedness, who also wrote a companion white paper on the topic (see Appendix G). Redlener emphasized that the scenario being depicted is not a scientifically based prediction, and he asserted that the consequences of an IND attack would be so dire that none of the nation’s previous disasters can accurately inform planning. The scenario Redlener envisions is set in a fictitious community identified as Roberts County. A 10-kt IND has been detonated in a near- by major city in the middle of the workday. Roberts County, in this hy- pothetical scenario, has 350,000 residents spread across two smaller cities and numerous smaller towns. It has 5 acute-care hospitals with 1,200 total beds and 1 psychiatric hospital. Its emergency medical ser- vices are composed primarily of volunteers. Its workforce of public health and public safety employees has been depleted over the years be- cause of extensive budget cuts. In the first days after detonation, a massive number of people will try to flee the city in their cars in spite of exhortations to shelter in place. This mass exodus may hamper or paralyze rescue and response efforts. The emergency response also may be hampered by workers unwilling to show up for duty because of fear for personal safety or the imperative to find and save family members (Barnett et al., 2012; Tippett et al., 2010). Roberts County hospitals will be overwhelmed with people whose radia- tion status is not known. Furthermore, many people will seek care even though they are unaffected except for extreme anxiety. Fights may break out in hospitals as people compete for care. By day 30, according to this scenario, Roberts County is in dire straits. It has experienced a 50 percent population increase in each of its two cities, based on estimates by a new model predicting population surge after an IND attack (Meit et al., 2011). Two-thirds of 100,000 evacuees are in motels, makeshift temporary shelters, or cars. Five thou- 

16 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK sand evacuees no longer have jobs and do not know the status of their health insurance. Local authorities are still in crisis mode, with only spo- radic help from local, state, and federal governments. The authorities find themselves in competition with other nearby counties for scarce fed- eral and state resources. There has been little planning for the sort of co- ordination between levels of government that is necessary to equitably distribute resources to communities that need them. Roberts County has experienced 500 deaths since the arrival of the evacuees. The deaths have been caused not only by radiation exposure but also by heart attacks and other conditions for which medications are in short supply. Besides health issues, the economic issues are enormous. Evacuees do not have the funds to pay for food, shelter, or transportation. Theft and other crimes are rampant. Schools are saddled with an addi- tional 25,000 child evacuees. The overcrowding in the schools is exacer- bated by many teachers’ having left the area. The evacuated children are stigmatized and ostracized. Mental health problems, in both children and adults, are pervasive in terms of the incidence of acute stress disorder, sleeping disorders, depression, paralyzing grief, and suicide. One of the greatest hurdles facing Roberts County is family reunifi- cation. It is exceedingly difficult to determine if a missing family mem- ber has perished or has been transported to a different area. At least 500 children are separated from parents. Even though the National Commis- sion on Children and Disasters recommended in 2010 that the Depart- ment of Homeland Security lead the development of a nationwide information technology capability to collect, share, and search data from any patient and evacuee tracking or family reunification system (Nation- al Commission on Children and Disasters, 2010) and other efforts in the private sector are ongoing, no current national system is capable of han- dling and tracking down displaced persons and reuniting families. Planning Priorities In Redlener’s view, outlying communities need to conduct pre–IND attack planning relating to the following areas of concern: x Competition for federal, state, and local resources for all types of public services. Resources are expected to be scarce. 

PUBLIC HEALTH AND LOGISTICAL CONSIDERATIONS 17 x Ensuring adequate supply of medical countermeasures, health care and health services, and deferral of elective and non-urgent procedures. x Sheltering and feeding evacuees, volunteers, and relief workers. x Sustaining public safety and order, particularly at hospitals and shelters. x Ensuring disposal of excess hazardous waste and human waste, especially from makeshift evacuee encampments. x Ensuring safety of the food supply, especially agricultural prod- ucts that may be contaminated by radiation. x Delivery of mental health and crisis services, especially to chil- dren and other vulnerable populations. x Suspension and curtailment of routine state and local govern- ment public health and safety functions. While admitting that the list of planning activities may be over- whelming, Redlener encouraged communities to engage in discussions. Such discussions should include not only public health but also health care, emergency management, hazmat, sanitation, transportation, and other community-based services. Several participants in the discussion session following his presentation stressed the importance of developing high-level political support for detailed planning activities. Considering planners’ competing priorities, the magnitude of the task, the diversity of players providing services, the extreme resource needs, and the unchart- ed terrain, Redlener said, in addition to simply providing guidance, high- level political support is needed to put IND attack planning on the radar of outlying communities throughout the country. One of the discussants suggested that, after the detonation of an IND, the outlying communities will not be facing a temporary problem, as they would if they had experi- enced a hurricane, earthquake, or other natural disaster, after which cities are rebuilt. Instead, the discussant said, population displacement may be permanent because “the city is gone, nobody is coming back. There’s no way to fix the problems that make it worth staying.” SUMMARY An IND is a nuclear weapon bought illicitly or stolen from a nuclear state or fabricated by a terrorist group from illegally obtained nuclear weapons material (e.g., plutonium or highly enriched uranium). Through 

18 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK a fission reaction, the IND releases a massive amount of energy greater than any chemical reaction. By contrast, an RDD, or dirty bomb, com- bines explosives with radioactive material, but it is not sophisticated enough in design to undergo a fission reaction. The explosion from a dirty bomb does not release the mammoth energy or fission products of a nuclear detonation. An IND is far more likely than an RDD to cause acute radiation syndrome, a dose-related illness defined by three main symptom clusters—gastrointestinal, hematopoietic, and neurovascular. After an IND detonation, federal policy recommends sheltering in place. Federal policy also recommends a zoned approach to the emergency re- sponse: It calls for attending to casualties in the MDZ over the SDZ be- cause most people in the SDZ cannot survive even with treatment and resources, and the resources should be spent where they will have the most impact. Public health activities and responsibilities in outlying communities will also be highly impacted during this time. Thousands of evacuees will be fleeing through surrounding areas, potentially needing medical attention, housing, and schooling and straining the area infrastructure. Although answers may not be immediately available, Redlener stressed, it is important to begin having these conversations now and call attention to planning priorities.