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

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Appendix A Workshop Agendas ASSESSING MEDICAL PREPAREDNESS TO RESPOND TO A TERRORIST NUCLEAR EVENT: WORKSHOP 1 Committee on Medical Preparedness for a Terrorist Nuclear Event PUBLIC AGENDA Day 1 Thursday, June 26, 2008 Lecture Room National Academy of Sciences 2101 Constitution Avenue, N.W. Washington, DC Workshop Objectives: The purpose of the workshop is to assess the current level of medical pre- paredness for a nuclear detonation of up to 10 kilotons (kts) in Tier 1 Urban Area Security Initiative (UASI) cities (New York/New Jersey; National Capitol Region; Houston; Chicago; Los Angeles; and San Francisco/Bay Area). The specific objectives of the workshop are to 115 

116 medical preparedness for a terrorist nuclear event • review and summarize the overall emergency response activities and available health care capacity (including shelter, evacuation, decontamination, and medical infrastructure interdependencies) to treat the affected population; • examine the capacity and identify gaps in the capability of the fed- eral, state, and local authorities to deliver available medical coun- termeasures in a timely enough way to be effective; • review and summarize available treatments for pertinent radiation illnesses, including the efficacy of medical countermeasures; and • appraise the expected benefit of medical countermeasures, includ- ing those currently under development. 8:30 a.m. Welcome, Introductions, and Overview of Workshop Purpose and Objectives Georges C. Benjamin, Committee Chair Executive Director American Public Health Association B. Tilman Jolly Office of Health Affairs Department of Homeland Security Session 1 NUCLEAR ATTACK 101: HEALTH AND Health System IMPACTS OF AN IMPROVISED NUCLEAR DEVICE EXPLOSION Session Objectives: Provide basic information on the scope of the emer- gency medical needs that would be created by the detonation of a 10-kt nuclear device in a major city, including primary and secondary blast and thermal effects and the effects of prompt nuclear radiation and radiation from fallout on inhabitants and emergency responders. The main focus will be on the acute injuries caused by the blast, thermal, and prompt radiation effects of the initial explosion and by acute radiation exposure from fallout during the first three days after the explosion (excluding other important but longer-term impacts, such as long-term radiation effects, environmental contamination, and displacement of residents from contaminated areas). The potential impacts of the explosion on local emergency response and health system capacities will also be described. At the end of the session, workshop participants will have a basic understanding of the medical situation faced 

APPENDIX A 117 by emergency responders during the first 3 days post-explosion, which in turn will be the basis for assessing current medical preparedness at the local, state, and federal levels.   9:00 a.m. Session Overview and Objectives Daniel F. Flynn, Session Moderator Department of Radiation Oncology Caritas Holy Family Hospital and Medical Center Methuen, MA   9:05 a.m. Health Effects of a 10-kt-Equivalent Nuclear Explosion on an Urban Population and Emergency Responders Brooke Buddemeier Radiation Safety Specialist Radiological and Nuclear Countermeasures   Division Global Security Principal Directorate Lawrence Livermore National Laboratory   9:35 a.m. Health System Impacts of a 10-kt-Equivalent Nuclear Explosion on an Urban Area Cham Dallas Director, Institute for Health Management and   Mass Destruction Defense, University of Georgia Chair, Department of Health Policy and   Management, College of Public Health,   University of Georgia Department of Pharmaceutical & Biomedical  Sciences, College of Pharmacy, University of Georgia Department of Emergency Medicine,   Medical College of Georgia 10:05 a.m. Discussion led by Daniel F. Flynn, Session Moderator 10:35 a.m. BREAK 

118 medical preparedness for a terrorist nuclear event Session 2 Emergency MEDICAL Care: STATE OF THE ART Session Objective: Provide an overview of current approaches to medical response in the event of an improvised nuclear device (IND) explosion. The first presentation will cover the triage, decontamination, evacuation, and medical care of casualties from the immediate effects of a nuclear detonation (i.e., treatment of blast, thermal, and prompt radiation effects, including combined injuries). The second presentation will cover medical decision making and care of casualties from the delayed effects of a nuclear detonation (i.e., secondary triage and injuries from radioactive fallout). 10:45 a.m. Session Overview and Objectives Donna F. Barbisch, Session Moderator President Global Deterrence Alternatives, LLC Washington, DC 10:50 a.m. Urban Nuclear Detonation: Operational Conditions, Human Response and Casualty Management John Mercier Director of Military Medical Operations Armed Forces Radiobiology Research Institute 11:20 a.m. Medical Decision Making and Care of Casualties from Delayed Effects of a Nuclear Detonation Fred A. Mettler, Jr. Professor Emeritus Department of Radiology New Mexico Federal Regional Medical Center University of New Mexico 11:50 a.m. Discussion led by Donna F. Barbisch, Session Moderator 

APPENDIX A 119 12:20 p.m. WORKING LUNCH IN THE LECTURE ROOM  Committee, speakers, participants, and staff will briefly recap the discussions from the morning sessions of the first day of the workshop. Session 3 Radiation COUNTERMEASURES Session Objective: Provide an overview of current medical countermeasures for the acute effects of radiation exposure and of their efficacy as well as an assessment of the expected benefit of medical countermeasures currently under development.   1:30 p.m. Session Overview and Objectives Richard J. Hatchett, Session Moderator Associate Director of Radiation Countermeasures   Research and Emergency Preparedness National Institute of Allergy and Infectious Diseases   1:35 p.m. Efficacy and Expected Benefit of Currently Available Radiation Countermeasures Albert L. Wiley, Jr. Radiation Emergency Assistance Center/Training  Site and World Health Organization Collaborating Center for Radiation Emergency Assistance Oak Ridge Associated Universities   2:05 p.m. Expected Benefit of Radiation Countermeasures Currently Under Development Nelson J. Chao Professor of Medicine and Immunology Chief, Division of Cellular Therapy Duke University Medical Center 

120 medical preparedness for a terrorist nuclear event   2:35 p.m. Distribution and Dispensing of Medical Countermeasures (i.e., How and When Will Countermeasures Get to Those Who Need Them?) Carmen T. Maher Policy Analyst Office of Counterterrorism and Emerging Threats Food and Drug Administration Steven A. Adams Deputy Director Division of Strategic National Stockpile Centers for Disease Control and Prevention   3:00 p.m. Discussion led by Richard J. Hatchett, Session Moderator   3:30 p.m. BREAK Session 4 Protective ACTIONS AND INTERVENTIONS: Part I Session Objective: Provide an overview of current policies and programs to protect first responders and medical personnel from radiation exposure. 3:45 p.m. Session Overview and Objectives Paul E. Pepe, Session Moderator Professor of Medicine, Surgery, Pediatrics, and  Public Health and Riggs Family Chair in Emergency Medicine University of Texas Southwestern Medical Center at   Dallas 3:50 p.m. Radiation Protection Standards Sara D. DeCair Health Physicist Center for Radiological Emergency Preparedness,   Prevention, and Response Environmental Protection Agency 

APPENDIX A 121 John MacKinney Deputy Director Nuclear/Radiological/Chemical Threats and  Science and Technology Policy, Office of Policy Development Department of Homeland Security Jill A. Lipoti Director Division of Environmental Safety and Health New Jersey Department of Environmental   Protection Eric G. Daxon Health Physicist Battelle Memorial Institute–San Antonio Operations   4:40 p.m. Discussion led by Paul E. Pepe, Session Moderator   5:10 p.m. ADJOURNMENT ASSESSING MEDICAL PREPAREDNESS TO RESPOND TO A TERRORIST NUCLEAR EVENT: WORKSHOP 1 Committee on Medical Preparedness for a Terrorist Nuclear Event PUBLIC AGENDA Day 2 Friday, June 27, 2008 Auditorium National Academy of Sciences 2101 Constitution Avenue, N.W. Washington, DC 8:30 a.m. Welcome, Introductions, and Overview of Workshop Purpose and Objectives Georges C. Benjamin, Committee Chair Executive Director American Public Health Association 

122 medical preparedness for a terrorist nuclear event Session 5 PROTECTIVE ACTIONS AND INTERVENTIONS: Part II Session Objective: Provide overview of best population protection practices during an IND incident. Issues include risk communication, psychosocial factors, and readiness to implement interventions to reduce mental and physical impacts.   8:45 a.m. Session Overview and Objectives Robert J. Ursano, Session Moderator Professor of Psychiatry and Neuroscience Chairman, Department of Psychiatry Uniformed Services University of the Health   Sciences 8:50 a.m. Behavioral and Risk Communication Issues, and Intervention Strategies, in Nuclear Detonation Incidents Steven M. Becker Associate Professor of Public Health Vice Chair, Department of Environmental Health   Sciences Director, Disaster and Emergency Communication   Research Unit Director, Community Resilience and Disaster   Management Program University of Alabama at Birmingham H. Keith Florig Senior Research Engineer Department of Engineering and Public Policy Carnegie Mellon University 

APPENDIX A 123 Ann E. Norwood Senior Associate Center for Biosecurity University of Pittsburgh Medical Center Dori B. Reissman Senior Medical Advisor Office of the Director National Institute for Occupational Safety and   Health 10:20 a.m. BREAK 10:30 a.m. Behavioral and Risk Communication Issues, and Intervention Strategies, in Nuclear Detonation Incidents (continued) 11:00 a.m. Discussion led by Robert J. Ursano, Session Moderator Session 6 summary 11:30 a.m. Summary of workshop discussions Jerome M. Hauer The Hauer Group 12:00 p.m. Wrap-up and final thoughts Georges C. Benjamin, Committee Chair 12:30 p.m. ADJOURNMENT OF OPEN SESSION 

124 medical preparedness for a terrorist nuclear event ASSESSING MEDICAL PREPAREDNESS TO RESPOND TO A TERRORIST NUCLEAR EVENT: WORKSHOP 2 Committee on Medical Preparedness for a Terrorist Nuclear Event AGENDA Day 1 Thursday, August 7, 2008 Auditorium National Academy of Sciences 2101 Constitution Avenue, N.W. Washington, DC Workshop Objectives: The purpose of the workshop is to assess the current level of medical pre- paredness for a nuclear detonation of up to 10 kts in Tier 1 Urban Area Security Initiative cities (New York/New Jersey; National Capitol Region; Houston; Chicago; Los Angeles; and San Francisco/Bay Area). The specific objectives of the workshop are to • review and summarize the overall emergency response activities and available health care capacity (including shelter, evacuation, decontamination, and medical infrastructure interdependencies) to treat the affected population; • examine the capacity and identify gaps in the capability of the federal, state, and local authorities to deliver available medical countermeasures in a timely enough way to be effective; • review and summarize available treatments for pertinent radiation illnesses including the efficacy of medical countermeasures; and • appraise the expected benefit of medical countermeasures, includ- ing those currently under development. 8:30 a.m. Welcome, Introductions, and Overview of Workshop Purpose and Objectives Georges C. Benjamin, Committee Chair Executive Director American Public Health Association 

APPENDIX A 125 Session 1 CURRENT Preparedness for aN improvised nuclear device, Part I: IMMEDIATE CASUALTIES Session Objective: In response to the committee’s statement of task, this session will explore the current level of medical preparedness for detona- tion of an IND of up to 10 kts in yield in a Tier 1 Urban Area Security Initiative area. Panels of local, state, and federal emergency response and medical personnel will review overall emergency response preparedness and ­capacity of the health care system to treat the population injured by the blast, thermal, and prompt radiation from an IND detonation, includ- ing the capacity of emergency medical services (EMS) to triage, treat, and transport the injured to treatment facilities and the capacity of the health care system to provide appropriate medical care to the numbers, types, and severities of likely injuries. The panels will address four aspects of emer- gency response preparedness: (1) the capacity of the emergency medical response to reach the injured and perform field triage and treatment, (2) the capacity to transport injured to area health care facilities, (3) the capacity of area health care facilities to evaluate and treat the likely numbers and types of injuries, and (4) the capacity to evacuate those who are seriously injured to appropriate health care facilities nationally.   8:55 a.m. Session Overview and Objectives George J. Annas, Session Moderator Edward Utley Professor and Chair Department of Health Law, Bioethics and Human   Rights Boston University School of Public Health   9:00 a.m. Panel 1. Preparedness for emergency response to the d ­ etonation of a 10-kt IND (i.e., What capability is there to reach, triage, and treat those injured by the detonation safely?) John F. Brown, San Francisco (San Francisco EMS   Agency) Brooke Buddemeier, Lawrence Livermore   National Laboratory 

126 medical preparedness for a terrorist nuclear event Michael Fitton, New York (Fire Department of   New York) Kathleen “Cass” Kaufman, Los Angeles  (Los Angeles County Department of Public Health) Joseph S. Newton, Chicago (Chicago Fire   Department) Richard P. Zuley, Chicago (Chicago Department   of Public Health) 10:00 a.m. Panel 2. Preparedness to transport casualties to area treat- ment facilities (i.e., What capability is there to know which treatment facilities are open, and what is the capac- ity to get them there?) Richard L. Alcorta, National Capital Region   (Maryland Institute for EMS Systems) Craig DeAtley, National Capital Region   (Washington Hospital Center, Washington, DC) Bryan Hanley, Los Angeles (Los Angeles County   EMS Agency) Douglas Havron, Houston (Southeast Texas   Trauma Regional Advisory Council) Carl E. Lindgren, National Capital Region   (Arlington Fire Department, Virginia) 11:00 a.m. BREAK 11:15 a.m. P  anel 3. Preparedness of the metropolitan area’s medical system to treat casualties from a 10-kt IND Joseph A. Barbera, Institute for Crisis, Disaster, and Risk Management, George Washington University John F. Brown, San Francisco (San Francisco EMS Agency) Patricia Hawes, National Capital Region (Suburban Hospital, Bethesda, Maryland) Nathaniel Hupert, Weill Medical College of Cornell University Amy Hideko Kaji, Los Angeles (Harbor-UCLA Medical Center) Katherine Uraneck, New York (New York City Department of Health and Mental Hygiene) 

APPENDIX A 127 12:15 p.m. WORKING LUNCH TO CONTINUE PANEL DISCUSSIONS   1:00 p.m. P  anel 4. Preparedness to evacuate serious casualties from a 10-kt IND from area hospitals to appropriate treatment facilities statewide and nationally Joseph A. Barbera, George Washington University Dan Hanfling, National Capital Region (Inova Health System, Falls Church, Virginia) Jerome M. Hauer, The Hauer Group Aashish Shah, Houston (Texas Department of State Health Services) Katherine Uraneck, New York (New York City Department of Health and Mental Hygiene)   2:00 p.m. State of Preparedness for Immediate Casualties: An Open Discussion by Committee Members and Audience   3:00 p.m. BREAK Session 2 Currently available medical resources Session Objective: Discuss federal and state medical preparedness for an IND event in a Tier 1 UASI area, the assets that will be available in such an event, and the plans to use those assets.   3:15 p.m. Session Overview and Objectives Judith A. Monroe, Session Moderator State Health Commissioner Indiana State Department of Health President, Association of State and Territorial Health Officials 

128 medical preparedness for a terrorist nuclear event   3:20 p.m. Department of Health and Human Services Response Assets and Plans in the Event of an IND Detonation Ann R. Knebel Office of the Assistant Secretary for Preparedness and Response Department of Health and Human Services   3:35 p.m. Department of Energy Response Assets and Plans in the Event of an IND Detonation Alan L. Remick Office of Emergency Response National Nuclear Security Administration Department of Energy   3:50 p.m. National Guard Response Assets and Plans in the Event of an IND Detonation Col. Daniel Bochicchio U.S. Army War College   4:05 p.m. State Preparedness for an IND Event James S. Blumenstock Association of State and Territorial Health Officials   4:20 p.m. Discussion led by Judith A. Monroe, Session Moderator   5:20 p.m. ADJOURNMENT 

APPENDIX A 129 ASSESSING MEDICAL PREPAREDNESS TO RESPOND TO A TERRORIST NUCLEAR EVENT: WORKSHOP 2 Committee on Medical Preparedness for a Terrorist Nuclear Event AGENDA Day 2 Friday, August 8, 2008 Auditorium National Academy of Sciences 2101 Constitution Avenue, N.W. Washington, DC 8:00 a.m. Welcome, Introductions, and Overview of Workshop Purpose and Objectives Georges C. Benjamin, Committee Chair Executive Director American Public Health Association Session 3 CURRENT Preparedness for aN improvised nuclear device, Part II: PREVENTING AND TREATING fallout CASUALTIES Session Objective: Discuss the preparedness of Tier 1 UASI areas to man- age the effects of the radiation fallout from a 10-kt IND and to identify, mitigate, and manage long-term effects. Issues include effectiveness of risk communication, short- and long-term mental health, efficacy of nonmedi- cal protective actions such as sheltering in place and evacuation, and plans and expectations for state and federal response resources to augment local resources. This session will conclude with an assessment of what remains to be done. 

130 medical preparedness for a terrorist nuclear event   8:30 a.m. Session Overview and Objectives Colleen Conway-Welch, Session Moderator Nancy and Hilliard Travis Professor of Nursing Dean, Vanderbilt University School of Nursing 8:35 a.m. Panel 5. Preparedness to mitigate, identify, and address fallout casualties and to manage long-term consequences Thomas N. Ahrens, Los Angeles and San Francisco (California Department of Public Health) Brooke Buddemeier, Lawrence Livermore National Laboratory Kathleen “Cass” Kaufman, Los Angeles (Los Angeles County Department of Public Health) Jeanine Prud’homme, New York (New York City Department of Health and Mental Hygiene) Irwin Redlener, Columbia University Adela Salame-Alfie, New York (New York State Department of Health) Reuben K. Varghese, National Capital Region (Arlington Public Health, Virginia) Michael Welling, National Capital Region (Virginia Department of Health) 10:30 a.m. BREAK 10:45 a.m. State of Preparedness for Fallout Casualties: An Open Discussion by Committee Members and Audience Session 4 summary 11:30 a.m. Wrap-up and final thoughts Georges C. Benjamin, Committee Chair Executive Director American Public Health Association 12:00 p.m. ADJOURN WORKSHOP