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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25372.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Exploring Medical and Public Health Preparedness for a Nuclear Incident PROCEEDINGS OF A WORKSHOP Leslie Pray, Benjamin Kahn, and Scott Wollek, Rapporteurs Forum on Medical and Public Health Preparedness for Disasters and Emergencies Board on Health Sciences Policy Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 This activity was jointly supported by contracts between the National Academy of Sciences and the American Burn Association; American College of Emergency ­ Physicians; American College of Surgeons’ Committee on Trauma; American Hospital Association; American Red Cross; Association of Public Health Labora­ tories; Association of State and Territorial Health Officials; Council of State and T ­ erritorial Epidemiologists; East West Protection; Emergency Nurses Association; G ­ laxoSmithKline; Healthcare Ready; Infectious Diseases Society of America; N ­ ational Association of Chain Drug Stores; National Association of County & City Health Officials; National Association of Emergency Medical Technicians; Robert Wood Johnson Foundation; Sequirus; Trauma Center Association of America; U.S. Depart­ ent of Defense (Contract No. HHSP233201400020B/ m HHSP23337014); U.S. Department of Defense, Uniformed Services University of the Health Sciences (Contract No. HU0001-16-1-0022); U.S. Department of Health and Human Services, Administration for Children and Families (Contract No. HHSP23320140020B/HHSP23337065); U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (Contract No. 200-2011- 38807, TO #54); U.S. Department of Health and Human Services, Food and Drug Administration (Contract No. 1R13FD005495-01); U.S. Department of Health and Human Services, National Institutes of Health (Contract No. HHSN26300084); U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response (Contract No. HHSO100201550005A); and U.S. Department of Transportation, National Highway Traffic Safety Administration (Contract No. DTNH22-14-H-00468). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25372 Additional copies of this publication are available 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. Copyright 2019 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. Exploring medical and public health preparedness for a nuclear incident: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25372. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the char- ter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineer­ ing, and Medicine to provide independent, objective analysis and a ­ dvice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, E ­ngineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typi- cally include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and ­ pinions o contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

PLANNING COMMITTEE ON EXPLORING MEDICAL AND PUBLIC HEALTH PREPAREDNESS FOR A NUCLEAR INCIDENT1 JAMES BLUMENSTOCK (Co-Chair), Chief, Health Security, Association of State and Territorial Health Officials TENER VEENEMA (Co-Chair), Professor of Nursing and Public Health, Johns Hopkins University School of Nursing and Johns Hopkins Bloomberg School of Public Health STEVEN M. BECKER, Professor, Community and Environmental Health, Old Dominion University JOHN BENITEZ, Medical Director, Emergency Preparedness, Tennessee Department of Health STEPHEN BROOMELL, Assistant Professor, Social and Decision Sciences, Carnegie Mellon University CHAM DALLAS, University Professor of Health Policy and Management, Director, Institute for Disaster Management, University of Georgia DAVID EISENMAN, Associate Professor, David Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles BRUCE EVANS, Fire Chief, Upper Pine River Fire Protection District CHAD HRDINA, Director, Division of Requirements, U.S. Department of Health and Human Services ANN KNEBEL, Deputy Scientific Director, Division of Pre-Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health JOHN KOERNER, Senior Special Adviser, Chemical, Biological, Radiological, Nuclear, High-Yield Explosive (CBRNE) Science and Operations, Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services ROBERTA LAVIN, Executive Associate Dean of Academic Affairs and Professor, University of Tennessee College of Nursing MARTHA LINET, Senior Investigator, Radiation Epidemiology Branch, National Cancer Institute, National Institutes of Health MATTHEW K. WYNIA, Director, Center for Bioethics and Humanities, University of Colorado Denver 1  The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rap­ porteurs and the institution. v PREPUBLICATION COPY—Uncorrected Proofs

Health and Medicine Division Staff SCOTT WOLLEK, Senior Program Officer BEN KAHN, Associate Program Officer REBECCA RAY, Senior Program Assistant (until December 2018) ANDREW M. POPE, Director, Board on Health Sciences Policy Consultant LESLIE PRAY, Science Writer vi PREPUBLICATION COPY—Uncorrected Proofs

FORUM ON MEDICAL AND PUBLIC HEALTH PREPAREDNESS FOR DISASTERS AND EMERGENGIES1 DAN HANFLING (Co-Chair), Contributing Scholar, Center for Health Security, Johns Hopkins Bloomberg School of Public Health SUZET M. McKINNEY (Co-Chair), Executive Director and Chief Executive Officer, Illinois Medical District STACEY J. ARNESEN, Branch Chief, Disaster Information Management Research Center, National Library of Medicine, National Institutes of Health ERIC BLANK, Senior Director, Public Health Programs and Systems, Association of Public Health Laboratories DUANCE C. CANEVA, Chief Medical Officer, U.S. Department of Homeland Security MARY CASEY-LOCKYER, Senior Associate, Disaster Health Program Development, American Red Cross BROOKE COURTNEY, Senior Regulatory Counsel, Office of Counterterrorism and Emerging Threats, Food and Drug Administration JOHN J. DREYZEHNER, Commissioner, Tennessee Department of Health DAVID EISENMAN, Associate Professor, David Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles BRUCE EVANS, Fire Chief, Upper Pine River Fire Protection District JAMES R. FICKE, Robert A. Robinson Professor and Director, Department of Orthopaedic Surgery, Johns Hopkins Medicine LORI GRUBSTEIN, Program Officer, Health Care Group, Robert Wood Johnson Foundation JOHN L. HICK, Associate Medical Director for EMS and Medical Director of Emergency Medicine, Hennepin County Medical Center ROBERT KADLEC, Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services CLAUDIA M. KELLY, Senior Director, Value Access and Policy, Seqirus THOMAS KIRSCH, Professor of Military and Emergency Medicine, Director, National Center for Disaster Medicine and Public Health, Uniformed Services University of the Health Sciences NICOLETTE A. LOUISSAINT, Executive Director, Healthcare Ready FREDA GAIL LYON, Vice President, Emergency Services, WellStar Health System 1  The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. vii PREPUBLICATION COPY—Uncorrected Proofs

PHILLIP MAYTUBBY, Director, Public Health Protection, Oklahoma City-County Health Department CAROLYN BRADY MEIER, Acting Director, Office of Human Services Emergency Preparedness Response, Administration for Children and Families, U.S. Department of Health and Human Services AUBREY K. MILLER, Senior Medical Adviser, Office of the Director, National Institute of Environmental Health Sciences, National Institutes of Health BARBARA MULACH, Director, Office of Science Coordination and Program Operations, National Institute of Allergy and Infectious Diseases, National Institutes of Health IRA NEMETH, Chair, Disaster Medicine Section, American College of Emergency Physicians JOHN OSBORN, Operations Manager and Assistant Professor of Health Care Systems Engineering, Department of Surgery, Mayo Clinic College of Medicine TARA O’TOOLE, Senior Fellow and Executive Vice President, In-Q-Tel ANDREW T. PAVIA, George and Esther Gross Presidential Professor, Division of Pediatric Infectious Diseases, The University of Utah School of Medicine TERRY RAUCH, Acting Deputy Assistant Secretary of Defense for Health Readiness Policy and Oversight, Office of the Assistant Secretary of Defense for Health Affairs, U.S. Department of Defense STEPHEN C. REDD, Director, Center for Preparedness and Response, Centers for Disease Control and Prevention SARA ROSZAK, Director of Research, National Association of Chain Drug Stores COLLEEN RYAN, Professor of Surgery, Harvard Medical School ROSLYNE SCHULMAN, Director, Policy Development, American Hospital Association RICHARD SERINO, Distinguished Visiting Fellow, National Preparedness Leadership Initiative, Harvard T.H. Chan School of Public Health ALAN SINISCALCHI, Surveillance Coordinator for Influenza, Bioterrorism, and Public Health Preparedness, Connecticut Department of Public Health W. CRAIG VANDERWAGEN, Co-Founder and Director, East West Protection TENER VEENEMA, Professor of Nursing and Public Health, Johns Hopkins University School of Nursing and Johns Hopkins Bloomberg School of Public Health JENNIFER WARD, President, Trauma Center Association of America viii PREPUBLICATION COPY—Uncorrected Proofs

GAMUNU WIJETUNGE, EMS Specialist, Office of Emergency Medical Services, National Highway Traffic Safety Administration, U.S. Department of Transportation MATTHEW K. WYNIA, Director, Center for Bioethics and Humanities, University of Colorado Denver Forum Staff SCOTT WOLLEK, Forum Director LISA BROWN, Senior Program Officer BEN KAHN, Associate Program Officer KIMBERLY SUTTON, Senior Program Assistant ANDREW M. POPE, Director, Board on Health Sciences Policy ix PREPUBLICATION COPY—Uncorrected Proofs

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Reviewers This Proceedings of a Workshop was reviewed in draft form by indi­ viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical com­ ments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: AMANDA BETTENCOURT, University of Pennsylvania School of Nursing MARTHA LINET, National Cancer Institute, National Institutes of Health PHILLIP MAYTUBBY, Oklahoma City County Health Department Although the reviewers listed above provided many constructive com­ ments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by HELLEN GELBAND, independent consultant. She was responsible for making certain that an independent examination of this proceedings was carried out in accordance with stan­ dards of the National Academies and that all review comments were care­ fully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies. xi PREPUBLICATION COPY—Uncorrected Proofs

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Contents ACRONYMS AND ABBREVIATIONS xvii 1 INTRODUCTION 1 Organization of the Proceedings, 4 2 FEDERAL PLANNING FOR NUCLEAR INCIDENTS 5 Setting the Stage: Nuclear Detonation Response Planning, 6 Updated Modeling: Nuclear Blasts and Fallout in an Urban Environment, 10 Exploring the Medical and Public Health Preparedness for a Nuclear Incident: From the Perspective of the Office of the Assistant Secretary for Preparedness and Response, 20 Resources and Capabilities Available at the Federal Level, 25 Discussion, 32 3 CURRENT STATE OF NUCLEAR PREPAREDNESS 35 Current State of Medical and Public Health Preparedness for a Nuclear Incident, 36 Emergence of State Actor Threats: Has It Changed Preparedness Planning? Has It Changed Who Is at the Table?, 39 Workforce Turnover: A Major Challenge to Preparedness, 41 Complacency: An Obstacle to Nuclear Preparedness, 43 Discussion with the Audience, 43 xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv CONTENTS 4 UPDATING PLANNING ASSUMPTIONS OF NUCLEAR 47 PREPAREDNESS Magnitude of Emerging Nuclear Threats, 48 A State-Level Perspective: North Carolina, 54 Regional Response: Opportunities and Challenges, 56 Role of the Private Sector in Preparedness Planning, 57 Fear of Radiation: Implications for Planning, 59 5 IMPLICATIONS OF COMMUNICATION, EDUCATION, 61 AND INFORMATION CHALLENGES Nuclear Events: Communication, Education, and Information Challenges, 62 Wireless Emergency Alerts, 69 Risk Communication in Nuclear Incident Management, 74 A Unique, Video-Based Public Information Campaign: Ventura County, California, 78 Nuclear Incident Public Communication: Tools and Teachable Moments, 82 Discussion with the Audience, 87 6 CHALLENGES FOR BUILDING CAPACITY WITHIN THE 93 HEALTH CARE SYSTEM Priorities for Response Capabilities, 95 Discussion: Shortage of Burn Expertise, 108 7 CAPABILITY-BUILDING CHALLENGES AND 111 OPPORTUNITIES: BUILDING RESPONSE CAPABILITY Large-Scale Testing for Acute Radiation Sickness After a Nuclear Incident, 112 Use of the Strategic National Stockpile in a Nuclear Scenario, 113 Use of Volunteers During a Nuclear Incident, 114 Role of the U.S. Department of Veterans Affairs in a Nuclear Incident, 115 Community Response Following a Nuclear Event: The Capacity of a Prepared Citizenry, 117 Nuclear/Radiological Incident Annex of FEMA, 118 Discussion, 119 8 CAPABILITY-BUILDING CHALLENGES AND 121 OPPORTUNITIES: ENSURING WORKFORCE READINESS AND RESPONSE CAPACITY Health Workers’ Willingness to Respond to Nuclear Events, 122 A Pennsylvania Health Care System Perspective, 124 PREPUBLICATION COPY—Uncorrected Proofs

CONTENTS xv A U.S. Public Health Service Nurse Perspective, 127 National Disaster Medical System, 128 Provider Knowledge of Disaster Preparedness, 129 Nurse Workforce Readiness for Radiation Emergencies and Nuclear Events, 133 Moderator’s Summary of Overarching Topics, 136 Gaps in Workforce Readiness and Ways to Close Those Gaps, 136 9 BUILDING PREPAREDNESS AND RESPONSE CAPABILITY: 139 LOOKING TO THE FUTURE ASPR’s Office of Critical Infrastructure Protection, 139 Moving Forward: Priorities Identified by Individuals on the Reaction Panel, 140 Additional Topics Identified by the Audience, 144 REFLECTIONS ON THE WORKSHOP AND 10  147 OPPORTUNITIES FOR MOVING FORWARD Blumenstock’s Key Messages, 147 ASPR’s Closing Remarks: Call for an Action Plan, 151 REFERENCES 155 APPENDIXES A Workshop Agenda 161 B Speaker Biographies 171 PREPUBLICATION COPY—Uncorrected Proofs

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Acronyms and Abbreviations AACN American Association of Colleges of Nursing ABA American Burn Association ACS American College of Surgeons ALC absolute lymphocyte count AMS Aerial Monitoring System ARC American Red Cross ARS acute radiation sickness ASPR Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services ASTHO Association of State and Territorial Health Officials BARDA Biomedical Advanced Research and Development Authority CBC complete blood count CBRN chemical, biological, radiological, and nuclear CDC Centers for Disease Control and Prevention CEMP Comprehensive Emergency Management Program, U.S. Department of Veterans Affairs CIP Office of Critical Infrastructure Protection, Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services CIR critical information requirement CMRT Consequence Management Response Team CMS Centers for Medicare & Medicaid Services xvii PREPUBLICATION COPY—Uncorrected Proofs

xviii ACRONYMS AND ABBREVIATIONS CONOPS continuity of operations CRC community reception center DHS U.S. Department of Homeland Security DMAT disaster medical assistance team DoD U.S. Department of Defense DoE U.S. Department of Energy EMAC Emergency Management Assistance Compact EMP electromagnetic pulse EMS emergency medical services EOC emergency operations center EPA Environmental Protection Agency ESF#15 Emergency Support Function #15 FDA Food and Drug Administration FEMA Federal Emergency Management Agency FRMAC Federal Radiological Monitoring and Assessment Center GAO Government Accountability Office HAP The Hospital + Healthsystem Association of Pennsylvania HHS U.S. Department of Health and Human Services HPP Hospital Preparedness Program ICBM intercontinental ballistic missile ICU intensive care unit IND improvised nuclear device kt kilotons MDP Mobile Device Project MERRT Medical Emergency Radiological Response Team MRC Medical Reserve Corps Mt megaton NACCHO National Association of County & City Health Officials NARAC National Atmospheric Release Advisory Center, U.S. Department of Energy NARR National Alliance for Radiation Readiness NCDMPH National Center for Disaster Medicine and Public Health NDMS National Disaster Medical System PREPUBLICATION COPY—Uncorrected Proofs

ACRONYMS AND ABBREVIATIONS xix NEST Nuclear Emergency Support Team, U.S. Department of Energy NHSS National Health Security Strategy NIH National Institutes of Health NRF National Response Framework NRIA Nuclear/Radiological Incident Annex NRITF Nuclear/Radiological Incident Task Force NYC New York City OADN Organization for Associate Degree Nursing PEMDP Pre-Event Message Development Project PHEP public health emergency preparedness PHIT Public Health Infrastructure Training PSA public service announcement PSI pounds per square inch RAP Radiological Assistance Program RDD radiological dispersal device RDHRS Regional Disaster Health Response System REAC/TS Radiation Emergency Assistance Center/Training Site RED radiation exposure device RITN Radiation Injury Treatment Network RSL Remote Sensing Laboratory SNS Strategic National Stockpile START Study on Terrorism and Responses to Terrorism USPHS U.S. Public Health Service VA U.S. Department of Veterans Affairs WEA wireless emergency alert WHO World Health Organization WMD weapon of mass destruction PREPUBLICATION COPY—Uncorrected Proofs

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Dedication This Proceedings of a Workshop is dedicated to our science writer Leslie Pray (1964–2018). Leslie worked for many years as a science writer with the National Academies, and our staff will always remember her kind nature, skillful writing, and sharp intellect. xxi PREPUBLICATION COPY—Uncorrected Proofs

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The National Academies of Sciences, Engineering, and Medicine held a workshop on August 22–23, 2018, in Washington, DC, to explore medical and public health preparedness for a nuclear incident. The event brought together experts from government, nongovernmental organizations, academia, and the private sector to explore current assumptions behind the status of medical and public health preparedness for a nuclear incident, examine potential changes in these assumptions in light of increasing concerns about the use of nuclear warfare, and discuss challenges and opportunities for capacity building in the current threat environment. This publication summarizes the presentations and discussions from the workshop.

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