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Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop (2019)

Chapter: 4 Updating Planning Assumptions of Nuclear Preparedness

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Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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:"4 Updating Planning Assumptions of Nuclear Preparedness." 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:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 49
Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 50
Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 51
Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 52
Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 53
Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 54
Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 55
Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 56
Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 57
Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 58
Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 59
Suggested Citation:"4 Updating Planning Assumptions of Nuclear Preparedness." 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.
×
Page 60

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4 Updating Planning Assumptions of Nuclear Preparedness Key Points Made by Individual Speakers • Stakeholders in nuclear preparedness need to begin consider­ ing the threat of larger yield weapons (up to 100 kilotons [kt], 475 kt) and devote more attention to burn care, which could prove to be the “Achilles’ heel” of a response due to the n ­ umber of injuries and lack of expertise in that field. (Dallas) • A state-sponsored nuclear attack anywhere in the United States would require a national response because fallout from larger weapons is greater, with radioactive material traveling farther and higher in the atmosphere. Despite gains made in the past decade, resiliency in the new threat environment is still a work in progress. (Whitcomb) • At the state level, there is acknowledgment that the state would need additional resources to respond to attack, but there is confusion about whether such aid would originate through federal resources such as the U.S. Department of Defense or through mutual aid with other states. (Young) Nuclear preparedness planning has been underway for decades, par­ ticularly in the past 20 years, but the reemergence of state actors has changed the threat calculus. In Panel Discussion II, moderated by Cham Dallas, university professor of health policy and management and direc­ 47 PREPUBLICATION COPY—Uncorrected Proofs

48 EXPLORING PREPAREDNESS FOR A NUCLEAR INCIDENT tor of the Institute for Disaster Management at the University of Georgia, panelists continued to explore possible changes to planning assumptions for nuclear incidents in response to the reemergence of state actor threats and the implications of these changes for the challenges of nuclear incident prevention, planning, and response. Based on his extensive field expe­ rience in radioactively contaminated areas, including 12 expeditions to C ­ hernobyl and 6 expeditions to Fukushima, Dallas opened the panel with ­ a brief presenta­ion on the magnitude of the problem, with an emphasis t on the overwhelming number of thermal burn casualties to be expected in the event of a thermonuclear detonation. Dallas was followed by Robert Whitcomb, chief, Radiation Studies Section, National Center for Environmental Health, Centers for Disease Control and Prevention (CDC). CDC’s work in this area has largely focused on assisting and supporting its state and local partners in public health pre­ paredness, mostly in communication, education, and training. Much of this work is done by a small staff of radiation experts, education and commu­ nication professionals, and contractors who help to test CDC messages in various scenarios. CDC also has experience working with communities that have been impacted by fallout from nuclear weapons testing (e.g., commu­ nities living near nuclear testing sites in the Pacific), and Whitcomb focused his presentation on this experience. Finally, James Young, program man­ ager, Radiological Emergency Preparedness and Emergency Management, North Carolina Department of Public Safety, offered a state-level boots on the ground perspective. Although his work focuses mostly on fixed nuclear power plants, other nuclear threats would fall under his purview too. His program has an active partnership with other state agencies, including law enforcement and intelligence organizations. This chapter summarizes these remarks and the panelist discussion that followed. Summaries of remarks made during the question-and-answer ­ eriod at the end of the panel are interspersed throughout the chapter p where relevant. MAGNITUDE OF EMERGING NUCLEAR THREATS Dallas reiterated concerns that thermonuclear weapons are once again an emerging threat after having faded following the Cold War, not only because of current geopolitical tensions with North Korea but also because of threats from other countries as well. He compared fatalities, casualties, and other impacts of three different nuclear weapon yield, all modeled based on what would happen if the detonations were to occur in Seoul, South Korea: PREPUBLICATION COPY—Uncorrected Proofs

PLANNING ASSUMPTIONS OF NUCLEAR PREPAREDNESS 49 1. 25 kilotons (kt), which is slightly larger than the Hiroshima and Nagasaki devices and larger than the 10 kt yield typically assumed for planning purposes 2. 100 kt, which is in line with the potential yield of a North Korean device 3. 475 kt, which matches the size of weapons on U.S. Trident nuclear submarines (see Table 4-1) With respect to fatalities in these modeling scenarios, there would be 33,000 from a 25 kt bomb, 110,000 from a 100 kt bomb, and 394,000 from a 475 kt bomb. Regarding prompt radiation, which is the radiation that occurs at the moment of detonation, there would be 97,000 casualties from a 25 kt detonation, compared to 176,000 for a 100 kt detonation and 341,000 for a 475 kt detonation. Dallas said casualties would be the major category of concern because those individuals would require treatment. While the relationship between yield and the number of people affected is nonlinear, the number of people affected by a larger yield detonation would quickly overwhelm any medi­ cal care system, as a typical hospital would already have 90–95 percent of its beds filled prior to a disaster. For a 25 kt bomb, there would be 67,000 casualties; for a 100 kt bomb, 229,000 casualties; and for a 475 kt bomb, 809,000 casualties. TABLE 4-1  Comparison of Predicted Casualty Distributions for 25, 100, and 475 kt Nuclear Weapon Detonations in Seoul, South Korea 25 kt 100 kt 475 kt Fatalities (50% fatality; blast 8.1 psi) 33,000 110,000 394,000 Prompt radiationa (300 REM) 97,000 176,000 341,000 Casualtiesb (50% casualty; blast 4.9 psi) 67,000 229,000 809,000 Residential buildings destroyed (blast 3 psi) 155,000 504,000 1,674,000 Mass fires (50% chance) 239,000 1,064,000 3,800,000 3rd-degree burns 443,000 1,850,000 5,382,000 2nd-degree burns 770,000 2,891,000 6,838,000 1st-degree burns 1,592,000 4,586,000 10,413,000 Broken glass (0.6 psi glass shatters) 3,950,000 6,842,000 14,248,000 aRadiation emitted instantaneously by a nuclear explosion. bPersons with injuries requiring treatment. SOURCE: Dallas presentation, August 22, 2018. PREPUBLICATION COPY—Uncorrected Proofs

50 EXPLORING PREPAREDNESS FOR A NUCLEAR INCIDENT Thermal Burns: A Weakness of the U.S. Health Care Systems in a Mass Casualty Situation To Dallas, the number of potential thermal casualties expected as a result of fires following a thermonuclear incident overshadows nonthermal casualties, and he clarified that thermal burn casualties are not the same as radiation burns. Dallas said that some fires would be in the direct line of sight from the air burst, while others would be generated on the ground when materials catch fire because of the intense heat of the explosion. He clarified that the estimates shown in Table 4-1 are speculative as there are no data for thermonuclear weapons in urban areas; even if the estimates are far from accurate, he said, the statistics are staggering because “thermal burns are the Achilles’ heel of our health care system for mass casualty management,” Dallas observed. Dallas was the first of several participants who emphasized the lack of capacity in the U.S. health care system to care for burn patients in a mass casualty situation. A typical hospital has three or four medical care per­ sonnel tending to a single burn patient. In a nuclear detonation situation, there would be an overwhelmingly large number of thermal burn patients and only a small number of qualified medical care personnel who would have survived to help, and he emphasized the importance of thermal burn care for the likely millions of patients who would require support in such a scenario. Burn Care Discussion Colleen Ryan, professor of surgery, Harvard Medical School, and a rep­ resentative of the American Burn Association (ABA), agreed with Dallas’s ­ characterization of burn care as the “Achilles’ heel” of the U.S. health care system and noted that there are approximately only 300 burn surgeons in North America. She described burn nursing as a similarly limited profes­ sion. Moreover, she stressed the need for enhanced capacity given that burn care requires months of attention and rehabilitation. James Jeng, surgeon, Crozer-Chester Medical Center (Pennsylvania), and chair of ABA’s Disaster Subcommittee, lamented the lack of ­ uality q training offered in burn surgery in the United States, noting that the re­ quirement for burn training was removed from the formal syllabus for surgical training approximately 10 years ago. “I think it is incumbent on this country and the leadership to do whatever they need to do to reinstate burn training into the general surgical syllabus of the United States,” Jeng said. PREPUBLICATION COPY—Uncorrected Proofs

PLANNING ASSUMPTIONS OF NUCLEAR PREPAREDNESS 51 Other Types of Care: Injuries and Pediatric Care Recognizing the dearth of burn surgeons and the limited number of training opportunities in burn care, Arthur Cooper, medical director, Harlem Hospital Injury Prevention Program, and a representative of the American Academy of Disaster Medicine, asserted that the situation is no less egregious in terms of preparation for pediatric burn and trauma care. Noting the numbers in Table 4-1, he pointed out that the expected injuries from falling glass are three times greater than the number of burn patients requiring care. He called for a better training and preparation for pediatri­ cians too. Modeling: Different Assumptions, Different Impacts During the open discussion with the audience, Buddemeier remarked on the “scary” and “defeatist” numbers presented by Dallas and clarified that the numbers are based on a simplified modeling approach that did not take into account the fact that 85 percent of the people in Seoul would be inside buildings at the time of an attack and thus have some protection from many of the prompt effects. With a warning system, many additional people would be able to take protective action from the detonation, Buddemeier said. In addition, actions taken immediately after a blast can help to avoid many of the fallout and post-detonation effects counted. Thus Buddemeier concluded that Dallas’s statistics were overestimates. “We can save a lot of lives,” he said. “I completely agree,” Dallas responded and noted that nonetheless the numbers illustrate the difference in impact between smaller and larger weapons. Fallout from a Large Thermonuclear Weapon: Regional Impact Whitcomb described differences in fallout between different-size ­ eapons. w The total atmospheric yield of all the above-ground nuclear weapons tests ­ conducted at the Nevada Test Site,1 primarily in the 1940s through the 1960s, was 1 megaton (Mt) total. Hundreds of small weapons tests were conducted there. In contrast, the yield of the more than 60 tests of large thermonuclear weapons conducted in the Pacific Proving Grounds2 in the Marshall Islands totaled more than 108 Mt. An accident occurred in 1954 during Castle Bravo, the largest test at the Pacific site, and Whitcomb used this as an example to explain the possible effects of large-yield devices. The 1  For more information, see https://www.atomicheritage.org/location/nevada-test-site (ac­ cessed December 10, 2018). 2  For more information, see https://www.cdc.gov/niosh/ocas/ppg.html (accessed Decem­ ber 10, 2018). PREPUBLICATION COPY—Uncorrected Proofs

52 EXPLORING PREPAREDNESS FOR A NUCLEAR INCIDENT fallout extended approximately 200 miles, with snowlike coral falling from the sky and exposing people on a Japanese fishing vessel and people on the Rongelap and Utirik Atolls to acute cutaneous radiation energy. Whitcomb explained that snow would have been an unusual phenomenon for a Pacific Island nation, so naturally children went outside and played in it. Those who were exposed experienced severe radiation burns between their toes, fingers, the crevices of their armpits, and around their necklines, and it was 1–2 days before islanders were evacuated. Whitcomb said that the fallout from higher yield tests is greater because radioactive particles are blasted higher into the atmosphere, where the winds are faster and move in different directions. This has implications for regional planning, namely that the impact could extend beyond the region where a blast occurs. In the event of a state-sponsored nuclear attack on the United States, the U.S. Department of Defense’s (DoD’s) focus would be on national defense, not defense support for civil authorities. As a result DoD medical resources should not be expected to be available for domestic response. Building Resiliency Whitcomb stressed the need to reconsider potential measures for building resiliency given that a thermonuclear detonation would likely divert DoD’s focus from civil support to national defense. To build resil­ iency, Whitcomb called for extensive communication networks nationally, regionally, and locally to encourage communities to recognize a state- sponsored nuclear event as a threat. He also noted that a nuclear event should activate Emergency Support Function #8 functions and encouraged leveraging lessons from recent disasters in preparedness and response plan­ ­ ning. Finally, he called for better coordination between the Office of the ­ ssistant Secretary for Preparedness and Response (ASPR), U.S. Depart­ A ­ ment of Health and Human Services (with its focus on medical systems), and CDC (with its focus on public health), emphasizing that the country’s preparedness relies on such partnerships. Individual resiliency plays a role too, Whitcomb argued. He recalled the self-preservation training that he completed in elementary school for tornadoes and hurricanes and said that, in his opinion, similar training for self-preservation in the event of a nuclear explosion should be part of the educational system. Educating the Public About What to Do in the Event of a Nuclear Incident During audience discussion, Ed McDonough, public information ­ fficer, o Maryland Emergency Management Agency, recalled the familiarity and call to action of a siren or television notification in the 1960s and 1970s. In his opinion, reeducating the public about what to do in the event of a nuclear PREPUBLICATION COPY—Uncorrected Proofs

PLANNING ASSUMPTIONS OF NUCLEAR PREPAREDNESS 53 emergency will require a massive effort across several agencies, includ­ ing many stakeholders outside of traditional public health and emergency management. “We can’t just have people hear a siren and go run out in the streets,” he warned. Whitcomb agreed, but remarked that these issues are being addressed at the national level. He mentioned Emergency Sup­ port Function #153,4 and a radiation/nuclear communications workgroup in Federal Radiological Preparedness Coordinating Committee, through which federal agencies have coordinated and tested messaging, he said. However, Whitcomb said the federal government’s primary focus has been for an improvised nuclear device (IND) scenario, and he suspected that the messages themselves and the source of messaging will both need to be updated. The source of the messaging is very important for compliance or self-preservation, he emphasized. Dallas explained that his fear is that media would spread dueling narratives, and as a result, the response community would need to be very aggressive in dealing with false information follow­ ing an event. Phil Maytubby, director, public health protection, Oklahoma City- County Public Health Department, commented on the often competing messages and situational instructions from different federal entities. For example, during the Oklahoma City bombing, law enforcement officers nearly exchanged gunfire due to mixed messages received from federal leadership. He was curious whether the federal government has a nuclear incident communications protocol and information dissemination strategy already in place in anticipation of a nuclear incident. Whitcomb replied that a strategy “is still a work in progress” but noted that efforts are ongoing (this and other communications topics are addressed in Chapter 5). Small Weapons Remain a Threat: The Importance of Preparedness at the Local Level During audience discussion, Cooper recognized that the focus in nuclear preparedness is shifting back toward a possible thermonuclear event ­ but cautioned that a smaller weapon may still be a perpetrator’s weapon of choice. He emphasized that preparedness should address both large and small weapons, especially because local jurisdictions are likely to play a larger role in a small device response. 3  The radiological-specific annex to Emergency Support Function #15 (ESF#15) can be found here: https://www.fema.gov/media-library-data/1524598859382-128a5164750ee5540812a6e 832bf0c4c/AnnexN.pdf (accessed December 10, 2018). 4  ESF#15 is responsible for external affairs. https://emilms.fema.gov/is230c/fem0104160text. htm (accessed January 18, 2019). PREPUBLICATION COPY—Uncorrected Proofs

54 EXPLORING PREPAREDNESS FOR A NUCLEAR INCIDENT Ripple Effects of a Nuclear Detonation “A nuclear detonation anywhere is a nuclear detonation everywhere,” Whitcomb said. It would impact communities far from the blast site, he said, particularly if it occurred on American soil. Whitcomb also touched on concerns that would arise should a nuclear attack occur elsewhere, including repatriation. The traveler screening guide from the National Alli­ ance for Radiation Readiness, which Hawkins mentioned, and other activi­ ties similar to it would be put into action beyond their original purpose. CDC gained important experience, Whitcomb continued, through its recent year-long preparation for Operation Gotham Shield, a tabletop exercise of an IND scenario on the border between New Jersey and New York, coordinated by the Federal Emergency Management Agency as part of the national exercise program. He said that the exercise represented one of the main activities in CDC’s Training Exercise and Preparedness Program, and such activities allow CDC to better assist state and local preparedness efforts too. A STATE-LEVEL PERSPECTIVE: NORTH CAROLINA Other Potential Targets to Consider in Addition to Metropolitan Areas: Military Bases Describing state-level preparedness, Young argued that typical discus­ sions of a nuclear weapon attack and preparedness for such an attack f ­ocus on metropolitan areas. In North Carolina, this includes Charlotte and Raleigh. Charlotte is a hub of business in the state as home to Wells Fargo, Bank of America, and Duke Energy. Raleigh is the state capital, home to North Carolina State University, and close to the University of North Carolina at Chapel Hill and Duke University. However, Young noted, when considering a potential state actor attack in North Carolina, other potential targets could include the state’s three military bases: Fort Bragg, which is the largest Army base in the United States; Camp Lejeune, a Marine Corps base on the coast and the only operational Marine Corps base in North Carolina (i.e., with actual war fighters, not just training and education commands); and Seymour Johnson Airforce Base. When considering the logistics of preparedness for a nuclear attack on one of these bases, an important difference between them and a metropoli­ tan area is that they are located in areas with small populations. Young counted 13–15 hospitals within 35 miles of Charlotte, compared to only 3 hospitals within 35 miles of Camp Lejeune. Not only are there fewer hospitals, but in the event of a nuclear attack, transportation would be a major challenge near the bases because of less developed roads and infra­ PREPUBLICATION COPY—Uncorrected Proofs

PLANNING ASSUMPTIONS OF NUCLEAR PREPAREDNESS 55 structure (e.g., a four-lane highway in Charlotte versus a two-lane road near the base). In addition, housing would be a challenge. As was learned with Hurricane Matthew, Young said that residents who live in affected areas are often reluctant to relocate, and even if they agree to do so, there are limited temporary housing options (e.g., hotels). Young predicted that it would be very difficult to temporarily house more than 1,000 people. There are also fewer first responders in rural areas, Young said. If a blast were to occur in Charlotte or Raleigh, it is likely that a battalion chief for either the city or county fire department would be able to take control. That may not be the case in one of the smaller counties in which there may be only two or three first responders who themselves may have been impacted by the blast. Mutual aid would be a vital resource for these counties, Young said. A Shift in Reliance on Federal Resources Young agreed with Whitcomb that in the event of a state-sponsored attack, it is not clear which federal agencies the state could rely on with DoD’s attention on national security concerns. He mentioned a Command Support Team that is part of the North Carolina National Guard and handles CBRN (chemical, biological, radiological, and nuclear) threats. Whereas a terrorist attack typically involves a single detonation, this may not be true in the case of a state actor. Similarly, when there is a problem at one of North Carolina’s nuclear power plants, Young’s office counts on the Federal Radiological Monitoring and Assessment Center to show up for support within 48 hours. He suspected that this may no longer be a valid assumption in the event of multiple detonations, and he ceded that decision- making responsibilities would become muddled in such a chaotic event. A Shift in Reliance on Mutual Aid North Carolina’s emergency management community has an active and effective mutual aid program, Young said. In the past 2 years, the state has sent teams to support Puerto Rico’s response to Hurricane ­ aria, helicopters M and swift water boats to Houston to help evacuate people during Hurricane Harvey, and an incident management team to Hawaii to support the response to the Kilauea Volcano eruption. In return, North Carolina received ample support during Hurricane Matthew. However, Young explained that respond­ ers question their own safety at response sites too, and their level of comfort following a terrorist attack versus a state actor attack may differ if there is uncertainty about the possibility of multiple detonations. In that case, Young said, mutual aid may not arrive as quickly. When asked by Dallas what North Carolina would “give up” to other jurisdictions if an attack occurred PREPUBLICATION COPY—Uncorrected Proofs

56 EXPLORING PREPAREDNESS FOR A NUCLEAR INCIDENT elsewhere—for example, in Atlanta or Washington, DC—Young clarified that a state’s primary responsibility is to take care of its own citizens, so that determination would be made first. After that, “everything is on the table,” he said. He referred to the Emergency Management Assistance Compact’s (EMAC’s) standardized process for identifying a threat and determining mutual aid and noted that all 50 states belong to EMAC. North Carolina’s All-Hazards Approach Young said that North Carolina uses an all-hazards approach to pre­ paredness; the North Carolina Emergency Operations Plan covers most threats, with annexes covering certain individual threats, including hur­ ricanes, winter storms, pandemic flu, and various types of agricultural disasters. The state does not have an annex for a nuclear detonation, he said. In the event of a nuclear attack, the state would rely on its all-­ hazards plan, supplemented by the North Carolina Radiological Emergency R ­ esponse Plan. Young mentioned certain counties or cities where there are select radiologically trained state personnel, such as Charlotte, but those personnel are not distributed broadly or evenly across the state. Young echoed McClendon’s and Williams’s calls for a directive from the federal government—or, Young added, from senior elected leaders in the state, law enforcement, or the intelligence communities—that a nuclear incident is more likely to occur than previously believed. REGIONAL RESPONSE: OPPORTUNITIES AND CHALLENGES Building on Yeskey’s description of ASPR’s Regional Disaster Health Response System, Dallas asked the panelists how the regional planning process would be useful and what obstacles to its implementation exist. Young opined that with a larger weapon, a regional response would essen­ tially become mandatory. Although North Carolina may have the capacity to respond to a smaller weapon, if, for example, Charlotte were destroyed or incapacitated, he said, ”there is no way the state is going to handle that alone.” State leaders recognize this, he said. He explained that, through its hurricane evacuation efforts, the state has built a good working relationship with neighboring states such as South Carolina, Tennessee, and Virginia, so state leaders understand the concept of a regional partnership and have a framework on which they can build. However, he said, the details of plan­ ning a nuclear incident response are daunting. Whitcomb referred to the summary of a National Academies work­ shop, Nationwide Response After an Improvised Nuclear Device Attack: Medical and Public Health Considerations for Neighboring Jurisdictions: Workshop Summary (IOM, 2014), in which several key issues relevant to PREPUBLICATION COPY—Uncorrected Proofs

PLANNING ASSUMPTIONS OF NUCLEAR PREPAREDNESS 57 a regional response were identified. While the proceedings are more than 5 years old, he offered that these concerns remain relevant. They included • competition for federal and regional resources; • loss or absence of jobs, income, schools, health care, and other basic components of daily life; • increased mental health problems, including fear and other acute stresses from this type of overwhelming event; • overwhelmed local medical and public health systems; • increased concern about public safety (e.g., looting, increased crime); • radiation concerns; • sanitation problems (e.g., no sanitary pickup, wastewater treatment systems no longer functioning); • sheltering needs; • special needs of vulnerable populations; and • suspension and curtailment of routine state and local government, public health, and safety functions. Logistical Challenges: Moving Materials, Transporting Patients, and Accessing the Strategic National Stockpile Andrew Scott, senior radiological/nuclear health adviser, Counter­ ing Weapons of Mass Destruction Office, U.S. Department of Homeland S ­ ecurity, voiced concern about the logistical problems of moving materials into and around an impacted site and simultaneously moving patients out of an impact zone to receive treatment at a regional or national health care facility. These problems would be especially challenging in the event of a state agent nuclear detonation, in which case all of the U.S. military’s heavy airlift assets would be deployed elsewhere. Dallas commented on U.S. aeromedical evacuation capability, in particular the C-130 transport plane. In his opinion, it is an underused transport capability in nuclear incident planning given that ground transportation would be very limited and that helicopter availability would likely be limited as well. He imagined bull­ dozers removing debris to create makeshift runways for the planes to land. Veenema mentioned the Strategic National Stockpile (SNS) and expressed skepticism that the stockpile would be accessible within 12 hours of an event. She said access would depend on the scope of the event—including the possibility of multiple blast sites—and the location. ROLE OF THE PRIVATE SECTOR IN PREPAREDNESS PLANNING Dallas mentioned several countermeasures held in the SNS that are used to address acute radiation: sodium alginate (for strontium-90), PREPUBLICATION COPY—Uncorrected Proofs

58 EXPLORING PREPAREDNESS FOR A NUCLEAR INCIDENT d ­ iethylenetriamine pentaacetate (pentetic acid) (for plutonium), and insolu­ ble Prussian blue (commonly referred to by its brand name, Radiogarse) (for ­ cesium-137). Dallas was unaware of a single Food and Drug ­ dministration– A licensed facility that can produce any of the radio-protective agents in the stockpile. In his opinion, engaging the private sector would be an enor­ mous resource for medical countermeasure production and other response c ­ apabilities, and he commended private sector involvement in other recent disasters. Whitcomb replied that the private sector already plays a role in procurement of SNS material, although it is true that there are no pharma­ ceutical companies involved with the stockpiled radiation-specific mate­ ials r as many of these were produced elsewhere. The good news, he said, is that he believed ASPR’s Biomedical Advanced Research and Development A ­ uthority (BARDA) has put significant investment in research and develop­ ment of new medical countermeasures, including for acute radiation syn­ drome, and diagnostic tools for acute radiation. However, during audience discussion, Paul Eder, senior medical diagnos­ tics analyst with Tunnell Consulting and a contractor with the diagnostics division of BARDA, clarified that the diagnostic tools are not yet procured for the SNS, although discussions are underway to consider that action. In addition, he clarified that the medical countermeasures mentioned by Dallas are for inhalation radiation. In a nuclear weapon attack, cutaneous radia­ tion injury would be the greater threat, and there are currently no medical countermeasures stockpiled for that. (Further discussion of medical counter­ measures can be found in Chapter 7.) Motivating the Private Sector Eder suggested that states could play a role in supporting diagnos­ tic testing through the private sector. He posed a scenario in which a large nuclear event leads to 100,000–200,000 individuals requiring testing for radia­ion absorption. In theory, states like North Carolina that have t large reference testing laboratories (e.g., Quest, LabCorp) could provide very rapid testing within 1–7 days of an event. He noted, however, that such a quick response would require labs to prioritize the radiation test­ ing and would require technicians to work around the clock during that p ­ eriod. Although the federal government could arrange contracts with these ­aboratories in advance of an event, until such logistics are worked out, l Eder wondered whether there were actions that states could take in the meantime to incentivize the private sector to assist in testing. While Young was unaware of any North Carolina state-level legal or contractual structure that would compel the private sector to respond, over the past several years, the state has been emphasizing partnerships with the business community, he said. Recently the state founded what it calls “the PREPUBLICATION COPY—Uncorrected Proofs

PLANNING ASSUMPTIONS OF NUCLEAR PREPAREDNESS 59 business EOC” (emergency operations center), whereby for every emer­ gency the state includes representatives from the relevant business sectors. For example, if a regular cell tower is damaged or destroyed, the state can request that AT&T or Verizon provide a cell tower on wheels. The banks headquartered in North Carolina have become active as well, Young noted, for example, by providing ATMs on trailers so that members of the public can access cash. Based on these experiences, Young did not anticipate that engaging private laboratories would prove to be an issue. Dallas added that while engaging the companies may work, training the technicians and motivating them to participate would be a separate challenge. Rather than a just-in-time training, he imagined some sort of short-term training con­ ducted well in advance of an emergency event. William Blakely, senior staff scientist, Armed Forces Radiobiology Re­ search Institute, Uniformed Services University of the Health Sciences, commented on the World Health Organization (WHO) BioDoseNet,5 a network of about 65–70 biodosimetry laboratories worldwide dedicated to dose assessment by cytogenetics. Most of the labs are federally funded, and most participate in annual exercises to demonstrate performance compe­ tency. Blakely’s lab participates in these exercises every year. He suggested tapping into the network as a resource in the event of a national incident during which local resources are overwhelmed. In addition, he mentioned that there are more than 200 commercial laboratories in the United States with automated dicentric assay scoring systems, which are very helpful for high throughput analyses. He suggested an initiative to certify these labs to serve as a force multiplier in a response to a nuclear incident. Finally, Blakely also mentioned that WHO and the International Atomic Energy Agency are creating other international networks of a wider range of diag­ nostic labs (i.e., noncytogenetic) that could potentially be of use. FEAR OF RADIATION: IMPLICATIONS FOR PLANNING Workforce Incentives Dallas echoed Hawkins’s earlier concerns about the fear of radiation events and lack of willingness among medical care and public health per­ sonnel to respond in the event of a nuclear disaster. He wondered what guidance, moral appeals, or other incentives would encourage medical and public health personnel to show up to work at various response levels. CDC relies on monetary incentives, Whitcomb replied, and he mentioned the Division of State and Local Readiness within the Office of Public Health 5  For more information, see https://www.who.int/ionizing_radiation/a_e/biodosenet/en (ac­ cessed December 10, 2018). PREPUBLICATION COPY—Uncorrected Proofs

60 EXPLORING PREPAREDNESS FOR A NUCLEAR INCIDENT Preparedness and Response that issues the public health emergency pre­ paredness (PHEP) grants. Although many of the preparedness efforts that began after 9/11 were initially bioterrorismcentric, that focus has changed. Now many of the state and local jurisdictions receiving PHEP funding a ­ ddress radiation preparedness too. Whitcomb said that in addition to monetary incentives, there is a need to convince state and local preparedness and public health partners that the nuclear threat is a true risk. This applies even outside of major metropoli­ tan areas or other target areas, he argued, stressing the regional nature of such an event. Young said that the fear factor is difficult to assess in North Carolina because most of the people who have been trained to respond to a nuclear power plant incident are volunteer firefighters, whom he described as likely to be afraid of radiation. He suspected that this fear would drive the volunteer response. Young stressed the need to ensure that both vol­ unteers and professionals be certain that their families are being cared for so that they can concentrate on their jobs. He added that the challenge is not only convincing the workforce to show but also forcing nonqualified responders away. “Some folks are going to run to the fire no matter what their qualifications are,” he said. Ultimately, Young said, focusing on the potential to save lives during a response is critical to responders’ success. “Focus on the positives and the people you can help,” he said, “instead of zeroing in and getting tunnel vision on the people you can’t help or the things that you can’t fix.” Public Fear: Implications for Assumptions About a Perimeter Dallas elaborated on the fear of radiation and said that despite federal guidance for sheltering in place and public knowledge that buildings can provide significant protection from fallout, people have a natural tendency to flee. “Radiation is just different,” he said. He recalled the “stunning” fear of birth defects in Chernobyl. Approximately 30,000 of the 90,000 women who were pregnant while exposed to the contamination terminated their pregnancies, citing a fear of birth defects. Yet, according to Dallas, a follow-up of the other 60,000 full-term pregnancies showed no birth defects; even after this discovery, agitation about possible birth defects persisted. He suggested setting up a perimeter around a blast site to quell fear. Young replied that in nuclear power plant planning, the assumption is that a perimeter will be set up around the plume and contaminated area and that individuals entering and exiting the perimeter will be tracked. However, he admitted that implementing such a strategy would be diffi­ cult. “I’m not sure it’s going to be feasible, to be perfectly honest,” he said. Dallas suggested that the National Guard may play a role in maintaining perimeters when the fear factor is so significant. PREPUBLICATION COPY—Uncorrected Proofs

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Exploring Medical and Public Health Preparedness for a Nuclear Incident: Proceedings of a Workshop Get This Book
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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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