The Panel IV objective was to explore challenges, opportunities, and implications for building capability to respond to and recover from a nuclear incident, including building capacity for monitoring and long-term health surveillance among survivors. The panel, moderated by John Benitez, medical director of emergency preparedness, Tennessee Department of Health, included six panelists from across academia, government, and response organizations.
Amesh Adalja, senior scholar, Center for Health Security, Johns Hopkins Bloomberg School of Public Health, described a previously published “thought experiment” that described a potential solution to testing millions of survivors following a nuclear incident for acute radiation sickness (ARS): the formation of a public–private partnership with two major national laboratory chains—Quest and LabCorp—to test and identify individuals at risk for ARS (Adalja et al., 2011). Following a nuclear detonation, Adalja explained, millions of people would likely be exposed to radiation, with the potential for hematopoietic patients—those who could be treated with antibiotics—to be saved following rapid and accurate identification. However, several challenges could emerge, including the sheer number of individuals who would need to be tested and population dispersal. Adalja and colleagues considered which factors to assess to understand who would be at risk for ARS; time to vomiting, a common side effect in the immediate period after exposure, was deemed to be too variable, and other high-tech solutions were not scalable. These included chromosomal
dicentrics, which Adalja said is the gold standard but also acknowledged that it would be difficult to implement due to the need for specially trained personnel to conduct testing and the inability to scale it up.
Ultimately, Adalja said, he and his colleagues settled on absolute lymphocyte count (ALC) as the most reasonable solution to mass test for ARS. ALC, he said, is a common result on every complete blood count (CBC) test, and it records the amount of a specific type of white blood cells. The result is predictable and time dependent and decreases with radiation; thus, Adalja said, if practitioners record the time of the blast and time of exposure, extrapolation of the radiation dose is feasible. Moreover, the CBC test is automated and is a common task at laboratories and hospitals across the country, meaning the CBC test for ALC is a potentially scalable solution. Keeping in mind the likely reality that local medical infrastructure would be destroyed by a nuclear incident, Adalja said that he and colleagues approached the two major national laboratory chains about the feasibility of their role in this scenario. He explained that the companies would be a good fit for this role due to their national reach and their transportation and logistical capabilities. Based on feedback from the companies, Adalja believes that conducting 1 million CBC tests in 24 hours would be feasible. A potential benefit to partnering with the laboratories, he said, is the fact that many Americans already have active Quest or LabCorp accounts through routine medical care. Adalja said he hopes that with the reemergence of nuclear threats, this solution could prove useful in potential planning.
Steve Adams, deputy director of the Division of Strategic National Stockpile (DSNS), Center for Preparedness and Response, Centers for Disease Control and Prevention (CDC), provided background on the Strategic National Stockpile (SNS) program and described formulas in the stockpile that would be distributed and dispensed in the event of a nuclear incident. He explained that the SNS has existed since 1999, and while it remained under the purview of CDC during the workshop, it moved under control of the Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services, on October 1, 2018. The SNS maintains a portfolio of approximately $7 billion worth of medical materiel held in a series of strategically arranged repositories across the country to ensure proximity to populations and efficient transport. On the business side, Adams said, the SNS works with third-party vendors in the private sector to maintain business logistics and material oversight. For example, FedEx and UPS both play a role in the rapid transportation
of supplies across the country. On the supply chain side, Adams said that in recent years the SNS has collaborated more with private-sector partners to amplify and complement the capacities that the SNS controls directly, either supporting materiel held in SNS warehouses or through contracts that guarantee the SNS access to vendor-managed inventory. Adams said that this day-to-day control over products provides insight on the supply chain and allows for better marriage between supply and demand.
Next, Adams reviewed products held in the SNS that would be relevant during a potential nuclear incident. First, he listed products held for radiation injuries:
- Cytokines, including Neupogen, Neulasta, and Leukine
- Nausea medications, including ondansetron
- Pain medications, including morphine and Oxycodone
- Antibiotics, including levofloxacin and amoxicillin
- Antivirals, including acyclovir
- Antifungals, including voriconazole
Adams also discussed SNS countermeasures used for burn and blast injuries, including electrolyte replacement (saline), wound care products, laceration repair kits, topical ointments, eye care kits, and burn care kits. However, Adams noted that the SNS and the Biomedical Advanced Research and Development Authority (BARDA) are working to revisit the formulary and potentially add new burn care items to the stockpile.
Lastly, Adams addressed distribution and dispensing of SNS products at the state and local levels. All states have response plans that include an SNS annex, as well as pre-identified receipt, stage, and store sites where SNS products would be received via commercial transport and distributed down to local jurisdictions. Ultimately, Adams said that jurisdictions are responsible for transport once they receive products from the SNS, but in a nuclear incident in particular, transport and distribution would be a major concern. Accessing the impacted areas would likely be difficult, and distribution strategies specifically for nuclear scenarios will need to be developed to ensure success, he said.
Mary Casey-Lockyer, senior associate, Disaster Health Services, American Red Cross (ARC), stressed that a nuclear incident would be a catastrophic event that would require additional support beyond medical professionals. “We can’t do this alone,” she said. Willingness of health care professionals to respond, as well as the portability of health care licensure across jurisdictional borders, could prove to be major issues dur-
ing a response, Casey-Lockyer said. Tied to this, she said, is the leveraging of nonprofit resources across borders; while the Emergency Management Assistance Compact allows states to share assets, it does not apply to nonprofit or nongovernmental organizations—for example, members of the Medical Reserve Corps (MRC) or professionals who serve on a volunteer basis with ARC—which are critical assets during major public health emergency responses.
Casey-Lockyer described her optimal state of readiness for a nuclear incident. She described a need for more CBRN (chemical, biological, radiological, and nuclear)-specific training (including individual- and family-level preparedness), ensuring that all health care professionals in the United States have a basic understanding of radiation physics and protection from radiation exposure/contamination; she said this type of education could go a long way in preventing fear among responders and suggested that it could be included in medical school, nursing school, and other formal health care education curricula (for staff in all 17 Centers for Medicare & Medicaid Services–covered entities). In order to maximize volunteers’ impact during a nuclear incident, Casey-Lockyer said that volunteers should pre-affiliate themselves with a recognized disaster relief operation such as that of ARC.
Casey-Lockyer grappled with potential incentives for volunteers to respond to a nuclear incident, including financial incentives to health care systems for allowing providers to volunteer, as well as incentives for the volunteers themselves. Regarding surge, she discussed the possible use of a global health workforce to complement the 2.9 million nurses in the United States. Lastly, Casey-Lockyer said that above-ground radiation areas would be a major challenge for volunteer organizations, especially when incorporating volunteers from outside the event area. Shelters would need to be set up not only for survivors, she said, but also for the volunteer workforce itself. Additionally, organizations would be challenged to reconsider their responsibilities in areas such as decontamination, long-term care for orphans, and other unique issues.
In the field of public health emergency response for nuclear incidents, the Comprehensive Emergency Management Program (CEMP) of the U.S. Department of Veterans Affairs (VA) could serve as a potential model for other hospital systems, said Mary Pat Couig, program manager, Office of Nursing Services, VA. Describing VA’s health mission and responsibilities, Couig said that 6 million veterans used health care services at VA in fiscal year 2016, and there are 25,000 physicians and 98,000 nurses in the VA system. She noted that its public health emergency response responsibili-
ties emerged out of Public Law 97-174 (1982), which founded the VA–U.S. Department of Defense contingency hospital system. In 1987, VA worked with the Federal Emergency Management Agency (FEMA) and other agencies to found the National Disaster Medical System, and in 2006 VA was included in the Pandemic and All-Hazards Preparedness Act (PAHPA), allowing VA to provide assistance to nonveterans. VA’s Office of Emergency Management is the focal point for coordination of these activities, Couig said, and the office’s vision is to create a resilient and prepared health care system in an all-hazards environment. Its work includes both field programs and response programs working with other government agencies in responses to recent disasters such as Hurricane Maria in Puerto Rico.
Couig said that CEMP offers several education and training programs, including the Veterans Health Administration First Receivers Decontamination Program; it is required at all 141 VA facilities with emergency departments or urgent care clinics. The training curriculum is designed to teach receivers the protocol for handing patients who arrive at the emergency department with radiation exposure, according to Occupational Safety and Health Administration regulatory requirements. She noted that the training includes a practical exercise component as a capstone, and there is a work-group that regularly reviews and updates course materials. Importantly, she noted, the course is required every 3 years in order to maintain continuing education units, an incentive for course participation.
Couig discussed challenges to VA’s emergency preparedness. She said the aging health professional workforce—more than two-thirds of VA nurses are over the age of 45—could prove to be problematic because advanced age could limit some individuals’ capability to respond to a nuclear incident. Additionally, in the context of high workforce turnover, there is a constant need for continual training, especially among new employees. Couig also reiterated the importance of all-hazards training, especially in a 21st-century threats environment.
Couig ended her presentation by describing opportunities to leverage VA as a preparedness and response resource. She said that many VA medical centers have core teams for all-hazards preparedness, providing continuity during disasters. Additionally, MRC, Citizen Corps, and the National Guard/Reserves could provide training opportunities for responders. Couig closed with a call to action: the implementation of public health emergency preparedness training in schools down to the elementary level. She said that elementary students already conduct drills for active shooter events and other emergencies, so resiliency could be an easy concept to incorporate more broadly. In secondary schools, she said, public health preparedness concepts—including individual- and community-level preparedness and resiliency—could be incorporated into mandatory health classes.
James J. James, executive director, Society for Disaster Medicine and Public Health, and editor-in-chief, Disaster Medicine and Public Health Preparedness, began his remarks by commenting on the diversity of participants in the room; as a veteran in the field of nuclear preparedness, he said, it was refreshing to see new stakeholders advancing the cause at this workshop. He subsequently noted that in emergency preparedness at large, responders too frequently take on the mentality of “the blind leading the blind,” with distinct groups participating in a response without good communication, coordination, and leadership (he emphasized the 2010 earthquake in Haiti as a prime example of this problem). He also noted that planners are often blind to the realities and accurate predictions of all-hazards threats, making planning all the more difficult but still necessary.
James subsequently described the devastation of the atomic bomb dropped on Hiroshima in 1945, noting that of the 350,000 people who lived there, more than 30 percent died. More than 90 percent of the physician and nursing workforce in the area was wiped out, and medical infrastructure—including all hospitals—was destroyed. Expanding on the Hiroshima example, James admitted that medical systems in the United States and elsewhere likely do not have the capacity to care for all the casualties in the short term following an event, but he emphasized that they do have the ability to decrease the potential number of casualties before a nuclear incident occurs through the evolution of a more prepared citizenry. A prepared citizenry is an informed citizenry, he said, and this requires better public education about the potential threat.
James referred to an example discussed by Robert Whitcomb earlier in the workshop, the Castle Bravo nuclear test and its subsequent effect on the Lucky Dragon 5 fishing boat. He said that among the 23 crew members who suffered from ARS, only 1 died as a result of injuries from this event; “radiation sickness is not a death warrant,” he said. Long term, James said, they lived average lifespans, and the fear of genetic injuries and cancer as a result of radiation exposure remains overblown to this day. In popular culture, the Lucky Dragon 5 event was incorporated into the legend of Godzilla, which only served to promote more antinuclear sentiment and fear around radiation in Japan and elsewhere. Helping the public better understand the true risks of radiation exposure will help the population stay safer after a nuclear event. James closed by announcing that he is currently planning to organize a working group on the topic of creating a more informed citizenry to further advance this cause.
Luis Garcia, chief, CBRN Support Branch, Response Directorate, Office of Response and Recovery, FEMA, described the Nuclear Radiological Incident Annex (NRIA), which is housed in FEMA and provides guidance for federal planning efforts around nuclear and radiological incidents (including improvised nuclear devices, radiological dispersal devices, radiation exposure devices, nuclear facilities, found radioactive materials, transportation incidents, foreign incidents, etc.). It serves as an operational annex to the Response and Recovery Federal Interagency Operations Plans, he said. Garcia presented a list of questions that are addressed in NRIA:
- How will various incident management roles be integrated and coordinated?
- How will interagency partners access the incident area or crime scene?
- What protocols, equipment, and expertise are needed to monitor responders’ accumulated radiation dose data?
- How can we improve pre-incident preparedness at the federal level?
- How will large-scale radioactive waste be managed?
- What is the policy for reimbursing host states that provide sheltering and support services?
- How will resource requests be de-conflicted?
Garcia then described executive decision points, which he called a series of time-phased decision points for executive leadership with guidance on decision criteria, responsible entities, and other information. The decision points ensure that leadership, over the course of a long-term response, can accurately address key topics such as public information, crisis standards of care, waste management, population relocation, and remediation, among other topics, he said. NRIA also allowed for the creation of an interagency Nuclear Radiological Incident Task Force (NRITF), Garcia said, which was stood up within FEMA’s National Response Coordination Center to allow subject-matter experts the opportunity to provide guidance and direction to senior leaders during national-level incident planning. Garcia explained that NRITF is an advisory body that does not replace any emergency support or recovery support functions; rather, he said, it provides recommendations on potential courses of action, guiding the prioritization of certain activities. It does not, however, have an operational or oversight capacity. Ultimately, NRITF members are asked to provide insight to meet mission requirements, known as critical information requirements (CIRs). CIRs can include incident characterization and protective actions. Garcia closed by describing the Radiological Operations Support Specialist training program, which
bridges science and emergency management. As an emergency management agency, FEMA understands the importance of connecting complex scientific knowledge with an understanding of incident command structures and other logistical concerns, he said.
Validity of the Assumptions When Building Response Capability
Following the panel presentations, Benitez thanked the speakers and offered his own reactions. He said that in regard to response timing, many of our assumptions may not be valid during a chaotic and devastating nuclear incident; local capabilities will likely be completely destroyed near the impact site. Additionally, in regard to medical countermeasures, he said that third-party distributors may be in competition with one another to access disaster areas. Adams added that it is entirely possible that the demands asked of private distributors during an event would go beyond what they are reasonably able to support, a potential challenge in the distribution of important supplies and medications. He said that this makes pre-event planning all the more important, and the SNS, along with partners such as BARDA and the Healthcare Industry Distributors Association, are working to identify preferred areas for delivery and treatment.
Involvement of Private Laboratories
Benitez asked how distribution issues could affect Adalja’s suggestion for mass testing. Adalja suggested that satellite laboratories could play a role as the national chains already have a footprint in many small towns and the companies employ many phlebotomists who would be able to participate in a mass CBC test drive.
Strategic National Stockpile
William Blakely of the Armed Forces Radiobiology Research Institute asked Adams about the use of diagnostic tools and devices in the SNS, including blood cell counts, needles, tubes for bioassay fecal collection, nasal swabs, and other products. Adams said that, as a general policy decision, the SNS largely does not focus on diagnostic products, largely because of the scarce resource environment in the commercial market. Blakely noted previous work he had done recommending more of those products be included in the stockpile, and he urged Adams to consider seeking out the recommended list.
Shelters and Displaced Populations
Casey-Lockyer remarked that there is a disconnect between sheltering and the medical resources being discussed, such as SNS materiel and testing centers; she said that individuals in shelters will need access to those resources, not only people in the hospital system. On a similar note, James expressed concern over the potential number of displaced persons as a result of a nuclear event; many families may even choose to leave their homes out of fear of proximity to an event. Garcia agreed that population displacement and relocation would be an issue during response and recovery, especially in relation to decontamination. Dan Hanfling, contributing scholar, Center for Health Security, Johns Hopkins Bloomberg School of Public Health, cited family separation at the U.S. border as an example of possible challenges that could occur with transportation of people, population management, and population connectivity.
Crisis Standards of Care: Questioning Whether It Is Actionable
James Jeng called out crisis standards of care as a recurring topic of discussion but asserted that it is not yet actionable due to a lack of situational awareness that would drive the concepts from theory into practice. Hanfling agreed that crisis standards of care is not a fully actionable concept yet, but it is worth further exploration by the National Academies and other bodies to identify barriers to implementation and possible methods to overcome them. John Dreyzehner, commissioner, Tennessee Department of Health, also agreed that crisis standards of care is a topic that requires further discussion; separately, he also urged others to consider crisis standards of privacy during a mass medical emergency, citing the Las Vegas shooting as a frustrating example of a time when privacy laws prevented practitioners from relaying important information to victims’ family members.