Foodborne Terrorism Tabletop Exercise

1. Foodborne Terrorism Tabletop Exercise October 21, 2005 Intro by Ryan Mason, beginning at 9:00Intro by Ryan Mason, beginning at 9:00

2. Schedule 8:00 � 8:30 Mingling over Breakfast 8:30 � 9:00 Introduction 9:00 � 11:15 Exercise, Phase 1 11:15 � 12:30 Lunch 12:30 � 1:15 Guest Presentation 1:15 � 2:15 Exercise, Phase 2 2:15 � 3:00 Media Segment 3:00 � 4:00 Debriefing Breaks will occur both in the morning and afternoon at a time to be decided by the moderator. Discuss Bathroom Location. After discussing this slide, turn things over to John SanfordDiscuss Bathroom Location. After discussing this slide, turn things over to John Sanford

3. Acknowledgements Sponsored by the TN Food Safety Taskforce Funding from The University of South Carolina Center for Public Health Preparedness Developed by TN Department of Health in conjunction with TN Dept. of Agriculture, Metro Public Health Department of Nashville/Davidson Co., and Center for Public Health Preparedness, University of South Carolina

4. Special Thank You to the Planning Committee Tim Jones Ryan Mason Karen Patton Brady John Sanford Jerry Rowland Jane Richter Erik Svendsen John Dunn

5. Schedule 8:00 � 8:30 Mingling over Breakfast 8:30 � 9:00 Introduction 9:00 � 11:15 Exercise, Phase 1 11:15 � 12:30 Lunch 12:30 � 1:15 Guest Presentation 1:15 � 2:15 Exercise, Phase 2 2:15 � 3:00 Media Segment 3:00 � 4:00 Debriefing Breaks will occur both in the morning and afternoon at a time to be decided by the moderator. Discuss Bathroom Location. After discussing this slide, turn things over to John SanfordDiscuss Bathroom Location. After discussing this slide, turn things over to John Sanford

6. Purpose This tabletop exercise will enable participants to demonstrate and evaluate the response capabilities, communication, resources, data, coordination, and organizational elements involved in a food security emergency response.

7. Purpose Participants will have an opportunity to assess their own preparedness for responding to such a scenario and identify individual needs for information and/or training.

8. Tabletop Exercise? Informal group discussion stimulated by a scripted disaster scenario Low stress, designed to promote free and open exchange of ideas Identify issues (e.g., data, coordination, communication, resources, and policy) Familiarize players with roles, functions, plans, and procedures

9. Objectives of the Exercise Identify the policy issues that would arise during a food-related terrorism event Identify and understand measures that can be performed at the local level Recognize the roles of various public officials Illustrate the need for intense teamwork and communication

10. Objectives of the Exercise Identify gaps in local preparedness plans, policies and/or procedures Build relationships with participants from other key agencies Identify additional training needs in your organization/agency

11. House Rules This is an exercise only. Please preface and end all phone calls pertaining to this exercise which extend outside of this facility with the statement �this is an exercise�. What happens in this room stays in this room with the exception of the lessons we learn and the relationships we develop. Please be sensitive to the noise level. Above all, courtesy and professionalism prevail. Name tags are required at all times. There will be no actual news media involved in this exercise.

12. Various Roles Moderator � Dr. Allen Craig Participants � You Facilitators � Planning Committee Members Evaluator � Dr. Erik Svendsen

13. Participants� Roles Play your own role in your agency (if possible) Identify gaps and strengths of response plans Take note of perceived deficiencies to be discussed during The Debriefing

14. Instructions to Remember Respond as a group as the information emerges Maintain your agency�s role throughout the exercise Not all will participate equally Lack of active participants does not mean lack of learning

15. Components of Exercise Phase 1 The Setting The Scenario Unfolds Various Agency Roles/Responses After discussing this slide, turn things over to Karen BradyAfter discussing this slide, turn things over to Karen Brady

16. Components of Exercise Phase 2 The Contamination Event Guest Presentation Media Segment Debriefing

17. THE SETTING (Metropolitan Davidson County)

18. The Setting Nashville / Davidson County, Tennessee 596,000 residents 946,000 people who commute to Nashville from neighboring counties

19. The Setting Approximately 30 medical centers, including 10 hospitals and specialty centers located throughout the county Numerous nursing homes and day care centers

20. The Setting Public water supply Public Health Department of Nashville/Davidson Co. is a local health department with approximately 500 employees/ State Health Dept.

21. The Setting Tourism and agriculture are major industries

22. Day 1 � Friday Afternoon Isn�t it always?

23. Phone Call Mary, school nurse from Dan Mills Elementary School (Metro-Davidson Co.) calls the Metro Health Department concerned that 4 children, (ages 6-9), have reported to her clinic, ill, with vomiting and diarrhea, 1 of which is bloody diarrhea.

24. Parents have been called, and are on their way to pick up their children.

25. Same Day Health Department advises obtaining stool samples, which were collected and submitted to Vanderbilt ER (4 Total). Results are pending.

26. VARIOUS AGENCY ROLES/RESPONSES For this next section, have the class raise hands with answers.For this next section, have the class raise hands with answers.

27. Question ? Which agencies do you think need to concern themselves with this information?

28. Question ? What would be their response?

29. THE SCENARIO UNFOLDS

30. Day 4�Monday 11:00 am School nurses from Bellevue Middle and Crieve Hall Elementary report to Metro Health Dept. that 7 and 4 children, respectively, are exhibiting symptoms of vomiting and diarrhea with 3 children also experiencing bloody diarrhea.

31. Same Day The ages of the children ranged from 6-13. Several of the sick children apparently have not been in contact with any of the other children who exhibited similar symptoms. No Link has been established between the groups of ill children.

32. VARIOUS AGENCY ROLES/RESPONSES For this next section, have the class raise hands with answers.For this next section, have the class raise hands with answers.

33. Question ? Which agencies need to concern themselves with this information?

34. Question ? What would be their response?

35. THE SCENARIO UNFOLDS

36. Day 6�Wednesday 10:00 am Private practice physicians are reporting an unusual number of sick children (symptoms of nausea and vomiting) to the Metro Health Department. Concerned parents, hearing rumors of food poisoning are also calling schools and the Department of Education in an attempt to get more information.

37. VARIOUS AGENCY ROLES/RESPONSES For this next section, have the class raise hands with answers.For this next section, have the class raise hands with answers.

38. Question ? Which agencies should be involved?

39. Question ? What needs to be done (and by whom) ?

40. Communication Who needs to be communicating with whom (and why) ?

41. THE SCENARIO UNFOLDS

42. Metro Health Dept. started interviews at 3 schools. Approximately 20% of students had some gastrointestinal symptoms.

43. Ongoing Epidemiological Investigation Reveals� No adult family members are presenting these symptoms. Most of the sick children ate at school cafeterias, but some brought lunch and only bought milk or juice at the cafeteria.

44. Metro environmental health specialists (health inspectors) report cafeteria inspection scores are 94 and 98 for Bellevue Middle and Crieve Hall Elementary Schools (no critical or serious violations were observed).

45. One inspector even remarked that Bellevue Middle Cafeteria was the cleanest one he had ever seen.

46. Approximately 40% of hospitalized children return to the hospital with similar symptoms after being discharged. None of these children have returned to school.

47. 48 Students have been seen in area ER�s. 2% of people who reported symptoms are teachers.

48. VARIOUS AGENCY ROLES/RESPONSES Refer to Handout # 1: Event Recap. For this next section, have the class raise hands with answers.For this next section, have the class raise hands with answers.

49. Question ? Who is in charge of the situation?

50. Question ? What would your agency�s role be now?

51. Question ? With whom would your agency be communicating?

52. THE SCENARIO UNFOLDS

53. Day 6�Wednesday 2:30 PM(Same Day) All stool cultures from ill people are negative. TN State Dept. of Education reports that absenteeism is up 18% in eleven counties in Middle TN.

54. Day 7�Thursday, throughout day Epi-X (surveillance tracking software) reveals to state epidemiologists that Huntsville, AL; Rome, GA, Hopkinsville and Louisville, KY and their surrounding areas are all reporting similar activity. After discussing this slide ask them to turn to handout # 2. Spend 5 minutes answering questionsAfter discussing this slide ask them to turn to handout # 2. Spend 5 minutes answering questions

55. VARIOUS AGENCY ROLES/RESPONSES Handout # 2 For this next section, have the class raise hands with answers.For this next section, have the class raise hands with answers.

56. Question ? Would your agency be impacted, if so, how?

57. Question ? What are your initial actions?

58. Question ? Within your own agency, with whom would you communicate first? Why? Others and why?

59. Question ? Due to the negative stool culture results and interstate involvement, which aspects of the investigation would change?

60. Question ? Who is in charge of the situation? Why?

61. Question ? What is your agency�s involvement at this point? After this slide, turn things over to John DunnAfter this slide, turn things over to John Dunn

62. THE SCENARIO UNFOLDS

63. Day 8�Friday 9:00 AM Media picks up story about possible strain of stomach flu raging through the community and nearby areas of AL, KY, and GA.

64. VARIOUS AGENCY ROLES/RESPONSES For this next section, have the class raise hands with answers.For this next section, have the class raise hands with answers.

65. Question Would your agency be talking to the media about this issue?

66. Question Who would be responding?

67. Question Outside your agency, with whom would you communicate first? Why? Others and why? After this slide, pass out Additional Information Packet A (Day 10 through slide before �The contamination Event�.After this slide, pass out Additional Information Packet A (Day 10 through slide before �The contamination Event�.

68. THE SCENARIO UNFOLDS

69. Day 11�MondayEpi. Investigation Reveals� Another cluster of cases with similar symptoms was uncovered through an investigation of local hospital records. Several employees of Sunrise Dairy have been out of work sick for nearly 2 weeks, many have been hospitalized, and some keep returning to the hospital.

70. Same Day Vanderbilt Children�s Hospital notifies the Metro Nashville Health Department that two of the sick children from Crieve Hall Elementary School have died.

71. Epidemiological Investigation Reveals� Metro Health Dept. implicates milk as being associated with the �unknown� sickness (odds ratio of 8.3). After discussing this slide have them spend 5 minutes working on Handout # 3.After discussing this slide have them spend 5 minutes working on Handout # 3.

72. VARIOUS AGENCY ROLES/RESPONSES Handout # 3 For this next section, have the class raise hands with answers.For this next section, have the class raise hands with answers.

73. Question ? What are your agency�s urgent priorities now?

74. Question ? Within your agency, with whom would you communicate first? Why? Others and why?

75. Question ? With whom would you be communicating outside your agency? Why?

76. Question ? Which aspects of the investigation/situation have changed?

77. Question ? Who is in charge of the situation? Why?

78. Question ? What are your resources?

79. THE CONTAMINATION EVENT

80. Day 18 �Monday 4:00 pm Letter received at WSMV, a local news station, from a terrorist claiming responsibility for contamination of milk with a radioactive material.

81. Effects on your agency? Media onslaught ! Personal concerns and fears ! Community reaction ! Magnitude of public inquiry ! Financial implications !

82. Radiation Exposure 1. Emergency Department Management of Radiation Casualties This training program was prepared by the Radiological Emergency Medical Preparedness & Management Subcommittee of the Homeland Security Committee of the Health Physics Society.* Every emergency department should have a medical radiation emergency plan that will allow effective and efficient handling of potentially contaminated radiation accident victims. When such a plan exists and is tested through periodic drills, it minimizes the potential for apprehension and panic should activation of the plan ever be needed. Talking points are provided with each slide to assist the presenter in answering questions. It is not expected that all the information in the talking points must be presented during the training. ? Health Physics Society Version 2.5 Disclaimer: The information contained herein was current as of October 5, 2004, and is intended for educational purposes only. The authors and the Health Physics Society (HPS) do not assume any responsibility for the accuracy of the information presented herein. The authors and the HPS are not liable for any legal claims or damages that arise from acts or omissions that occur based on its use. *The Health Physics Society is a non profit scientific professional organization whose mission is to promote the practice of radiation safety. Since its formation in 1956, the Society has grown to approximately 6,000 scientists, physicians, engineers, lawyers, and other professionals representing academia, industry, government, national laboratories, the department of defense, and other organizations. Society activities include encouraging research in radiation science, developing standards, and disseminating radiation safety information. Society members are involved in understanding, evaluating, and controlling the potential risks from radiation relative to the benefits. Official position statements are prepared and adopted in accordance with standard policies and procedures of the Society. The Society may be contacted at: 1313 Dolley Madison Blvd., Suite 402, McLean, VA 22101; phone: 703-790-1745; FAX: 703-790-2672; email: HPS@BurkInc.com. 1. Emergency Department Management of Radiation Casualties This training program was prepared by the Radiological Emergency Medical Preparedness & Management Subcommittee of the Homeland Security Committee of the Health Physics Society.* Every emergency department should have a medical radiation emergency plan that will allow effective and efficient handling of potentially contaminated radiation accident victims. When such a plan exists and is tested through periodic drills, it minimizes the potential for apprehension and panic should activation of the plan ever be needed. Talking points are provided with each slide to assist the presenter in answering questions. It is not expected that all the information in the talking points must be presented during the training. ? Health Physics Society Version 2.5 Disclaimer: The information contained herein was current as of October 5, 2004, and is intended for educational purposes only. The authors and the Health Physics Society (HPS) do not assume any responsibility for the accuracy of the information presented herein. The authors and the HPS are not liable for any legal claims or damages that arise from acts or omissions that occur based on its use. *The Health Physics Society is a non profit scientific professional organization whose mission is to promote the practice of radiation safety. Since its formation in 1956, the Society has grown to approximately 6,000 scientists, physicians, engineers, lawyers, and other professionals representing academia, industry, government, national laboratories, the department of defense, and other organizations. Society activities include encouraging research in radiation science, developing standards, and disseminating radiation safety information. Society members are involved in understanding, evaluating, and controlling the potential risks from radiation relative to the benefits. Official position statements are prepared and adopted in accordance with standard policies and procedures of the Society. The Society may be contacted at: 1313 Dolley Madison Blvd., Suite 402, McLean, VA 22101; phone: 703-790-1745; FAX: 703-790-2672; email: HPS@BurkInc.com.

83. Radioactive Sources 157,000 licensed users in U.S. 2,000,000 devices containing radioactive sources Approximately 400 sources lost or stolen in U.S. every year

86. Goi�nia Morbidity 249 exposed; 54 hospitalized Eight with radiation sickness Four people died 112,000 people monitored (>10% of total population)

87. What Is Radiation?

88. Radiation is NOT contagious!

89. Electromagnetic Spectrum

90. Ionizing Radiation 4. Ionizing Radiation Alpha particles, beta particles, gamma rays and x-rays are types of ionizing radiation. When they interact with other atoms, they have enough energy to cause ionization of these atoms. Patients with radioactive material on them or inside their bodies are said to be contaminated. Contaminated patients require care in handling to effectively remove and control the contamination. Patients who have only been exposed to the radiation from a radioactive source or a machine, such as an x-ray machine or a linear accelerator, are not contaminated and do not pose any radiation contamination or exposure potential for hospital personnel. Radiation safety precautions are not needed for patients who have only been exposed and are not contaminated. 4. Ionizing Radiation Alpha particles, beta particles, gamma rays and x-rays are types of ionizing radiation. When they interact with other atoms, they have enough energy to cause ionization of these atoms. Patients with radioactive material on them or inside their bodies are said to be contaminated. Contaminated patients require care in handling to effectively remove and control the contamination. Patients who have only been exposed to the radiation from a radioactive source or a machine, such as an x-ray machine or a linear accelerator, are not contaminated and do not pose any radiation contamination or exposure potential for hospital personnel. Radiation safety precautions are not needed for patients who have only been exposed and are not contaminated.

91. Types of Ionizing Radiation 5. Types of Ionizing Radiation Alpha particles. Alpha particles are ejected (thrown out of) the nuclei of some very heavy radioactive atoms (atomic number > 83). An alpha particle is composed of two neutrons and two protons. Alpha particles do not penetrate the dead layer of skin and can be stopped by a thin layer of paper or clothing. If an alpha emitting radioactive material gets inside the body through inhalation, ingestion, or through a wound, the emitted alpha particles can cause ionization that results in damage to tissue. It is less likely that a patient would be contaminated with an alpha emitter. Beta particles. A beta particle is an electron ejected from the nucleus of a radioactive atom. Depending on its energy, beta radiation can travel from inches to many feet in air and is only moderately penetrating in other materials. Some beta radiation can penetrate human skin to the layer where new skin cells are produced. If high enough quantities of beta emitting contaminants are allowed to remain on the skin for a prolonged period of time, they may cause skin injury. Beta emitting contaminants may be harmful if deposited internally. Protective clothing (e.g., universal precautions) typically provides sufficient protection against most external beta radiation. Gamma rays and x-rays (photons). Gamma rays and x-rays are able to travel many feet in air and many inches in human tissue. They readily penetrate most materials and are sometimes called �penetrating� radiation. Thick layers of dense materials are needed to shield against gamma radiation. Protective clothing provides little shielding from gamma and x radiation, but will prevent contamination of the skin with the gamma emitting radioactive material. Gamma and x radiation frequently accompanies the emission of beta and alpha radiation. 5. Types of Ionizing Radiation Alpha particles. Alpha particles are ejected (thrown out of) the nuclei of some very heavy radioactive atoms (atomic number > 83). An alpha particle is composed of two neutrons and two protons. Alpha particles do not penetrate the dead layer of skin and can be stopped by a thin layer of paper or clothing. If an alpha emitting radioactive material gets inside the body through inhalation, ingestion, or through a wound, the emitted alpha particles can cause ionization that results in damage to tissue. It is less likely that a patient would be contaminated with an alpha emitter. Beta particles. A beta particle is an electron ejected from the nucleus of a radioactive atom. Depending on its energy, beta radiation can travel from inches to many feet in air and is only moderately penetrating in other materials. Some beta radiation can penetrate human skin to the layer where new skin cells are produced. If high enough quantities of beta emitting contaminants are allowed to remain on the skin for a prolonged period of time, they may cause skin injury. Beta emitting contaminants may be harmful if deposited internally. Protective clothing (e.g., universal precautions) typically provides sufficient protection against most external beta radiation. Gamma rays and x-rays (photons). Gamma rays and x-rays are able to travel many feet in air and many inches in human tissue. They readily penetrate most materials and are sometimes called �penetrating� radiation. Thick layers of dense materials are needed to shield against gamma radiation. Protective clothing provides little shielding from gamma and x radiation, but will prevent contamination of the skin with the gamma emitting radioactive material. Gamma and x radiation frequently accompanies the emission of beta and alpha radiation.

92. Radiation Doses and Limits Flight from Los Angeles to London 5 mrem Annual public dose limit 100 mrem Annual natural background 300 mrem Fetal dose limit 500 mrem Barium enema 870 mrem Annual radiation worker dose limit 5,000 mrem Heart catheterization (skin dose) 45,000 mrem Life saving actions guidance (NCRP-116) 50,000 mrem Mild acute radiation syndrome 200,000 mrem LD50/60 for humans (bone marrow dose) 350,000 mrem Radiation therapy (localized & fractionated) 6,000,000 mrem 7. Radiation Doses and Dose Limits Radioactive material has always been a natural part of the earth. It has existed for millions of years in the crust of the earth, in building materials, in the food we eat, the air we breathe, and in nearly everything that surrounds us. Radiation from these materials, as well as cosmic radiation from the sun and universe, makes up the natural background radiation to which we are constantly exposed. On the average, persons are exposed to about 300 millirem per year from natural sources (NCRP Report No. 101). The guidance from NCRP Report No. 116, Limitation of Exposure to Ionizing Radiation, states that for life saving or equivalent purposes, workers may approach or exceed 50,000 mrem to a large portion of the body. Emergency exposures are considered once-in-a-lifetime. This is below the threshold for the acute radiation syndrome, discussed later. If an individual is exposed to more than 100 rem at one time, predictable signs and symptoms will develop within a few hours, days, or weeks depending on the magnitude of the dose. About half of all people exposed to a single dose of 350 rem will die within 60 days (LD50/60) without medical intervention. The large doses used in medicine for radiation therapy, while higher than this dose, are given to only part of the body and are typically given over a period of weeks. Heart catheterization is a skin dose; barium enema is an effective dose. (NRPB Report R-200, 1986) The dose limits are highlighted in orange. 7. Radiation Doses and Dose Limits Radioactive material has always been a natural part of the earth. It has existed for millions of years in the crust of the earth, in building materials, in the food we eat, the air we breathe, and in nearly everything that surrounds us. Radiation from these materials, as well as cosmic radiation from the sun and universe, makes up the natural background radiation to which we are constantly exposed. On the average, persons are exposed to about 300 millirem per year from natural sources (NCRP Report No. 101). The guidance from NCRP Report No. 116, Limitation of Exposure to Ionizing Radiation, states that for life saving or equivalent purposes, workers may approach or exceed 50,000 mrem to a large portion of the body. Emergency exposures are considered once-in-a-lifetime. This is below the threshold for the acute radiation syndrome, discussed later. If an individual is exposed to more than 100 rem at one time, predictable signs and symptoms will develop within a few hours, days, or weeks depending on the magnitude of the dose. About half of all people exposed to a single dose of 350 rem will die within 60 days (LD50/60) without medical intervention. The large doses used in medicine for radiation therapy, while higher than this dose, are given to only part of the body and are typically given over a period of weeks. Heart catheterization is a skin dose; barium enema is an effective dose. (NRPB Report R-200, 1986) The dose limits are highlighted in orange.

93. Examples of Radioactive Materials 10. Examples of Radioactive Materials Radioactive materials emit ionizing radiation. They are used in medical diagnosis (nuclear medicine), medical therapy (cancer treatment), industry (food irradiation), and for research. Many radioactive materials, including radioactive waste, are commercially shipped in special containers. A radionuclide is chemically identical to and behaves in the body the same way as the non-radioactive form of the element. For example, radioactive iodine (e.g. I-131) is concentrated in the thyroid in the same way as non-radioactive iodine (i.e. I-127). Quantities of radioactive material (i.e. activity) range from trivial amounts in typical laboratories, to much larger quantities, such as in nuclear reactors. Half-lives can range from seconds to millions of years. The nuclides that are in orange are those that are considered to be potential nuclides that could be present in a radiological dispersal device.10. Examples of Radioactive Materials Radioactive materials emit ionizing radiation. They are used in medical diagnosis (nuclear medicine), medical therapy (cancer treatment), industry (food irradiation), and for research. Many radioactive materials, including radioactive waste, are commercially shipped in special containers. A radionuclide is chemically identical to and behaves in the body the same way as the non-radioactive form of the element. For example, radioactive iodine (e.g. I-131) is concentrated in the thyroid in the same way as non-radioactive iodine (i.e. I-127). Quantities of radioactive material (i.e. activity) range from trivial amounts in typical laboratories, to much larger quantities, such as in nuclear reactors. Half-lives can range from seconds to millions of years. The nuclides that are in orange are those that are considered to be potential nuclides that could be present in a radiological dispersal device.

94. Causes of Radiation Exposure/Contamination Accidents Nuclear reactor Medical radiation therapy Industrial irradiator Lost/stolen radioactive sources Transportation Terrorist Event Radiological dispersal device (dirty bomb) Attack on or sabotage of a nuclear facility Low yield nuclear weapon 12. Causes of Radiation Exposure and Contamination Accidents - There are several settings or scenarios in which radiation accidents may occur: nuclear reactor accidents; medical radiation therapy accidents or errors in treatment dose; accidental overexposures from industrial irradiators; lost, stolen or misused medical or industrial radioactive sources; and accidents during the transportation of radioactive material. Terrorist Use of Nuclear Materials - The use of radioactive materials in an RDD or a nuclear weapon by a terrorist is a remote but plausible threat. The medical consequences depend on the type of device used in a terrorist event. An attack on or sabotage of a nuclear facility, such as an irradiation facility or a nuclear power plant, could result in the release of very large amounts of radioactive material. Radiological Dispersal Device (RDD) - A RDD disperses radioactive material for the purpose of terrorism. A RDD that uses a conventional explosive (e.g., TNT or a plastic explosive) to disperse the radioactive material is called a �dirty bomb�. A dirty bomb is NOT an atomic bomb. The initial explosion may kill or injure those closest to the bomb, while the radioactive material remains to expose and contaminate survivors and emergency responders. Low Yield Nuclear Weapon - A low yield nuclear weapon or partial failure of a high yield weapon could cause a low yield nuclear detonation. For example, if one considers the consequences of a 0.1 kiloton yield nuclear detonation (less than 1/100 the size of the weapon used on Hiroshima), then the following would occur within one minute surrounding ground zero. The effects listed below do not take into account that multiple injuries caused by the interaction of the various types of injury will increase the probability of fatality. (NCRP Report No. 138) - The range for 50% mortality from trauma from the blast is approximately 150 yards. - The range for 50% mortality from thermal burns is approximately 220 yards. - The range for 400 rad from gamma and neutron radiation would be approximately 1/3 mile. - The range for 400 rad in the first hour from radioactive fallout would be almost 2 miles in the downwind direction. - As the size of the weapon increases, the effects encompass a greater distance. This will result in the release of widespread contamination and substantial air blast and heat. 12. Causes of Radiation Exposure and Contamination Accidents - There are several settings or scenarios in which radiation accidents may occur: nuclear reactor accidents; medical radiation therapy accidents or errors in treatment dose; accidental overexposures from industrial irradiators; lost, stolen or misused medical or industrial radioactive sources; and accidents during the transportation of radioactive material. Terrorist Use of Nuclear Materials - The use of radioactive materials in an RDD or a nuclear weapon by a terrorist is a remote but plausible threat. The medical consequences depend on the type of device used in a terrorist event. An attack on or sabotage of a nuclear facility, such as an irradiation facility or a nuclear power plant, could result in the release of very large amounts of radioactive material. Radiological Dispersal Device (RDD) - A RDD disperses radioactive material for the purpose of terrorism. A RDD that uses a conventional explosive (e.g., TNT or a plastic explosive) to disperse the radioactive material is called a �dirty bomb�. A dirty bomb is NOT an atomic bomb. The initial explosion may kill or injure those closest to the bomb, while the radioactive material remains to expose and contaminate survivors and emergency responders. Low Yield Nuclear Weapon - A low yield nuclear weapon or partial failure of a high yield weapon could cause a low yield nuclear detonation. For example, if one considers the consequences of a 0.1 kiloton yield nuclear detonation (less than 1/100 the size of the weapon used on Hiroshima), then the following would occur within one minute surrounding ground zero. The effects listed below do not take into account that multiple injuries caused by the interaction of the various types of injury will increase the probability of fatality. (NCRP Report No. 138) - The range for 50% mortality from trauma from the blast is approximately 150 yards. - The range for 50% mortality from thermal burns is approximately 220 yards. - The range for 400 rad from gamma and neutron radiation would be approximately 1/3 mile. - The range for 400 rad in the first hour from radioactive fallout would be almost 2 miles in the downwind direction. - As the size of the weapon increases, the effects encompass a greater distance. This will result in the release of widespread contamination and substantial air blast and heat.

95. Time: Distance: Shielding:

96. Protective Action Guides Sheltering Evacuation Relocation Decontamination Worker PPE

97. Common Shelters

98. Protective Actions If you are inside, shelter in place Stay indoors Turn off ventilation systems Close and lock windows and doors If you are outside, Cover your nose and mouth with a cloth Leave the area and go inside

99. Protective Actions If you think you may be contaminated, Remove outer layer of clothing and seal it in a plastic bag Shower or wash your hands and face Listen for further instructions Seek medical attention only for severe injuries

101. Basic Mechanism DNA is the primary target for biological effects

102. Health Effects of Radiation Exposure Lethal at high doses Mutagenic Carcinogenic Other biological effects, especially at high doses

104. Patient Management - Triage Triage based on: Injuries Signs and symptoms - nausea, vomiting, fatigue, diarrhea History - Where were you when the bomb exploded? Contamination survey 23. Patient Management - Triage Resuscitation and stabilization are the primary objectives. Decontamination efforts should be secondary to patient stabilization. Severity and time of onset of nausea, vomiting, diarrhea and fatigue are noted and treated in routine clinical manner. Patient history will assist in the triage process to predict the potential extent of radiation injury. Contamination surveys are secondary to patient stabilization. 23. Patient Management - Triage Resuscitation and stabilization are the primary objectives. Decontamination efforts should be secondary to patient stabilization. Severity and time of onset of nausea, vomiting, diarrhea and fatigue are noted and treated in routine clinical manner. Patient history will assist in the triage process to predict the potential extent of radiation injury. Contamination surveys are secondary to patient stabilization.

105. Treatment for Unknown Radionuclide Unless treatment is instituted quickly, its effectiveness will be limited. Use of emetics, lavage, charcoal, and/or laxatives are common.

106. 27. Treatment of Internal Contamination Deposition of radioactive materials in the body (i.e., internal contamination), is a time-dependent, physiological phenomenon related to both the physical and chemical natures of the contaminant. The rate of radionuclide incorporation into organs can be quite rapid. Thus, time can be critical and treatment (decorporation) urgent. Several methods of preventing incorporation (e.g., catharsis, gastric lavage) might be applicable and can be prescribed by a physician. Some of the medications or preparations used in decorporation might not be available locally and should be stocked. NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides, addresses the strategies to limit the exposure from internal contamination by radioactive materials. Radiation Protection Dosimetry published a Guidebook for the Treatment of Accidental Internal Radionuclide Contamination of Workers (1992) that provides additional information on patient management. In January 2003, the Food and Drug Administration (FDA) determined that Prussian blue had been shown to be safe and effective in treating people exposed to radioactive elements such as Cesium-137. In August 2004, the FDA determined that two drugs, pentetate calcium trisodium injection (Ca-DTPA) and pentetate zinc trisodium injection (Zn-DTPA), are safe and effective for treating internal contamination with plutonium, americium, or curium. The drugs increase the rate of elimination of these radioactive materials from the body.27. Treatment of Internal Contamination Deposition of radioactive materials in the body (i.e., internal contamination), is a time-dependent, physiological phenomenon related to both the physical and chemical natures of the contaminant. The rate of radionuclide incorporation into organs can be quite rapid. Thus, time can be critical and treatment (decorporation) urgent. Several methods of preventing incorporation (e.g., catharsis, gastric lavage) might be applicable and can be prescribed by a physician. Some of the medications or preparations used in decorporation might not be available locally and should be stocked. NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides, addresses the strategies to limit the exposure from internal contamination by radioactive materials. Radiation Protection Dosimetry published a Guidebook for the Treatment of Accidental Internal Radionuclide Contamination of Workers (1992) that provides additional information on patient management. In January 2003, the Food and Drug Administration (FDA) determined that Prussian blue had been shown to be safe and effective in treating people exposed to radioactive elements such as Cesium-137. In August 2004, the FDA determined that two drugs, pentetate calcium trisodium injection (Ca-DTPA) and pentetate zinc trisodium injection (Zn-DTPA), are safe and effective for treating internal contamination with plutonium, americium, or curium. The drugs increase the rate of elimination of these radioactive materials from the body.

107. Surface Contamination�Injury First irrigate wounds, then follow the same clothing removal and washing routine. After decontamination, continue to treat wounds in the usual manner.

108. Key Points Medical stabilization is the highest priority Train/drill to ensure competence and confidence Pre-plan to ensure adequate supplies and survey instruments are available Universal precautions and decontaminating patients minimizes exposure and contamination risk Early symptoms and their intensity are an indication of the severity of the radiation injury The first 24 hours are the worst; then you will likely have many additional resources 40. Key Points Emphasize that medical stabilization of the patients is the highest priority. Patients will not succumb immediately from radiation injury. Radiation exposure and contamination are not immediately life threatening nor are contamination levels or exposure levels of significant hazard to personnel. Training and drills are the best preparation to ensure competence and confidence by the the ED and other staff identified in the Emergency Plan. Pre-plan to ensure that adequate supplies and survey instruments are available. Identify non-ED staff that can assist. Staff from Nuclear Medicine, Radiation Oncology and Radiation Safety have expertise in radiation protection practices and the use of survey meters. The staff can protect themselves from radioactive contamination by using universal precautions while treating these patients. Treating these patients is not an immediate hazard to ED staff health and the long term risks from the radiation exposure are small. Early symptoms and their intensity in patients are an indication of the severity of the radiation injury. The first 24 hours are the worst. Then you will likely have many additional resources from state and federal agencies. 40. Key Points Emphasize that medical stabilization of the patients is the highest priority. Patients will not succumb immediately from radiation injury. Radiation exposure and contamination are not immediately life threatening nor are contamination levels or exposure levels of significant hazard to personnel. Training and drills are the best preparation to ensure competence and confidence by the the ED and other staff identified in the Emergency Plan. Pre-plan to ensure that adequate supplies and survey instruments are available. Identify non-ED staff that can assist. Staff from Nuclear Medicine, Radiation Oncology and Radiation Safety have expertise in radiation protection practices and the use of survey meters. The staff can protect themselves from radioactive contamination by using universal precautions while treating these patients. Treating these patients is not an immediate hazard to ED staff health and the long term risks from the radiation exposure are small. Early symptoms and their intensity in patients are an indication of the severity of the radiation injury. The first 24 hours are the worst. Then you will likely have many additional resources from state and federal agencies.

109. All Emergencies Are Local

110. Local Government Responsibilities Local Chief Executive Officer (i.e., mayor, city or county manager) Coordinates local resources Suspends local laws or ordinances Communicates with the public

111. State and Local Public Health Response Monitor workers� health and safety Assure safe shelters and healthy food and water supplies Coordinate sampling and laboratory analysis of samples

112. State and Local Public Health Response Field investigations and monitoring of people Criteria for entry and operations at the incident site Disease control and prevention measures

113. Medical Support Evaluate health and medical impacts on the public and emergency personnel Develop medical intervention recommendations Treat impacted citizens Request Strategic National Stockpile (formerly National Pharmaceutical Stockpile)

115. Facility Recovery Remove waste from the treatment area Survey facility for contamination Decontaminate as necessary Normal cleaning routines (mop, strip waxed floors) typically very effective Periodically reassess contamination levels Replace furniture, floor tiles, etc. that cannot be adequately decontaminated Goal: Less than twice normal background� higher levels may be acceptable 29. Facility Recovery If you have in-house radiation safety staff, they will supervise decontamination efforts. Environmental Services staff should remove waste from the Emergency Department and triage area and take it to a holding place until it can be surveyed for radioactive material before disposal. A radiation survey of the facility will identify any areas that need decontamination. Normal cleaning routines are typically very effective. If there is residual contamination after normal cleaning, items such as furniture and floor tiles can be replaced. The decontamination goal is for the equipment and floors to be less than twice the normal background reading. Higher levels of fixed contamination should not deter the use of emergency facilities during periods of critical need. 29. Facility Recovery If you have in-house radiation safety staff, they will supervise decontamination efforts. Environmental Services staff should remove waste from the Emergency Department and triage area and take it to a holding place until it can be surveyed for radioactive material before disposal. A radiation survey of the facility will identify any areas that need decontamination. Normal cleaning routines are typically very effective. If there is residual contamination after normal cleaning, items such as furniture and floor tiles can be replaced. The decontamination goal is for the equipment and floors to be less than twice the normal background reading. Higher levels of fixed contamination should not deter the use of emergency facilities during periods of critical need.

116. Long-term Response Issues Application of EPA and FDA Protective Action Guides Food and water Non-food use of agricultural products Recovery operations Develop plans for decontamination, re-entry, and recovery of affected areas

117. Long-term Response Issues Surveillance and epidemiological studies Establish exposure registry and monitor long-term impacts Provide information to public and responders on long-term health effects

118. Day 18 �Monday 4:00 pm Letter received at WSMV, a local news station, from a terrorist claiming responsibility for contamination of milk with a radioactive material. This is where we last left offThis is where we last left off

119. VARIOUS AGENCY ROLES/RESPONSES Handout # 4 For this next section, have the class raise hands with answers.For this next section, have the class raise hands with answers.

120. Question ? How would this new information change the investigation/situation for your agency?

121. Question ? Who in your agency would be involved in the response?

122. Question ? Who is your agency�s primary point of contact?

123. Question ? With which other agencies would you be communicating? With whom exactly?

124. Question ? What are the three most urgent priorities for your agency at this point?

125. Question ? What resources does your agency have for the response? Where are they located? How will you access and mobilize them?

126. Question ? Who is in charge of the situation? Why? After this slide, turn things over to Andrea, for a media segment.After this slide, turn things over to Andrea, for a media segment.

127. MEDIA SEGMENT After Media Segment is over, turn things back over to Dr. CraigAfter Media Segment is over, turn things back over to Dr. Craig

128. THE SCENARIO UNFOLDS

129. Various agencies deployed to the Sunrise Dairy production facility to confirm presence and extent of residual radiation. Geiger counters measure radiation, identifies one milk-storage silo.

130. Investigation Reveals�. Law enforcement personnel trace source back to 2 suspects, get confessions, and learn through interrogation that 2 other suspects have died, likely due to exposure. Law enforcement personnel learn that 64 grams of Cesium-137 were placed in milk tanker by 4 terrorists.

131. THE DEBRIEFING

132. Debriefing Discuss the events of the exercise Identify gaps in plans, policies, and procedures Identify useful information (effective responses) Plan next steps Complete evaluation forms Ask them to please take a moment to fill out the evaluation form located in the back of their packet. Anonymous.Ask them to please take a moment to fill out the evaluation form located in the back of their packet. Anonymous.