Concept of Operations

The CONOPS of an Explosive RDD, non-Explosive RDD and RED have much in common. To avoid excess duplication and to emphasize the commonality, the CONOPS uses the following organization:

*Tasks are organized as in the ESF#8 Section of the National Response Framework.

*Non-boxed text is common to all scenarios.

CONOPS for Explosive RDDs is in the red framed box

CONOPS for non-explosive RDDs (NERDD) and Radiological Exposure Devices (RED) is in the blue framed box

As in the introduction, non-essential points are in the gray box

ESF #8 Missions: Initial Actions and Continuing Actions

Assessment of Public Health / Medical Needs

HHS, in collaboration with DHS, mobilizes and deploys ESF #8 personnel to support the ERT-A to assess public health and medical needs. This function includes the assessment of the public health care system/facility infrastructure.

Once the severity and scope of the Explosive RDD has been determined, HHS will deploy personnel including as appropriate from USPHS and, NDMS. In addition, civilian assets from the Medical Reserve Corps (MRC) may be requested to support the immediate and continuing staffing needs of providing health care to victims of the incident.

An RDD/IED will cause a surge in victims of blast injuries, burns and radiological exposure and/or contamination. HHS with the assistance of DOD, DOE (FRMAC), IMAAC, and local government will evaluate the size of blast, radiological dispersal, type of radionuclide(s), number of injuries and categories of injuries. HHS will evaluate the numbers and types of victims and along with the local/state/regional/tribal officials determine the effect on local and regional healthcare. HHS (Interagency A-Team) along with DOE (IMAAC and FRMAC),working with the Advisory Team (A-Team) will make recommendations to local and regional responders regarding radiation zones and advise on specific medical countermeasures. HHS will work with local/regional responders and healthcare systems to provide assets to help with surge capacity. The number of victims needing immediate medical intervention could be in the hundreds to a few thousand while the number needing some evaluation, appropriate assurance, and possible long-term epidemiological follow-up may be in the tens of thousands. Subsequently, HHS will determine the most appropriate public health and medical assets and their timing of deployment from among the USPHS Rapid Deployment Force, Commissioned Corps, NDMS assets and more. If appropriate, HHS will deliver countermeasures from the SNS.

A non-explosive RDD/Radiation Exposure Device NERDD/RED unlike an RDD/IED, which is identified by an explosion, may not be identified until epidemiological evidence is recognized as a covert radiological attack. Thus, a time Zero might never be known with certainty. As a result, the potential number of concerned persons could be exceedingly large and there may be a large requirement for triage and, in the long-term, epidemiological follow-up. Much of the triage will be done by medical history but some medical (blood, urine or tissue) analysis may be needed, likely requiring very specialized laboratories. The number of people requiring immediate medical intervention will likely be in the hundreds to few thousand. Public messaging and effective triage will mitigate potential surge of concerned citizens and allow for identification of injured persons at highest risk from radiological contamination or exposure. The potential build-up of victims from radiological exposure over time (as a result of non-detection) means that large numbers of actual victims requiring care, most likely for non-lethal exposures or contamination, will have to be addressed. In the same way as with an RDD, HHS will assist in the evaluation of potential victims, assess the magnitude of the ongoing incident and then send in appropriate federal resources to reduce surge and help deliver and/or resupply countermeasures.

Health Surveillance 

HHS, in coordination with State health agencies, enhances existing surveillance systems to monitor the health of the general population and special high-risk (sic [at-risk]) population, field studies and investigations, monitor injury and disease patterns and potential disease outbreaks, provide technical assistance and consultations on disease and injury prevention and precautions.

 

HHS will develop and institute a Population Monitoring Plan with CDC, NCI, USPHS or other designated experts. Identification and evaluation of victims of radiological exposure or contamination who may have long term risk of developing radiation-induced cancer, may require a long term monitoring program as an [recovery phase] extension of a victim registry, either through local and/or HHS experts. This is in addition to personnel to support the treatment of patients with obvious radiological injury. A key determinate for the volume of people needing assessment and possible long-term monitoring will be the dose cut off, likely above 50 or even 100 rem, but that remains to be determined at the incident.

 

 

The covert nature of an NERDD or RED means that surveillance of victims will require effective triage as to who needs medical intervention and who needs only follow-on monitoring. This might occur at multiple locations for a covert contamination (e.g. water supply). Those who are exposed to radiation or radiological contamination may require long term monitoring as with explosive RDD.

 

Medical Care Personnel

Immediate medical response capabilities are provided by assets internal to HHS (e.g., U.S. Public Health Service Commissioned Corps) and from ESF #8 supporting organizations (e.g., National Disaster Medical System (NDMS) [part of HHS], and Veteran Administration healthcare professionals). The Department of Defense (DOD) may be requested to provide support in casualty clearing/staging and other missions as needed. HHS may seek individual clinical health and medical care specialists from the Department of Veterans Affairs (VA) to assist State, local and tribal personnel.

 

Once HHS has evaluated the situation of an RDD/IED, the USPHS, NDMS, DMAT and FMS may be utilized accordingly for immediate, mid-term, and long term response/recovery. The nature of an RDD/IED requires immediate response capabilities that will be mostly provided by local response, aided by local federal assets. HHS will deploy Federal capabilities as appropriate to support the response. Potential uses, even for small events, would be to help with medical care for displaced individuals, assist in triage for potential exposure, assist with medical countermeasure administration and help establish a program for long-term follow-up. DOD has an even longer response time and may only be needed if the RDD incident is large enough that DOD response assets are still required on-scene after day five. Local DOD and VA medical centers will be requested to support surge of victims from an RDD/IED.

 

 

The NERDD/RED may not have an immediate indicator of radiological attack, although some scenarios (e.g. radiation in a ventilation system of a public building) may be obvious and have numerous seriously ill victims. HHS assets will be needed once the radiological incident is realized. Because of the potential for large numbers of concerned citizens following a covert attack, the requirement for immediate response assets may be much larger than for an RDD/IED. HHS will employ USPHS, NDMS, DMAT and FMS accordingly to best address the needs of the community during the response. Although HHS may not be able to support the early phase of the response, HHS can support the intermediate phase by providing surge capacity and potentially reducing surge numbers by strong public messaging regarding self-assessment for radiological injury or contamination. Key personnel might be those needed for epidemiological studies and local/regional education of concerned citizens, as opposed to those directly involved in medical care.

 

Health/Medical Equipment and Supplies

In addition to deploying assets from the Strategic National Stockpile (SNS), HHS may request DHS, DOD, or the VA to provide medical equipment and supplies, including medical, diagnostic, and radiation-emitting devices, pharmaceuticals, and biologic products in support of immediate medical response operations and for restocking health care facilities in an area affected by a major disaster or emergency.

 

A blast such as an RDD/IED will require medical supplies to treat burn, physical trauma, and radiation exposure and radiological contamination. These supplies are available through the Strategic National Stockpile via Supplier Managed Inventory (SMI), Vendor Managed Inventory (VMI) pre-positioned assets such as 12-hour push packs (including antibiotics and burn and trauma care supplies) and materiel stored at central SNS locations. The equipment and supplies will be for the blast as well as medical countermeasures for the radionuclide, if needed. Special diagnostic equipment may be needed for bioassay and biodosimetry and special transport of specimens to CDC or biodosimetry labs may be needed (likely by commercial shipper). Since many of the radionuclide specific treatments are FDA approved, they may already be forward deployed in the local/regional hospitals or storage places so that the SNS will assist in surge capacity and restocking. If needed, HHS may request support from the VA National Acquisition Center (via SNS), DOD and DOT for transport. As necessary, FMS and NDMS assets will be deployed to support healthcare in the region, and potentially displaced population. Additionally, the developing concept of a Virtual SNS would support surge requirements.

 

 

The Virtual SNS or User-Managed Inventory (UMI) UMI is a theoretical system under consideration where hospitals, distributors, manufacturers, etc., move equipment, supplies, and pharmaceuticals accordingly, to support the surge requirements of the response to any event or incident. The primary component of the Virtual SNS comprises hospitals and local, regional entities that stockpile additional amounts of equipment, supplies, and pharmaceuticals as a “bubble in their pipeline” above and beyond the daily requirements of the facility. Essentially, they create a miniature SNS within the facility and along with that of their partners in the region create a Virtual SNS.

 

 

The population affected by a NERDD or RED will likely require medical countermeasures to block radionuclides or, mitigate or treat the effects of radiation exposure/contamination. Like the RDD/IED, the SNS can support these requirements aided by VA, DOD, and DOT as needed. Additionally, the Virtual SNS can be used as needed. A NERDD incident may require both countermeasures for exposure to radiation and internal radiological contamination. Special diagnostic equipment may be needed for bio-assay and biodosimetry and special transport of specimens to CDC or biodosimetry labs may be needed (likely by commercial shipper). A RED incident will likely only require countermeasure for radiation exposure, because internal contamination would not occur.

 

Patient Evacuation [Medical]

In accordance with the NDMS four partner agreement, at the request of HHS, DOD coordinates with FEMA and DOT ( ESF #1) – Transportation to provide support for the evacuation of seriously ill or injured patients to locations where hospital care or outpatient services are available. DOD is responsible for regulating and tracking patients transported on DOD assets to appropriate treatment facilities (e.g., NDMS non-Federal hospitals).

 

A modest sized RDD/IED will likely be accommodated largely by local/regional facilities. If surge exceeds capacity for the local and regional response whether for patients generally or for specific types of patients, such as radiation victims or burn victims, HHS will support the patient transport to definitive care centers including the RITN (Radiation Injury Treatment Network). Additionally, transport of primary care patients, or low acuity patients to offload surge in the locale will be facilitated with the support of HHS, DOD, and DOT as needed. DOD will require victim decontamination prior to transportation.

 

 

A NERDD/RED will not likely be of sufficient size to require evacuation. Although the concerned population may cause an unmanageable surge, the local and regional governments can support evacuation as needed. HHS will support patient transport to definitive care as needed, as might be the case for radiation injury and/or radiation decorporation. The transport of primary care populations or low acuity or chronic populations will support reducing surge in the locale and region by releasing more assets and personnel to respond to the incident.

 

Patient Care

HHS may task its components and the Medical Reserve Corps [activated by SEC HHS], and request the Medical Reserve Corps [activated by SEC HHS], VA, DOD, and DHS to provide available personnel to support inpatient hospital care and outpatient services to victims who become seriously ill or injured regardless of location (which may include mass care shelters).

 

The RDFs and DMATs are HHS primary capabilities for timely response to an RDD/IED incident. These teams deliver strike medical care and triage capability. As the response to an RDD/IED progresses, additional HHS capabilities such as USPHS may be deployed as needed to support the response. FMS may be needed for large events to either offload lower acuity patients from local hospitals or to care for moderately ill victims. The Radiation Injury Treatment Network (RITN) will provide a surge capability for expert treatment of victims of radiation exposure or contamination. Special diagnostics may be needed for radiobioassay and biodosimetry as noted in Supplies Section.

 

 

Like an RDD/IED, RDF teams and DMATs provide a strike capability to manage the potential surge from concerned persons. As the magnitude of an NERDD/RED is determined, HHS will utilize the USPHS and NDMS assets accordingly to support patient surge and definitive care. FMS may be used to support care for low-acuity patients. Special diagnostics may be needed for radiobioassay and biodosimetry as noted in Supplies. The RITN will also be useful in the management and treatment of radiation victims.

 

Safety and Security of Human Drugs, Biologics, Medical Devices, and Veterinary Drugs, etc.

HHS may task its components to ensure the safety, efficacy, and advise industry on security measures of regulated human and veterinary drugs, biologics (including blood and vaccines), medical devices (including radiation emitting and screening devices), and other HHS regulated products.

As of July 2007, the decorporation and blocking agents are FDA approved. Drugs for acute radiation syndrome would require an Emergency Use Authorization (EUA).

 

This is the same as RDD/IED

Blood and Blood Products

HHS monitors blood availability and maintains contact with the American Association of Blood Banks Interorganizational Task Force on Domestic Disasters and Acts of Terrorism and, as necessary, its individual members, to determine:

• The need for blood, blood products, and the supplies used for their preparation, testing, and storage;
• The ability of existing supply chain resources to meet these needs; and
• Any emergency measures needed to augment or replenish existing supplies.

 

An RDD/IED will have blood requirements for trauma from the blast of an IED. These requirements will be met, if possible, by organizations in the Blood Bank community locally and regionally. Over time, other national entities may support blood requirements in the locale of the incident or as patients are transported to definitive care. In the dose range of an RDD, any marrow failure would likely take weeks to develop. The amount of blood and blood products (primarily platelets) required is dependent on the magnitude of the blast. For victims with potential ARS, it is critical that blood products be irradiated.

 

 

A NERDD/RED event has no requirements for blood or blood products except in the case of severe marrow injury. While radiation marrow injury takes weeks to fully develop, the time zero of a NERDD/RED may not be known so that victims may present with marrow failure. These requirements will be supported by the RITN (Radiation Injury Treatment Network) which will need HHS supported transport for the victims.

 

Food Safety and Security

HHS, in cooperation with ESF #11, may task its components to ensure the safety and security of federally regulated foods. (Note: HHS, through the Food and Drug Administration (FDA), has statutory authority for all domestic and imported food except meat, poultry, and egg products, which are under the authority of the USDA/Food Safety and Inspection Service.)

Radioactive contamination of food would be highly unlikely. Good public messaging will address the fact that the amount of radioactive materials in an RDD are unlikely to be a threat to a large water source such as a reservoir. However, the FDA, USDA and EPA should be aware of potential contamination and any regulatory messages that are necessary to protect the local/regional population.

NERDDs/REDs are of great concern for ensuring food and water safety even in the case of general (non-targeted) release of radioactive materials. NERDD incidents that specifically target food, milk or water sources could potentially paralyze a community or industry. Therefore, it is essential that upon determination of an NERDD, that HHS (FDA) aggressively seek identification of potential food, milk, or water source contamination with the assistance of EPA, USDA and the A-Team.

 

Agriculture Safety and Security

HHS, in coordination with ESF #11, may task its components to ensure the safety and security of food-producing animals, animal feed, and therapeutics. (Note: HHS, through the FDA, has statutory authority for animal feed and for the approval of animal drugs intended for both therapeutic and non-therapeutic use in food animals as well as companion animals.)

(See Food Safety and Security, above): It is unlikely any stock animal or animal food and water supply with be contaminated with an RDD/IED because the plume from an explosion is limited in size and strength, however, FDA, USDA, and EPA should assess suspected contamination. Coordination of recommendations and messaging is essential.

 

 

(See Food Safety and Security, above): Additionally, assessing the food and water supply for stock animals is important to prevent contamination of the food, milk, and water supply. FDA should work with USDA, and EPA to determine all aspects of food and water supplies are contamination free.

 

Worker Health/Safety

HHS may request the Department of Labor/Occupational Safety and Health Administration (DOL/OSHA) to implement the processes in the Worker Safety and Health Support Annex to provide technical assistance for worker safety and health. HHS may task its components and request support from DOL and other cooperating agencies, as needed, to assist in monitoring the health and well-being of emergency workers; performing field investigations and studies addressing worker health and safety issues; and providing technical assistance and consultation on worker health and safety measures and precautions.

 

DHS has released to the Federal Register, Interagency Protective Action Guidelines (PAGs). HHS/National Institute for Occupational Safety and Health (NIOSH) should work with EPA, OSHA, NRC, and DHS (which disseminates the information) to help the local community determine the PAGs they will use for workers with potential exposure to radiological contamination. If possible, these should be determined in advance and in the absence of such determination the PAGs in this Playbook should probably be used initially. Worker safety is a critical component of this event and the fear of radiation is what makes RDD a weapon of mass disruption. Additionally, HHS should work with the local/regional/state authorities to develop a process for monitoring radiation exposure and managing workers with exposure which may be a long-term program. State and local authorities may have different PAGs.

 

 

Once the NERDD/RED incident has been characterized NIOSH (HHS) should work with EPA, NRC, OSHA, FDA to determine potential exposure and PAGs for exposure to radioactive contamination. These determinations should be provided to DHS for dissemination. As needed, HHS will work with local/regional/state and tribal authorities to establish a monitoring system to assess potential radiation injuries in workers.

 

All-Hazard Public Health and Medical Consultation, Technical Assistance, and Support:

HHS may task its components to assist in assessing public health and medical effects resulting from all hazards. Such tasks may include assessing exposures on the general population and on high-risk (sic [at-risk]) population groups; conducting field investigations, including collection and analysis of relevant samples; providing advice on protective actions related to direct human and animal exposures, and on indirect exposure through contaminated food, drugs, water supply, and other media; and providing technical assistance and consultation on medical treatment, screening, and decontamination of injured or contaminated individuals. While State and local [Tribal] governments retain primary responsibility for victim screening and decontamination, ESF #8 can, at the request of a State or another Federal agency, deploy teams with limited capabilities for victim decontamination (e.g., NDMS, or DOE assistance for nuclear/radiological incidents). These teams typically arrive on scene within 24- 48 hours.

HHS will coordinate and provide guidance for decontamination of radiological contamination and decorporation. HHS has experts at NIH, NIOSH, CDC and ASPR and extensive, up-to-date information is on REMM. Diagnostic assessment of potential exposures to populations are supported by CDC (bioassay) AFRRI (DOD) and REAC/TS (DOE). At present, capacity for radiobioassay and biodosimetry is very limited. External monitoring and decontamination of possibly affected victims are accomplished locally and are the responsibility of State, local, and tribal governments. Federal resources are provided at the request of, and in support of, the affected State(s). HHS, through ESF #8 and in consultation with the coordinating agency, coordinates Federal support for external monitoring of people and decontamination. HHS assists and supports State, local, and tribal governments in performing monitoring for internal contamination and administering available pharmaceuticals for internal decontamination, as deemed necessary by State health officials. HHS assists local and State health departments in establishing a registry of potentially exposed individuals, perform dose reconstruction, and conduct long-term monitoring of this population for potential long-term health effects.

See RDD/IED. RED incidents will rarely have any contamination requirements.

 

Behavioral Health Care

HHS may task its components to assist in assessing mental health and substance abuse needs; providing disaster mental health training materials for workers; providing liaison with assessment, training, and program development activities undertaken by Federal, State, local, and tribal mental health and substance abuse officials; and providing additional consultation as needed.

 

RDD/IED incidents will likely generate a great deal of fear surrounding concerns of radiological injury or contamination. Additionally, the behavioral response to such a terrorist incident is unpredictable and will require mental health professionals to assist the population in coping with such an event. Substance Abuse and Mental Health Services Administration (SAMHSA) and the Administration for Children & Families (ACF) provide human services such as crisis counseling that support the behavioral response. The provision of accurate, understandable information to the affected populations is the most important behavioral health intervention. Providing consultation to primary care providers on strategies for managing fear in those who perceive themselves as being at risk is another valuable contribution. ACF provides crisis counseling only.

 

 

NERDD/RED incidents are similar to RDD/IED, however, NERDD/RED incidents can potentially generate huge large populations of concerned persons due to the covert nature of NERDD/RDD. As a result the demands for behavioral management may be much greater than for an RDD/IED. These are likely to be long-lasting needs that may be lessened by having excellent epidemiology studies.

 

Public Health and Medical Information

HHS may task its components to provide public health, disease, and injury prevention information that can be transmitted to members of the general public who are located in or near areas affected.

In all events, public health and medical information should be transmitted via DHS. This enables the Federal government to align all public messages and ensures no confusion is generated from external communication sources. PAGs, backgrounds, technical documents and instructional messages are currently available from ASPR, CDC for many incidents and on the internet and through REMM. While the public media will likely have its own expert opinions, referring them to REMM may help minimize conflicting messages

See RDD/IED above.

 

Vector Control

HHS may task its components and request assistance from other ESF #8 organizations, as appropriate, to assist in assessing the threat of vector-borne diseases; conducting field investigations, including the collection and laboratory analysis of relevant samples; providing vector control equipment and supplies; providing technical assistance and consultation on protective actions regarding vector-borne diseases; and providing technical assistance and consultation on medical treatment of victims of vector-borne diseases.

There are no vector concerns with an improvised explosive radiological dispersal device; however, radiological contamination is a concern and like vectors, requires certain actions to prevent the spread of radiological contamination. This is achieved by strong public messages that inform potential victims (including those with pets and service animals) about an RDD and how to avoid contamination, decontaminate themselves or seek decontamination. They can be informed about the symptoms and how to seek clinical assessment of potential contamination. HHS via CDC will seek assistance from DOE, DOD, the National Guard Bureau to aide in the detection, evaluation, and monitoring of victims of contamination. Although a National capability does not exist for extensive laboratory capabilities for determining internal radiological contamination, AFFRI, REAC/TS, and the CDC will be asked to support clinical laboratory diagnostics. International colleagues will likely be needed through mutual assistance and/or collegial agreements. The ASPR, CDC, AFFRI and others will provide subject matter advice on diagnosis, mitigation and treatment for internal radiological contamination.

NERDDs require assessments for potential radiological contamination. Persons requiring screening depends on where the radiological material is found and what it is. REDs do not involve a radiological contamination, however, this does not preclude an RED from accidentally releasing radiological material. The radiological contamination issues, assessment, and mitigation will be handled in the same way as an RDD/IED.

 

Potable Water/Wastewater and Solid Waste Disposal

HHS, in coordination with ESF #3 (Public Works and Engineering) and ESF #10 (Oil and Hazardous Materials Response) may task its components, and request assistance from other ESF #8 organizations as appropriate, to assist in assessing potable water, wastewater, solid waste disposal and other environmental health issues; conducting field investigations, including collection and laboratory analysis of relevant samples; providing water purification and wastewater/solid waste disposal equipment and supplies; and providing technical assistance and consultation on potable water and wastewater/solid waste disposal issues.

(See Food Security and Safety above). Potable water should be handled by the local/regional authorities. Additionally, waste management support will be provided by the EPA under ESF #10 for workers, health care facilities, and clean-up crews, etc.

(See Food Security and Safety above). If a major water source is contaminated, HHS may have to assist the local/regional/state/tribal authorities with potable water until the water supply can be deemed safe. Additionally, waste management will be directed by the EPA for workers, health care facilities, and clean-up crews, etc.

 

Victim Identification/Mortuary Services

HHS may request DHS and DOD to assist in providing victim identification and mortuary services; establishing temporary morgue facilities; performing victim identification by fingerprint, forensic dental, and/or forensic pathology/ anthropology methods; and processing, preparation, and disposition of remains.

HHS will deploy DMORTs and DPMUs as needed to identify and manage the dead. These HHS assets can be supported by DOD, and will be deployed in support of the jurisdictional Medical Examiner/Coroner. Forensic examination will likely be necessary. CDC has published guidance for handling contaminated remains.

It is unlikely that a NERDD or RED event will generate enough fatalities to require HHS assets for response; however, this will be determined by the scale of the event. HHS will provide guidance for handling contaminated remains. Victim identification and tracking are as for RDD/IED.

 

Protection of Animal Health

HHS, in coordination with ESF #11, protects the health of livestock and companion animals by ensuring the safety of the manufacture and distribution of foods and drugs given to animals used for human food production, as well as companion animals.

 

(See Agriculture Safety and Security above.) Pets and service animals within the contamination zone may require veterinary care per local/regional services.

 

 

(See Agriculture Safety and Security above.) Pets and service animals, as above.

 

Activation of Health/Medical Response Teams

Assets internal to HHS are deployed directly as part of the ESF #8 response. Public health and medical personnel and teams provided by ESF #8 organizations are requested by HHS and deployed by the respective organizations to provide appropriate public health and medical assistance.

 

The response to an RDD/IED will be supported as appropriate by the USPHS RDFs, and NDMS teams such as DMATs and DMORTs. In addition, HHS will request support from the VA MERRTs and National Guard CBRNE/WMD teams. Very specialized teams will be needed for educating victims about radiation injury and for conducting epidemiological studies. The latter will be coordinated by/with the NCI and CDC epidemiologists.

See RDD/IED

 

Communications

ESF #8 establishes communications necessary to coordinate Federal public health and medical assistance effectively.

The communications infrastructure will be intact. Messages as in Public Health and Medical Information.

Same as RDD.

 

Information Requests

Requests for information may be received at ESF #8 from various sources, such as the media and the general public, and are referred to ESF #15 for action and response.

 

Information Cell (ASPR) and ASPA will coordinate with CDC on information requests.

 

 

See RDD/IED.

RADIOLOGICAL DISPERSAL DEVICE (RDD) USING EXPLOSIVE DEVICE (IED).

AND

 

 

NON-EXPLOSIVE RDD (NERDD) AND RADIOLOGICAL EXPOSURE DEVICE (RED) .

 

RDD Detonation: 0-24 hours

A. Planning and Coordination

Emergency Declaration:

• An RDD detonation in any U.S. urban setting will likely trigger activation of the Catastrophic Incident Supplement to the National Response Framework by the Secretary of the Department of Homeland Security.
• Immediately following detonation of a Radiological Dispersal Device, the Secretary of HHS will initiate the Federal public health and medical response by:

 

1. Activating the Secretary’s Operation Center to accommodate a full Emergency Management Group (EMG) and Inter-agency Liaison Officers;
2. Appointing EMG staff to fulfill all critical functions and organize EMG authorities and reporting relationships into a NIMS-compliant Incident Command Structure;
3. Esuring that the EMG is adequately staffed and appropriately organized to manage all aspects of the massive, complex, and sustained Federal public health and medical response;
4. Deploying an Incident Response Coordination Team (IRCT) to coordinate the Federal response with the State and local responses;
5. Consider declaring a Public Health Emergency under §319 of the Public Health Service Act (42 U.S.C. §247d); and
6. Requesting and deploy U.S. Public Health Service, DHS, VA, DOT, DoD and other support agency assets to support the operations.

 

• If the Catastrophic Incident Supplement is activated, HHS as the primary agency for public health and medical response (ESF #8) would have the ability to immediately stage at Federal mobilization centers DMATs, Federal Medical Stations and other public health and medical assets that the Emergency Management Group expects the state to request. The EMG will work with FEMA and the support agencies of ESF #8 to assure a coordinated response.
• The initial medical response will be done hand-in-hand with forensic response by the Department of Justice, in that attribution is a key component of the USG response. Medical response would be done in coordination with the Department of Defense and other ESF #8 support agencies, recognizing that the uncertainty of a terrorist situation will require DOD to fulfill its defense mission as its top priority.

Physical Situation:

• There is not a radiation pulse as seen with an improvised nuclear device (IND). Radiation toxicity can result from contamination, groundshine, material contamination or internal contamination. Dust and debris from the blast will make initial actions difficult and will add to the confusion. The uncertainty of whether the blast is accompanied by other contaminants - radiation, chemical or biological - will likely slow the initial response. Detection of radiation by first responders does require appropriate guidance and precaution from the on-scene officials and reach-back experts. The major radioactive cloud from an RDD detonation dissipates within about 30 minutes resulting in surface contamination of the surrounding environment. Some small particles may be carried downwind, however the significant radiation exposure is only local.

 

NERDD/RED 0 - 72 hours Once an attack is suspected, this collective information will be communicated by the CDC through the HAN and EpiX to its surveillance network to assess if there has been more than one incident.

 

• There is no electromagnetic pulse and the damage to the infrastructure will be due to the explosion. Radiation contamination and the uncertainty of where responders can go and how much time they can spend in an area will slow and also limit the response.
• While training and education are essential for responders, healthcare workers and the general public, it is highly likely that the response to a radiological device detonation will be hindered by fears of radiation.

B. Healthcare, Emergency Response, and Human Services:

• A Radiological Dispersal Device (RDD) detonation will generate physical trauma, burn, radiation exposure and possible contamination from spread of radioactive material, and combined injuries ranging from fatal/severe to mild. Almost all of the initial injury will be from the explosion but some individuals will have superficial radiation contamination and others may have radioactive shrapnel or inhalation that requires decontamination, surgical removal and/or medical decorporation/blocking agent treatment. In addition, people may be injured by secondary sources such as car accidents and building collapse.
• The goal of federal public health and medical support will be to integrate with the state and local response to swiftly and effectively augment their capabilities. Accomplishment of this will require close communications with state and local jurisdictions as well as with their field assets. In the initial hours, the response will be somewhat chaotic and communications may be unreliable. First responders, fire fighters, police and other groups in the local / regional response have expertly trained individuals who can provide radiation detection services, and identify perimeters for the hot, warm, cold zones. Local health and medical physicists will provide subject matter expertise and will be advised to consult the Radiation Event Medical Management system (or other sources such as EPA, CDC, FEMA, FRMAC) for recommendations on radiation dose and safety. The information from the measured dose will guide the amount of time responders will be able to stay in a certain area. Federal assessment teams will be sent to assist state and local response operations as well as to enhance situational awareness for the U.S. government (USG).
• Except for an extraordinary event or multiple simultaneous events, the local/regional resources will likely be adequate to address the immediate medical needs. However, the surge in injured may require unusual efforts to obtain the maximal benefit from the available resources. Triage will be performed by local-regional providers based on pre-existing local triage guidance. There will be fatalities and “expectant” individuals who have a low likelihood of survival. This means that hospital, ICU and specialty care beds will be used for the injured patients whose odds of survival are best. It must be understood that prognosticating under these circumstances is imprecise at best, and only general protocols to fairly and justifiably distribute specialty care will be possible. To an extent much less than for an IND, triage will require difficult decisions regarding who will receive aggressive medical management and who will receive comfort measures only. Patients with minor injuries will receive care after more seriously affected patients are treated. If needed, patients will be cared for in alternative facilities such as mobile hospitals or lower acuity medical shelters, and some may need transportation to distant hospitals to either vacate acute care beds or for specialty care.
• Response teams will be activated including DMATs, DMORT and NDMS hospitals. The Radiation Injury Treatment Network (RITN) will be alerted once radiation is detected; the ASPR will activate the SNS or provide other sources of countermeasures should they be needed. Timing would be critical for an event requiring DTPA (Americium, Plutonium, Curium), Prussian Blue (Cesium) or Potassium Iodide (radioactive iodine).  

 

NERDD/RED 0 - 72 hours Once the type of attack is recognized, efforts will be made to identify potential exposed individuals. Many of those exposed to inhalation or ingestion may have little detectable radiation and those subject to an RED will have none. They may have alterations in blood count, but that is not very likely. It may be possible for health physicists to reconstruct the potential exposure and contamination dose. Medical management will depend on the symptoms and in particular, physical signs and laboratory data including skin burns, altered blood cell counts and as needed, appropriate analysis of urine, stool, blood or swabs from skin, nose, hair and clothing for RDD. Currently there is limited capacity to conduct cytogenetic analysis (CDC) and biodosimetry (AFRRI, REAC/TS, and international partners) to assist with determining whether individuals have actually been exposed to radiation. Management will likely involve symptomatic care, burn care and, although unlikely, treatment of ARS. Decorporation will be needed if there is sufficiently high level of internal contamination. The ASPR EMG will coordinate with CDC the deployment of appropriate countermeasures.

 

• The tiered triage, treatment and transport approach (RTR 1, 2 and 3, MC and AC sites are similar to that of an IND) is based on determining where medical interventions will occur. The radiation dose will change rapidly over time as the initial explosion settles, radiation dissipates and any plume is dissipated by air currents. For RDD, most of the major radioactive material will settle within 15 – 30 min. Guidance as to sheltering in place will relate to exposure from the fallout on the ground and on surfaces and not to airborne radiation which has already settled by the time the situation is assessed and announcements can be made.

 

RTR 1-3: RTR 1 locations will be determined by where the victims happen to be. The initial dose estimates and time-permitted for responders will be determined with guidance from health physicists based on blast size and knowledge of the radionuclide if any. Rapidly, the dose and time-permitted will be based on actual data obtained from the first responders. RTR 2 and RTR 3: Based on the size of the damage and dosimetry, additional RTR sites will be determined. In the absence of dose information, an initial radius of approximately 500 meters will be recommended but this will be altered as soon as information is known. In that the plume settles rapidly, the radiation is due to the footprint left by the settled plume. The area is cordoned so that those leaving it can be held at these RTR2 and 3 collection points for screening for radioactive contamination. A secondary perimeter farther out will be established to allow individuals leaving the zone to be screened for contamination. Individuals and groups within the fallout/footprint zone are given orders to evacuate once the major dust settles and to cover their nose and mouth with multiple layers of tissue, toilet paper or material. We can anticipate that some will panic and some individuals will evacuate through the fall-out and footprint zones thus increasing their radiation exposure. MC (Medical Care) Sites: Ambulances and self-evacuation would deliver and gather people at local hospitals. Some will have severe combined injury and may be triaged to expectant treatment and palliative care. RDF team (s) are placed on alert or activated in the event medical care is needed for evacuees. DMAT is mobilized to be set up near a major hospital for overflow, if needed. AC (Assembly Center) - Multiple Sites: These have will be set up next to hospitals for those not needing medical care and in facilities including convention centers, professional sports stadiums, school gymnasiums and churches. None of these people were in a zone with radiation and after initial calming down of their fears and concerns, most will return to their homes. The people who live in or near the zone that requires additional radiation dosimetry data to assess if it is safe to return will need food and shelter until the guidance is available. The American Red Cross will assist the local/state and regional authorities to provide food and shelter. An FMS may be used to support the medical needs of evacuees who have exacerbations of their chronic conditions.

 

C. Surveillance, Investigation, and Protective Health Measures:

• The EMG in cooperation with the IRCT will closely monitor information regarding the size of the event, extent of damage, presence of radiation and possibly identification of the radionuclide.
• Medical physicists with access to a gamma spectrophotometer (which is a common laboratory instrument in any facility performing radiological assays) may be able to analyze the radionuclide involved. If not, samples will be taken to environmental assay laboratories.

 

NERDD/RED 0 - 72 hours Covert radiological attacks include exposure devices and non-explosive RDDs may be difficult to detect initially. They may be detected by routine environmental surveillance and area monitors or they may be virtually undetected until injured victims present with illness. Astute clinicians may recognize presentation patterns that result from exposure to radiological materials. National surveillance reports may detect a pattern of symptoms. Due to the covert nature of these types of attacks, the concept of operations for response to an incident of this nature is different from the tiered triage response to an explosive or apparent point source device. The number of involved individuals can vary from a 100 or so from an RED, to 1000’s for an aerosolized RDD in an enclosed space, to 10,000’s in a food or water supply contamination. The likelihood of ARS is low and the major risk will be the concern for long-term radiation-related cancer and environmental contamination.

 

• Decontamination is a responsibility of the state and local responders with advice from ESF #8. Those severely injured should be transported even without decontamination, although it may be possible to remove superficial clothing and wrap victims in double sheets/blankets to try to avoid contaminating the ambulance or other conveyance vehicle.
• Those with limited contamination may undergo decontamination at collection points or exit points from control zones. Others who have left the area or are instructed to do so may undergo self-decontamination at home. Exposed personal items should not be taken inside the house, if at all possible. For self-decontamination people are instructed to go home, remove clothing outside of the house, place it in plastic bags, then shower and wash hair (no conditioner). Bags of contaminated items will be collected later.
• The CDC radionuclide assay laboratory will be activated in preparation for both environmental and clinical samples. The latter may be needed to identify internally contaminated individuals and to assist in guiding their treatment with decorporating agents. Depending on the number of casualties the laboratory capacity may be overwhelmed and precedence will be give to analyzing clinical samples. Transportation of equipment to the site may be necessary, as requested by CDC.
• Health physicists can help monitor dose to responding medical personnel. The plan is to limit personnel to 1 rem/shift and maximum 5 rem. Passive personal dosimeters (e.g., film, TLD, OSL badges, etc) are distributed widely to hospital personnel working with the contaminated victims and electronic real-time monitors are used for those in contact with the victims, until a patient and an area can be declared as “clear”.
• Health physicists will screen additional ambulatory patients. Depending on the number and type of casualties, some may require blood and urine sampling to calculate radiation contamination. Samples will be collected, per CDC instructions. The REMM website may be used to guide drug administration and FDA, CDC and other HHS experts are available for consultation.
• Deciding who needs screening will be done by medical personnel in conjunction with health physicists. Individuals who were likely within a radiation zone, those who were contaminated as assessed by survey meters and others whom physicians feel need screening will undergo the additional laboratory tests.
• Although it is still an early time point, it is essential to track both exposed victims and other concerned citizens. The opportunity to gather information should not be lost although detailed testing can be delayed as medically indicated. Victims who had significant exposure to fallout or those with internal contamination may be considered for biodosimetry risk assessment using radiation-induced chromosome changes. Epidemiologists and health physicists would help select those victims at risk, likely those who had a dose of 75-100 rem (possibly 50 rem or so for younger people). In that the chromosome changes are stable, there is no urgency in doing this test, which could be done months or years later.
• Cytogenetic analysis might be necessary for some individuals early on if there is concern that they had a dose above 2 Gy, although this would be very few people. The planned Radiation- Laboratory Response Network could meet this need once it is developed. (AFRRI, REAC/TS and others).

D. Pharmaceuticals, Medical Supplies and Equipment:

• Information from the local/state/regional area as to number and type of casualties will be received at the SOC. Determination will be made as to the extent of shortfalls and the need for special treatments such as burns and radiation management.
• NDMS, VA, RITN and Burn Centers will be notified and potentially activated, as necessary.
• When the radionuclide is identified, treatment will be initiated for those who might be at risk as determined by medical history and laboratory analysis. For those at risk for ARS, empiric therapy may be initiated.
• Appropriate medical countermeasures will be initiated. This will likely require coordination of local/state/regional personnel for deployment of locally owned and SNS stockpiles. Most of the decorporating/blocking agents are FDA approved. For those that are not, an Emergency Use Authorization will be provided from FDA.

E. Patient Evacuation:

• Experience with prior disasters suggests that victims will spontaneously gravitate toward familiar institutions for assistance, and these will become casualty collection points. This is especially of concern as the general populous in an affected metropolitan area becomes aware of radiological contamination without an understanding of the scope of dispersal. Efforts will be made to staff these ad hoc casualty collection points to support triage, initial treatment, and, when appropriate, contamination and palliative care at these locations. These would be RTR3 & AC sites and housed in buildings of opportunity, especially along near evacuation routes. While the number of casualties requiring medical intervention may be only a few hundred or thousand, the surge of concerned citizens and displaced persons will likely require federal medical response personnel to be deployed.

F. Communications and Outreach

• Education of the risk from radiation is important and this must be done immediately to minimize fear and panic.

 

While it is a carcinogen, radiation is relatively weak and radiation-induced cancers may not appear for decades. Thus, many individuals may not be particularly interested in undergoing this cytogenetic analysis. They might simply opt for good preventative care such as smoking avoidance, exercise and use of routine screening tests such as mammography and colonoscopy. An event with radioactive iodine would be different and require appropriate monitoring for children and young adults.

 

 

• Preplanning, and training to optimize coordination among local, regional and Federal response assets is essential. It is expected that there will be significant numbers of unaffiliated volunteers who will self deploy to assist. Local and state authorities will credential healthcare professionals.
• Recovery of human remains and mortuary care will be initiated as soon as it is safe to do so, but this will be a secondary priority if the same resources are needed for rescue and acute care of victims. Despite the conditions, recovery and mortuary operations will be conducted with respect and dignity. Messages which clearly explain what can be expected, how treatment can be obtained and what the public can do to support the response will be jointly scripted with the state and local authorities.

RDD detonation: 24-72 hours

A. Planning and coordination:

• Review damage assessments with FEMA in order to:
  • Coordinate rapid needs assessment
  • Discuss need for activating ESF #14 (Long-term community recovery and mitigation)
• Adjust HHS-EMG staffing level
  • Expand Operations, Planning, Logistics, Admin & Finance and SMEs as needed
  • Request Liaison Officers from ESF#8 partners
• Update situational awareness of hospital and healthcare infrastructure
• Make adjustments to pre-scripted Sub-Tasks
• Develop common operating picture for long-term recovery and establish a transition to recovery plan

B. Healthcare, Emergency Response, and Human Services

    Extension of medical care at MC sites:

• At this point almost all of the injured will have been brought for medical care. The need for surge capacity and special medical care will be determined. As needed, victims can be brought to expert care within NDMS, VA, RITN or other regional medical centers. Less acute patients may require transport from the local hospitals to distant sites.
• The radionuclide has been identified and appropriate medical countermeasures initiated.
• CDC bioassay laboratory will be operating to perform diagnostic tests. This will be necessary to screen people for internal contamination, who have been deemed at risk by medical and health physics personnel.

C. Surveillance, Investigation, and Protective Health Measures

    Long-term monitoring for risk of cancer and victim tracking:

• Large numbers of people will likely seek care due to concern about having been exposed to radiation. Federal experts including CDC and epidemiologists from NCI and other agencies, can assist states and localities in long-term tracking of both exposed victims and other concerned citizens.

 

The opportunity to gather information should not be lost although detailed testing can be delayed as medically indicated. Victims who had significant exposure to fallout or those with internal contamination may be considered for biodosimetry risk assessment using radiation-induced chromosome changes. Epidemiologists and health physicists would help select those victims at risk and most likely those who had a dose of 75-100 rem (possibly 50 rem or so for younger people).In that the chromosome changes are stable, there is no urgency to run this test, which could be done months or years later.

 

• Currently there is limited capacity to conduct cytogenetic analysis to assist with determining whether individuals have actually been exposed to radiation. The proposed Radiation Laboratory Response Network would greatly enhance our capability to separate those who have actually been exposed from those who are concerned that they may have been exposed.

D. Pharmaceuticals, Medical Supplies and Equipment:

• Potential shortages of medical supplies will be identified and restocking may be needed from regional hospitals via local/regional agreement, the SNS or vendor managed inventory.

E. Patient Evacuation:

• Transfer of less acutely ill patients to accommodate local surge capacity may be necessary. Surge capacity for decorporation may be necessary to RITN centers.

F. Communications and Outreach: 

• Education for the general population and medical practitioners of the risk from radiation is important and this must be done immediately to minimize the fear and panic. While it is a carcinogen, radiation is a relatively weak one and radiation-induced cancers may not appear for decades.

 

Many individuals may not be particularly interested in undergoing this cytogenetic analysis or even long-term follow up. They might simply opt for good preventative care such as smoking avoidance, exercise and use of routine screening tests such as mammography and colonoscopy. An event with radioactive iodine would be different and require appropriate monitoring for children and young adults.

 

Preparation for Long-Term Psychological Stress:

• By distinguishing those with significant contamination/exposure from those without them, and by providing information regarding radiation-induced cancers, the number of individuals who have a sustained long-term psychological stress should be reduced considerably. Nevertheless, as seen with other radiological disasters, this long term fear will need to be monitored and addressed with education, counseling and other medical interventions for stress-related illness as required.
• Messaging is critical. It must be correct, credible, prompt and understandable.
  Existing psychological counseling services may be overwhelmed requiring additional experts from PHS and/or other HHS components

RDD Detonation: Beyond 72 hours

A. Planning and Coordination

Demobilization of Federal medical response:

• The likely modest size of an RDD event will mean that there is a limited need for federal medical resources. It is likely that most displaced persons will be accommodated within a few weeks and most victims will be out of the hospital.

 

NERDD/RDD Should multiple sites be involved, there may be the need to deploy SMEs for a sustained period of time to conduct the activities listed above

 

 

B. Healthcare, Emergency Response, and Human Services:

• Ongoing support may be needed

C. Surveillance, Investigation, and Protective Health Measures:  

• The experts on epidemiology will likely have a sustained role. Other agencies involved in site remediation will be guided by HHS experts including CDC and NIH.

 

NERDD/RDD The time line may be uncertain so that these activities will be initiated early on. However, they will be sustained. Screening and identification of victims, using Rad-LRN. Risk assessment, using cytogenetic biodosimetry, as available. Education regarding the risk from radiation. This may require long-term education, and HHS experts participating in local discussions and presentations. Epidemiological assessment, using experts from HHS (CDC, NCI). Working with other agencies regarding safety of the food and water supply. Advising local/regional authorities on restoration and reoccupation of radiation zones.

 

 

D. Pharmaceuticals, Medical Supplies and Equipment:

• Those requiring a full course of decorporation will be under treatment. Some ongoing support from CDC radio-bioassay lab may be needed.

E. Patient Evacuation

• Continue as necessary

F. Communications and Outreach:

SMEs may be involved long-term with counseling and public education. Consultation may be needed from HHS along with other agencies (e.g., EPA, CDC, FEMA) regarding restoration and reoccupation of disaster site.

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