Medical response to a radiologic/nuclear event: integrated plan from the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services.

The end of the Cold War led to a reduced concern for a major nuclear event. However, the current threats from terrorism make a radiologic (dispersal or use of radioactive material) or nuclear (improvised nuclear device) event a possibility. The specter and enormousness of the catastrophe resulting from a state-sponsored nuclear attack and a sense of nihilism about the effectiveness of a response were such that there had been limited civilian medical response planning. Although the consequences of a radiologic dispersal device are substantial, and the detonation of a modest-sized (10 kiloton) improvised nuclear device is catastrophic, it is both possible and imperative that a medical response be planned. To meet this need, the Office of the Assistant Secretary for Preparedness and Response in the Department of Health and Human Services, in collaboration within government and with nongovernment partners, has developed a scientifically based comprehensive planning framework and Web-based "just-in-time" medical response information called Radiation Event Medical Management (available at http://www.remm.nlm.gov). The response plan includes (1) underpinnings from basic radiation biology, (2) tailored medical responses, (3) delivery of medical countermeasures for postevent mitigation and treatment, (4) referral to expert centers for acute treatment, and (5) long-term follow-up. Although continuing to evolve and increase in scope and capacity, current response planning is sufficiently mature that planners and responders should be aware of the basic premises, tools, and resources available. An effective response will require coordination, communication, and cooperation at an unprecedented level. The logic behind and components of this response are presented to allow for active collaboration among emergency planners and responders and federal, state, local, and tribal governments.

The "RTR" medical response system for nuclear and radiological mass-casualty incidents: a functional TRiage-TReatment-TRansport medical response model.

Developing a mass-casualty medical response to the detonation of an improvised nuclear device (IND) or large radiological dispersal device (RDD) requires unique advanced planning due to the potential magnitude of the event, lack of warning, and radiation hazards. In order for medical care and resources to be collocated and matched to the requirements, a [US] Federal interagency medical response-planning group has developed a conceptual approach for responding to such nuclear and radiological incidents. The "RTR" system (comprising Radiation-specific TRiage, TReatment, TRansport sites) is designed to support medical care following a nuclear incident. Its purpose is to characterize, organize, and efficiently deploy appropriate materiel and personnel assets as close as physically possible to various categories of victims while preserving the safety of responders. The RTR system is not a medical triage system for individual patients. After an incident is characterized and safe perimeters are established, RTR sites should be determined in real-time that are based on the extent of destruction, environmental factors, residual radiation, available infrastructure, and transportation routes. Such RTR sites are divided into three types depending on their physical/situational relationship to the incident. The RTR1 sites are near the epicenter with residual radiation and include victims with blast injuries and other major traumatic injuries including radiation exposure; RTR2 sites are situated in relationship to the plume with varying amounts of residual radiation present, with most victims being ambulatory; and RTR3 sites are collection and transport sites with minimal or no radiation present or exposure risk and a victim population with a potential variety of injuries or radiation exposures. Medical Care sites are predetermined sites at which definitive medical care is given to those in immediate need of care. They include local/regional hospitals, medical centers, other sites such as nursing homes and outpatient clinics, nationwide expert medical centers (such as cancer or burn centers), and possible alternate care facilities such as Federal Medical Stations. Assembly Centers for displaced or evacuating persons are predetermined and spontaneous sites safely outside of the perimeter of the incident, for use by those who need no immediate medical attention or only minor assistance. Decontamination requirements are important considerations for all RTR, Medical Care, and Assembly Center sites and transport vehicles. The US Department of Health and Human Services is working on a long-term project to generate a database for potential medical care sites and assembly centers so that information is immediately available should an incident occur.

Translating Battlefield Practices to Disaster Health.

We review aspects of the recently released National Academies of Sciences, Engineering, and Medicine report A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury most relevant to disaster health, particularly the concepts of focused empiricism and building a learning health system. The article references battlefield success utilizing these concepts and the emerging Disaster Research Response Program. We call upon disaster health researchers to apply the report's recommendations to their work. (Disaster Med Public Health Preparedness. 2017;11:510-511).

Ebola Virus Training: A Needs Assessment and Gap Analysis.

In response to the 2014 Ebola virus disease outbreak, the Worker Training Program embarked on an assessment of existing training for those at risk for exposure to the virus. Searches of the recent peer-reviewed literature were conducted for descriptions of relevant training. Federal guidance issued during 2015 was also reviewed. Four stakeholder meetings were conducted with representatives from health care, academia, private industry, and public health to discuss issues associated with ongoing training. Our results revealed few articles about training that provided sufficient detail to serve as models. Training programs struggled to adjust to frequently updated federal guidance. Stakeholders commented that most healthcare training focused solely on infection control, and there was an absence of employee health-related training for non-healthcare providers. Challenges to ongoing training included funding and organizational complacency. Best practices were noted where management and employees planned training cooperatively and where infection control, employee health, and hospital emergency managers worked together on the development of protective guidance. We conclude that sustainable training for infectious disease outbreaks requires annual funding, full support from organizational management, input from all stakeholders, and integration of infection control, emergency management, and employee health when implementing guidance and training.

Integrating Health Research into Disaster Response: The New NIH Disaster Research Response Program.

The need for high quality and timely disaster research has been a topic of great discussion over the past several years. Recent high profile incidents have exposed gaps in knowledge about the health impacts of disasters or the benefits of specific interventions-such was the case with the 2010 Gulf Oil Spill and recent events associated with lead-contaminated drinking water in Flint, Michigan, and the evolving health crisis related to Zika virus disease. Our inability to perform timely research to inform the community about health and safety risks or address specific concerns further heightens anxiety and distrust. Since nearly all disasters, whether natural or man-made, have an environmental health component, it is critical that specialized research tools and trained researchers be readily available to evaluate complex exposures and health effects, especially for vulnerable sub-populations such as the elderly, children, pregnant women, and those with socioeconomic and environmental disparities. In response, the National Institute of Environmental Health Science has initiated a Disaster Research Response Program to create new tools, protocols, networks of researchers, training exercises, and outreach involving diverse groups of stakeholders to help overcome the challenges of disaster research and to improve our ability to collect vital information to reduce the adverse health impacts and improve future preparedness.

Poxvirus countermeasures during an emergency in the United States.

Although smallpox was eradicated worldwide by 1980, national security experts remain concerned that it could be used in a deliberate attack. The United States and other governments have given priority to developing and stockpiling vaccines and antivirals to protect their populations from the potential reintroduction of this deadly disease. Public health officials are also concerned about the spread of related zoonotic orthopoxviruses such as monkeypox and cowpox, against which smallpox vaccine provides protection. This report analyzes how medical countermeasures available in the US Strategic National Stockpile will be given priority and used in the event of an intentional or accidental release of smallpox in the United States.

Emergency health and risk management in sub-saharan Africa: a lesson from the embassy bombings in Tanzania and Kenya.

In 1998, terrorists simultaneously bombed United States Embassies in Dar es Salaam, Tanzania and Nairobi, Kenya. The local response to these bombings was unorganized and ad hoc, indicating the need for basic disaster preparedness and improvement of emergency management capabilities in both countries. In this context, risk and risk management are defined and are related to the health hazards affecting Tanzanians and Kenyans. In addition, the growing number of injuries in Tanzania is addressed and the relationship between risk management and injury is explored. Also, an emergency medicine-based strategy for injury control and prevention is proposed. Implications of implementing such a protocol in developing nations also are discussed.

Allocation of scarce resources after a nuclear detonation: setting the context.

The purpose of this article is to set the context for this special issue of Disaster Medicine and Public Health Preparedness on the allocation of scarce resources in an improvised nuclear device incident. A nuclear detonation occurs when a sufficient amount of fissile material is brought suddenly together to reach critical mass and cause an explosion. Although the chance of a nuclear detonation is thought to be small, the consequences are potentially catastrophic, so planning for an effective medical response is necessary, albeit complex. A substantial nuclear detonation will result in physical effects and a great number of casualties that will require an organized medical response to save lives. With this type of incident, the demand for resources to treat casualties will far exceed what is available. To meet the goal of providing medical care (including symptomatic/palliative care) with fairness as the underlying ethical principle, planning for allocation of scarce resources among all involved sectors needs to be integrated and practiced. With thoughtful and realistic planning, the medical response in the chaotic environment may be made more effective and efficient for both victims and medical responders.

Mechanical ventilators in US acute care hospitals.

OBJECTIVE: The supply and distribution of mechanical ventilation capacity is of profound importance for planning for severe public health emergencies. However, the capability of US health systems to provide mechanical ventilation for children and adults remains poorly quantified. The objective of this study was to determine the quantity of adult and pediatric mechanical ventilators at US acute care hospitals. METHODS: A total of 5,752 US acute care hospitals included in the 2007 American Hospital Association database were surveyed. We measured the quantities of mechanical ventilators and their features. RESULTS: Responding to the survey were 4305 (74.8%) hospitals, which accounted for 83.8% of US intensive care unit beds. Of the 52,118 full-feature mechanical ventilators owned by respondent hospitals, 24,204 (46.4%) are pediatric/neonatal capable. Accounting for nonrespondents, we estimate that there are 62,188 full-feature mechanical ventilators owned by US acute care hospitals. The median number of full-feature mechanical ventilators per 100,000 population for individual states is 19.7 (interquartile ratio 17.2-23.1), ranging from 11.9 to 77.6. The median number of pediatric-capable device full-feature mechanical ventilators per 100,000 population younger than 14 years old is 52.3 (interquartile ratio 43.1-63.9) and the range across states is 22.1 to 206.2. In addition, respondent hospitals reported owning 82,755 ventilators other than full-feature mechanical ventilators; we estimate that there are 98,738 devices other than full-feature ventilators at all of the US acute care hospitals. CONCLUSIONS: The number of mechanical ventilators per US population exceeds those reported by other developed countries, but there is wide variation across states in the population-adjusted supply. There are considerably more pediatric-capable ventilators than there are for adults only on a population-adjusted basis.

Implications of the Emergency Medical Treatment and Labor Act (EMTALA) during public health emergencies and on alternate sites of care.

Hospitals throughout the country are using innovative strategies to accommodate the surge of patients brought on by the novel H1N1 virus. One strategy has been to help decompress the amount of patients seeking care within emergency departments by using alternate sites of care, such as tents, parking lots, and community centers as triage, staging, and screening areas. As at any other time an individual presents on hospital property, hospitals and providers must be mindful of the requirements of the Emergency Medical Treatment and Labor Act. In this article we review the act and its implications during public health emergencies, with a particular focus on its implications on alternative sites of care.

Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings.

In October 2001, the first inhalational anthrax case in the United States since 1976 was identified in a media company worker in Florida. A national investigation was initiated to identify additional cases and determine possible exposures to Bacillus anthracis. Surveillance was enhanced through health-care facilities, laboratories, and other means to identify cases, which were defined as clinically compatible illness with laboratory-confirmed B. anthracis infection. From October 4 to November 20, 2001, 22 cases of anthrax (11 inhalational, 11 cutaneous) were identified; 5 of the inhalational cases were fatal. Twenty (91%) case-patients were either mail handlers or were exposed to worksites where contaminated mail was processed or received. B. anthracis isolates from four powder-containing envelopes, 17 specimens from patients, and 106 environmental samples were indistinguishable by molecular subtyping. Illness and death occurred not only at targeted worksites, but also along the path of mail and in other settings. Continued vigilance for cases is needed among health-care providers and members of the public health and law enforcement communities.