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During this time, participants may participate in the learning experience by submitting questions via email to rsb.cdc.gov. Hi, I'm Sharon Collins and welcome to Radiological Population Monitoring and Decontamination. Coming to you live from the Centers for Disease Control and Prevention in Atlanta, Georgia. Now our program is two hours in length with a 10-minute break included. Our goal is to educate and inform you, the public health workforce and other persons involved in Radiological Emergency Preparedness and Response about Radiological Population Monitoring. Now we will discuss initial and long-term monitoring issues, considerations for establishing monitoring sites, as well as roles and responsibilities of local, state and federal public health and emergency preparedness authorities. Now let's take a look at this program's objectives. At the completion of this broadcast, participants will be able to define Radiological Population Monitoring. They'll be able to describe examples of previous Radiological Population Monitoring projects. They'll be able to describe challenges in planning for Population Monitoring, describe the roles of local, state and federal partners in Population Monitoring. They will be able to identify populations, including special populations for monitoring, to describe basic procedures in Population Monitoring, identify populations for dose assessment and dose reconstruction, and describe CDC's current resources for planning Population Monitoring. All right, now let's set the stage for the program with this scene from the 2005 film produced by HBO Films called Dirty War. It shows what would likely occur if a dirty bomb was detonated by terrorists. This is one possible terrorist scenario that you could face, one that would require Radiological Population Monitoring and Decontamination. A large bomb hidden in a van was detonated at 8am outside Liverpool Street Station. We believe that the bomb might have been used to disperse small amounts of radioactive contamination, which is why every necessary precaution is being taken. In the meantime, we need the public to stay calm and stay put. If you're already in your home, stay in your home. If you're in your office, please remain there. All Londoners, not in the vicinity of the incident, should go in, stay in and tune out. Public health and emergency preparedness officials must plan for the consequences of such an event. Now in the early stages of an event like this, it will be critical to make rapid decisions and communicate and direct resources effectively to save lives and protect public health. What would you do if this occurred in your community? Well, to help us answer that question, and many others, is our distinguished panel of experts in the field of radiation who will discuss Radiological Population Monitoring and Decontamination. First, I'd like to welcome Dr. Robert Whitcomb, who is a health physicist and team lead for the Radiological Assessment Team, Radiation Studies Branch at the Centers for Disease Control and Prevention. Joining Dr. Whitcomb is Kathleen Kass Kaufman. Kass is also a health physicist, as well as the Director of Radiation Management for the Los Angeles County Department of Health Services in California. And last but certainly not least, Mr. Greg Dempsey, who is a Senior Science Advisor with the Radiation and Indoor Environments National Laboratory of the U.S. Environmental Protection Agency. I'd like to welcome all of you today for this broadcast, and let's begin our discussion with Dr. Whitcomb. Now, Bob, could you get us started with some background about perhaps radiological population monitoring? How does it work? Sure, I'd be happy to, Sharon. Thank you. First, let me say that we use the term radiological population monitoring to describe the process of identifying, screening, measuring, and monitoring people for exposure to radiation or contamination with radioactive materials. On today's program, we are specifically addressing radiological population monitoring following a terrorist event and primarily activities during the first 24 to 48 hours. Before we get into more depth with this topic, though, I'd like to provide a brief description of the types of events that might require population monitoring and some basic radiation concepts that are involved in this process. As you may know, radioactive material could be released into the environment by terrorist in a nuclear incident or a radiological incident. Although there's some disagreement on the semantics, basically, a nuclear incident involves a fission or fusion reaction, that is, the splitting or uniting of atoms, whereas a radiological event does not. Examples of nuclear incidents include a targeted attack on a nuclear facility, a nuclear weapon, or an improvised nuclear device, sometimes referred to as an IND. Terrorist incidents that could be considered radiological include the use of a radiological dispersal device, such as a dirty bomb, in which radioactive material is spread over an area, contaminating people and the environment. It's common for the terms radiological dispersal device and dirty bomb to be used to refer to the same thing. A dirty bomb, of course, is a conventional explosive device that is laced with radioactive material. However, there are other ways besides the use of explosives in which radioactive material could be dispersed. Another radiological scenario involves the malicious use of radioactive substances, such as covertly placing high-energy radiations in source in an area where people would be exposed to radiation without their knowledge. One of the most confusing aspects of radiation is the notion of a person being contaminated versus being exposed. Simply put, contamination refers to having radioactive material on or inside of the body. Exposure, on the other hand, refers to radiation from radioactive material or other sources actually penetrating the body. Let's look at these concepts more closely. When we are near a source of radiation, such as radioactive material, we can be exposed to the radiation emitted without becoming contaminated by the source. One way to think about exposure is to consider x-rays. When you have a chest x-ray, for example, you are exposed to radiation, but you don't become contaminated with radioactive material. We can reduce our exposure to radiation if we are shielded in some way. For example, by standing behind a concrete wall or keeping the radioactive source inside of a lead container. To become contaminated, radioactive material must get on the skin or clothing or inside of the body. For example, consider a dirty bomb that is a conventional explosive such as dynamite that is laced with radioactive material. When the device is detonated, people could not only be injured by the blast, but become contaminated. External contamination refers to radioactive material on the outside of the body. When a person becomes externally contaminated, simply removing the clothing can remove as much as 90% of the contamination. Gently washing the skin and the hair can remove most of that which remains. If a person ingests or inhales radioactive material, it can become incorporated in the organs of the body, and this is called internal contamination. Depending on the type of radioactive material which someone is contaminated with, certain medications can be administered to accelerate the rate at which the material is eliminated from the body. Examples of such medications include Prussian Blue and DTPA. Now, getting back to population monitoring. As I just said a moment of go, it is a radiation and health monitoring process that involves identifying, screening, measuring, and monitoring people following a radiological or nuclear incident. You know, it seems like a pretty complicated process, Bob. I mean, can you break it down some for us? Certainly, Sharon. The first thing we need to do after the release of radioactive material into the environment is to first identify those people who were affected by the incident. If a terrorist accident or attack were to occur, people in the affected area will probably identify themselves. Many people may show up at hospitals, community clinics, and doctor's offices fearing that they have been exposed to radiation or contaminated with radioactive materials. Remember that a lot of people who self-identify as being affected by the incident may in fact be reacting to fears of radiation without actually being exposed to radiation or contaminated with radioactive material. We need to be very careful to help these people understand that they may not be at risk of injury or health effects from the radiation or radioactive material used in this incident. In fact, psychosocial issues will present significant challenges in the population monitoring process, which we will touch on later in the broadcast. While we imagine that people will identify themselves as being affected, in some cases, for instance, a covert release of radioactive material into the environment, the public health workforce may need to go out and identify people in the affected areas. Once the affected population has been identified, we can begin screening. We screen people to determine who is contaminated with radioactive materials, who has been exposed, who needs treatment, and who was not affected. Screening can involve performing radiation surveys either with handheld meters or polar monitors and taking a history of the incident to determine the proximity of each person to the source of radiation and the length of time of their exposure. Greg, you'll be talking about this in more detail later in the broadcast. Do you have any key points you'd like to mention here? Yes, Bob. I think my key concern is that we keep in mind that the goal of screening is to determine whether radiological contamination is present so that it can be removed promptly. So the initial screening will need to be conducted as expeditiously as possible, which may be a significant challenge if you have hundreds of thousands of people to assess. Thanks, Greg. Now, let's talk a bit about the process of measuring radioactive materials. Once we have identified and screened the population, then we must perform measurements on people who have been contaminated with radioactive material and or exposed to radiation. Measurements for people who were contaminated with radioactive materials may be done through whole body counts and bioassay, which is the measurement of radiation levels in samples of blood, urine, or feces. For people who were exposed to radiation either with or without being contaminated, we may perform biosymmetry to determine if radiation exposure caused any physiological changes that can be detected in body fluids. We might also need to perform dose reconstructions, that is, determining a person's exposure to radiation by calculating the length of time they were exposed, their distance from the radiation source, whether or not they were shielded from the radiation in any way, and other factors that might affect the radiation dose. Following identification, screening, and measuring, state and local agencies may want to consider establishing a registry so that long-term monitoring can be performed if needed. Those responding to the Chernobyl accident regretted that they had not established a registry early on. This lengthy process involves observing and recording any health effects that could be related to radiation exposure. We will need to establish a registry of the affected population as soon as practical, including those who were not exposed to radiation or contaminated with radioactive materials. This is because people may suffer from psychosocial effects such as post-traumatic stress disorder, even if they do not have any physical health effects from the radiological incident. It's important to remember the monitoring phase could go on for an indefinite period of time, perhaps into subsequent generations. Bob, has anyone performed this kind of population monitoring before? Unfortunately, Sharon, yes. There have been non-terrorism incidents that have required radiological population monitoring. These include the Chernobyl nuclear power plant accident in 1986 and the Guranya radiological accident in 1987. Most people are familiar with the Chernobyl reactor accident that occurred in the former Soviet Union in 1986. This incident resulted in a release of a large amount of highly radioactive materials into the environment. 28 people, mainly workers, died soon after the incident from acute radiation syndrome. Approximately 800,000 people were evacuated from areas around the reactor site and an additional 10,000 people received doses above 100 millisievert or about 10 REM, the common dose unit used in the U.S. More than 4,000 thyroid cancers have been reported, mainly in those exposed as children. There were also reports, numerous reports of abortions performed because of a fear that exposure to even small doses of radiation may have ill effects on the unborn child. Population monitoring-related projects have included follow-up whole-body scans for residual radioactive cesium, which can remain in the environment for decades and continue to be consumed in food in the contaminated region. More than 350,000 people have been screened for possible thyroid disease from exposure to radioiodine from the incident. Approximately 800,000 people have been included in a registry of affected people. It's difficult to establish an exact figure for those included in the Chernobyl registries because registration is ongoing. Those included in the registries are followed on an annual basis in medical examinations by general practitioners. Although less publicized, the accidental release of radioactive cesium-137 in Goiânia, Brazil in 1987 also required significant population monitoring activities. In this incident, local citizens entered an abandoned radiation therapy treatment facility in search of scrap metal. Once inside, they located a radiotherapy unit and removed the radiation source, which contained a significant amount of radioactive cesium-137 in the form of cesium chloride salt, a highly soluble chemical compound. As illustrated here, they returned home with the assembly, breached the shielding, and ruptured the canister containing the radioactive source. They then sold part of the damaged source to a scrapyard owner who admired the blue glow emitted by the cesium-137 source and brought it home with him. He gave small fragments of the source to friends and to neighbors, some of whom rubbed the material on their skin to admire its brightness. Over the next 16 days, the material was spread throughout the community, contaminating people and the urban environment. In this incident, 249 people were found to be contaminated. 49 individuals required medical treatment from the incident. 28 suffered radiation burns, and unfortunately, four people died. Out of about 1 million inhabitants of Goiânia, about 112,800 people from the general public were surveyed for contamination between September 30th and December 21st, 1987. The decontamination operation required more than 730 emergency workers who were assigned to a variety of decontamination tasks, which in turn generated approximately 3,500 cubic meters of radioactive waste. In addition to the immediate monitoring issues, there were many social and economic impacts to the community after this event. There was a decrease in agricultural sales from the region. Discrimination against citizens of Goiânia in the rest of the country and the need to issue official certificates to people to prove that they had been screened and were free of contamination. This episode, more than any other recorded radiation-related accident, proved to public health officials in the United States that even though the total population affected by a radiological incident may be small, the response from the rest of the population would be protracted and very complex. Thanks, Bob. Well, it would appear that population monitoring is definitely a significant part of the response to any large or small radiological terrorist incident. And I would think that there would be many challenges facing public health officials and emergency planners in the United States in preparing for that kind of monitoring. Bob, would you agree? Certainly. I do. Since all emergencies are local, planners and responders will have primary responsibility for this process. And they are certainly facing some challenges in preparing for it. I'll mention some of these challenges, and then during the rest of the program, we'll discuss the federal role and how we can support those state and local officials in population monitoring, as well as some examples and recommendations of how they might plan and prepare. As you can all imagine, resources are major issues in preparing for and responding to a radiological emergency event and monitoring the public. Most jurisdictions struggle already with finding adequately trained staff to conduct the broad range of public health services they are required to provide. In a radiological emergency, you may have additional problems finding staff willing to participate in a response, especially those adequately trained to perform these critical tasks. Recent research by the University of Alabama at Birmingham found that few employees of health departments feel adequately prepared to respond to radiological terrorist events. And some would even be reluctant to report to duty following such an incident. Another resource issue will be ensuring an adequate supply of equipment. Although equipment for conducting individual external monitoring may be available in state or local health and radiation management agencies, as well as from local responders, devices for mass screening such as portal monitors or for assessing internal monitoring will likely be very limited. Staff members who perform monitoring must be appropriately trained in the use of this specialized equipment. And of course, time limitations will provide challenges to adequately preparing for and responding to a radiological event, especially those requiring population monitoring. As you saw in our opening film clip, authorities will have to act quickly to set up any kind of monitoring system. Management of people, especially in a large-scale event, will be a critical component to population monitoring. An important aspect of the managing people will involve addressing psychosocial issues, both during and following the monitoring process. Public health and medical systems could be totally overwhelmed by individuals seeking assessment and assistance. There's been little planning in this area, but it's of critical importance in the management and monitoring of other response activities. And of course, we'll need to address how to monitor special populations, such as those in institutions in the community. We know from recent experience with Hurricane Katrina that identifying and making arrangements for individuals with specialized needs will require careful planning. And Greg will be discussing this at greater length later in the broadcast. Use of medical countermeasures for persons with internal contamination is another very important issue in radiological population monitoring. Decisions about treatment criteria, as well as the ability and distribution of those countermeasures will be key considerations. The Strategic National Stockpile currently stocks radiological countermeasures, such as potassium iodide to block the uptake of radioactive iodine, Prussian blue to treat internal cesium contamination, DTPA to treat internal transuranic contamination, including plutonium and americium, and nupogen to treat acute radiation syndrome. Along with medical countermeasures, communications with the public will be a huge challenge in a radiological event. Radiation is greatly feared and poorly understood by most people, including some professionals who will be called upon to respond, providing factual information that will enable individuals to make appropriate decisions and follow recommendations by public health officials is critical to the success of any response and recovery effort. And finally, I'd like to point out that many public health and emergency planning professionals at all levels of government have been working hard on radiological emergency preparedness issues. Although we thankfully have relatively little experience in monitoring large numbers of people exposed during actual emergencies, we do have extensive experience with radiation safety and emergency planning. As a result, we have different planning approaches being taken to prepare for population monitoring. Today, my colleagues will be presenting their approaches, which have been developed according to their expertise and their position. CDC is also working on guidance that may offer these or other approaches on these issues. Communities will need to consider their own needs and resources in adopting or adapting practices for population monitoring. But hopefully this program will give you some tools to use in this process. Bob, you've covered a lot of material. Thank you so much. Now, clearly this is an important issue for state and local health departments and emergency planners. Cass, you're here representing a large metropolitan area, and I'm sure you have a different, perhaps, perspective on how population monitoring should be handled. Yes, Sharon. I'd be glad to talk about our plans. My colleagues and I at the County of Los Angeles Department of Health Services are well aware of our primary role in consequence management following a disaster, including a radiological terrorist event. And we've been working on plans and preparations for just such an event. But before I talk about Los Angeles County's specific experience, I'd like to briefly review the role of local public health agencies in a radiological emergency event. If an incident occurred, the chief executive officer, that is the mayor or city or county manager, is responsible for coordinating the overall local response and our resources. State and local public health agencies will be responsible for monitoring workers' health and safety as well as the public's, ensuring that there are safe shelters available, ensuring healthy food and water supplies, coordinating sampling and laboratory analysis of biological and environmental samples, conducting field investigations, monitoring people who may have been contaminated with radioactive materials or exposed to radiation, which is of course population monitoring, developing criteria for entry and operations within the incident site, and recommending disease prevention and control measures. Local health agencies may call on state health officials who in turn may request assistance from the federal government. Bob's going to describe the types of federal assistance available later in our program. But right now, I'd like to tell you how the Los Angeles County Department of Health has approached planning for radiological population monitoring in hopes of giving you a more specific example of this process. As Bob noted, there are numerous issues to consider in planning for population monitoring after an RDD. One consideration is how large an event should one plan for. Population monitoring plans should be able to be scaled up or down based on the number of affected people. If there are only 100 people who need to be surveyed and decontaminated, then responders can perform a very thorough survey and decontamination. But if there are 100,000 people affected, plans will have to be modified so that people can be quickly and safely processed. While we obviously prefer not to have any contamination on people, low levels of contamination will not represent a threat to a person's health and safety, nor will they present a threat to anyone near them. In Los Angeles County, we consider the possibility that there could be three large RDD events at the same time, which would obviously require using every asset available to us. And we have venues that concede over 90,000 people, so we must plan for responding to major events in multiple locations involving large numbers of people. For example, what if three dirty bonds were detonated simultaneously at the Los Angeles Amphitheater, the LA Long Beach Ports, and the Los Angeles Airport? Another large consideration is resource availability and how quickly those resources can respond. In Los Angeles County, we have 88 incorporated cities and many of those have their own police and fire department, so coordinating becomes even more difficult. Many localities aren't aware that every state and some local agencies have radiation control programs that can provide considerable assistance both in planning for an event and in actually responding. Although radioactive contamination from an RDD would rarely, if ever, present an immediate health risk, that's not the perception of first responders or the public. Many responders have experience and decontamination protocols for toxic materials, but few have worked in a radiologically contaminated environment. First responders are more comfortable following their usual procedures for a toxic event, which is to try and keep the contamination to a local area rather than allowing those with some level of contamination on their persons to leave the scene. This is contrary to the guidance that we radiation experts promote, but it's one of the biggest considerations in planning. What will your local fire departments do? National and international guidance states that those with life-threatening injuries should be treated without regard for potential contamination. But for the people first to arrive on the scene, the practical reality and just their own native ingenuity will be key factors in their response. Those first responders likely will have to modify procedures to accommodate the event as it unfolds, so you need to have multiple contingency plans because people who are afraid probably are not all going to behave as we must. Predict. We're fortunate in Los Angeles and that we generally have relatively warm weather. So we believe it isn't likely to harm people if the fire department uses cold water to decontaminate people. It won't be comfortable, but it will do the job. But other colder climates would need to plan for providing either warm water in a heated location or plan to use dry decontamination procedures. And there are other concerns about using this cold water procedure. These people are going to be under considerable stress, and they may already have injuries. So soaking them with cold water may result in harmful physical responses. Also, towels and dry clothing have to be available for those who now have only wet clothing. The City of Los Angeles has about 15 tents and trucks that are specifically designed to decontaminate large numbers of people. They have flash heaters so that warm water is available, and they're specifically designed to decontaminate large numbers of people. They have different lanes so that men and women have their own areas, and several have rollers so that non-ambulatory victims can just be rolled under the showers. But you do need to make sure that there are provisions for families, especially those with small children, to stay together during this process. The Conference of Radiation Control Program Directors will soon be publishing a document called Handbook for Response to Incidents Involving Radiological Dispersion Devices. And this document provides guidance to cover zero to 12 hours after an explosion. We recognize that if there are large numbers of affected people, it may take some time to be able to survey and decontaminate everyone. Decontamination may be able to be accomplished more quickly if people simply go home and take a shower. And some people may prefer to just go home. In Los Angeles County, our advice is to let them go. And we've included a handout that gives them instructions on what they should do once they are home, how they can perform self-decontamination. As I've mentioned, it's very unlikely that any person not in the immediate blast area will have an amount of contamination on their person that would represent a significant risk to another person. So it is quite acceptable to allow people to go home and shower. The suggested release levels to allow individuals to leave without decontamination is 1,000 counts per minute using a pancake probe. In our handbook, we've provided radiation contamination levels in counts per minute, although that makes many health physicists uncomfortable. But we've done that because those may be the units that are indicated on the responder's instruments. But as I mentioned before, we also need to include plans for handling a larger population. And if there are large numbers of people, a quicker survey may be performed, covering primarily the hands, the head, and the shoulder areas. And we include the head because of concerns about possible internal contamination. And the release levels can go to 10,000 counts per minute or 0.1 MR per hour if using an instrument that reads out an exposure rate. However, those folks should be instructed to go directly home and shower and wash their hair. Note that individuals with radiation expertise could advise releasing at even higher levels. And if necessary, we could go to 100,000 counts per minute or 1 milli-ram per hour. We strongly urge first responders to contact their state or local radiation control program and establish a relationship before an event. These folks have years of experience in responding to radiological incidents, and we can provide considerable assistance both in planning for an event and during an event. We can also assist in planning exercises, and we should be participating in those exercises. State and local radiation management staffs who have nuclear power plants within their jurisdiction have always had plans for responding to a failure at a plant. And so, while many of the concepts for responding to a terrorist event are different, many are also quite similar, too. You can find your local radiation control program by going to the conference's website, which is www.crcpd.org and clicking on Maps. Potentially large numbers of people might either require or request a survey and decontamination. As Bob noted, we have to plan for more people asking to be surveyed and decontaminated than likely would be required if we were doing so based solely on health issues. How and where will that monitoring occur? Are instruments available? Who will use those instruments? What contamination levels are low enough that additional washing isn't necessary? Simply removing the person's clothing will likely eliminate about 80 to 90% of the contamination, but are clean clothes available? And how will their contaminated clothes be handled? What about important personal items like their driver's license? How will you identify people as having been surveyed and decontaminated? There are companies who make kits precisely for decontamination, and these kits include a change of clothes, a sealable plastic bag for placing the contaminated clothing, soap and shampoo, and some even have a barcode so that a person's information can be entered and then thereafter everything related to that person can be scanned. In 2004, Los Angeles County participated in three large-scale RDD exercises, and two of these exercises included an effort to survey and decontaminate people at the scene. These exercises included Operation Synergy, which was a Department of Energy exercise, Determined Promise, which was a Department of Defense exercise, and Operation Calavera, which was in Los Angeles County exercise. During the Operation Calavera exercise, 400 volunteers acted as victims, and our County Public Health Psychological Programs Unit instructed many of them on anticipated behavior for people involved in such a frightening event. Their actions allowed our first responders to practice dealing with upset and frightened groups, and please don't underestimate the impact of psychological trauma in such an incident. One of the lessons learned from the sarin chemical incident in Japan was that the hospitals in particular had a large number of people presenting with physical symptoms that were ultimately due to psychosocial issues. The public health and medical systems will need to be prepared to deal with people's concerns in this type of a stressful event. In an event, our Radiation Management staff will immediately begin driving around, taking measurements and trying to footprint the plume so that we can relatively quickly begin making decisions about potential evacuation areas. The data gets reported to one location so it can be recorded and the radiation fields tracked. The county has a radio system and everyone is equipped with a radio. We suspect that may be our only means of communication. We're investigating a telemetry system that will automatically transmit the data to a computer so that many decision makers can be looking at the data as it's acquired, but that system is not yet in place. LA County has 13 portal monitors which we believe will provide the quickest way to monitor large numbers of people. The person simply walks through the monitor and it alarms when it detects radiation above the level that you've set on the instrument. We wrap the poles of the monitors with layers of plastic wrap so that should they become contaminated, we can easily unwrap them and continue operations. We'll also have layers of heavy-duty plastic to place between the poles again so that any contamination can be quickly rolled up in the plastic and won't interrupt operations. Each of our monitors is self-contained and that each has an industrial-sized roll of plastic wrap, a large roll of heavy-duty plastic in a carrying case with wheels, scissors, and a radiation check source. These monitors also have adapters so that the poles can be placed farther apart so that vehicles can drive through. There will be people who, simply based on their location at the time of the explosion, are likely to be contaminated, but for those who are not clearly contaminated, our plan is to have people walk through the monitor and go through showers only if they set off the monitor. They then would walk through the monitor again and if they're still activating the alarm, we'll use a handheld instrument to try and better determination the localized contamination spots. We would then assist in washing those localized areas. If the area is over their chest and they've already washed the area, that radiation may be coming from internal contamination because the county has so much experience with disasters. Earthquakes are obviously a big risk in California, but we also have had floods, fires, high winds, and unfortunately riots. Mutual-aid agreements between cities, adjacent counties, and the state have been long established. Everyone recognizes that no single agency has the resources to respond alone to a major event, and we'd integrate our response with the California Radiologic Health Branch staff. We've also worked quite closely with our federal partners. Because the Federal Environmental Protection Agency has a local office, we anticipate that they'll arrive quite quickly. The Department of Energy should be able to get resources to us within about four to five hours, and although the county has stockpiled some key-lating agents which help speed the radioactive material through the body, the Strategic National Stockpile, which is overseen by the Centers for Disease Control, also contains a number of radiological countermeasures. You can visit both the CDC and the FDA websites for additional information. In our county, we've drafted canned media announcements that follow the timeline of events. So the first announcement simply discusses an explosion and that we're on the way that we don't yet know whether radioactive material is involved through ordering an evacuation of some areas. We'd only need to fill in the location blanks in the announcements. We prepared these announcements in conjunction with the county bioterrorism preparedness psychiatrist who has special expertise in dealing with terrorist events to ensure that the message is appropriately received. We also expect assistance from our federal partners should the event exceed our capabilities. We'd expect CDC to deliver information to our medical providers if we have people who require medical intervention. As noted earlier, the Department of Energy is going to assist us in footprinting the plume so that we know what, if any, areas would need to be evacuated. But it could be four to five hours until these folks arrive. Because we have a local environmental protection agency office, they're likely going to also assist us in managing the incident. However, it's important to note that governments must be prepared to handle these incidents on their own, at least for the first few critical hours. I believe the county health officer, Dr. Jonathan Fielding, has the best approach when it comes to planning a response to a terrorist event. He says we'll probably never get to the point where we can say we're completely prepared to respond to such a horrible disaster. The issue is, are we better prepared today than we were yesterday? If we can say yes to that question, we're doing the right thing. All right, thank you, Cass. Now, we've talked quite a bit about the need for population monitoring following a radiological terrorism incident, the scope of such a process, and some practical considerations in planning at the local level. But it would be helpful to understand how the federal government might be involved. Bob, could you tell us a little bit more about what kind of federal assistance we might expect? As I mentioned earlier in the program, the federal government is available to assist the state and local authorities with any response to a radiological terrorist event, including population monitoring. The framework of our response capabilities are defined in the National Response Plan, which was released in January of 2005. We consolidated earlier disaster response plans. I'll mention that there is a review of the plan underway with an eye on the lessons learned from the 2005 Hurricane Katrina response. But at this time, we are operating under this plan. If changes are made, CDC will post a summary of these on our radiological emergency preparedness website. And we'll provide that address again at the end of this broadcast. Now, the goal of the National Response Plan is to improve coordination among federal, state, local, and tribal organizations with the objective of saving lives, minimizing human suffering, and protecting human health. This is to be accomplished by increasing the speed, effectiveness, and efficiency of incident management. The National Response Plan includes the base plan, plus emergency support functions, support and incident annexes, and appendices. The base plan provides the structure and processes for the national incident management approach. It includes the concept of operations, roles and responsibilities, implementation, guidance, authorities, references, and preparedness and plans maintenance. There are 15 emergency support functions, or ESFs, that group capabilities and resources into functions most likely needed during an incident. The emergency support functions describe the responsibilities of primary and supporting agencies that are involved during incidents of national significance. Support annexes provide the procedures and administrative requirements common to most incidents, including public affairs, financial management, and worker safety and health. Incident annexes describe the procedures and roles and responsibilities for specific contingencies, such as terrorism, radiological response, catastrophic incidents, et cetera. These annexes are typically supplemented by more detailed supporting plans. The appendices offer other relevant information, including terms and definitions. So the role of federal agencies in a radiological or nuclear terrorist event could be guided or would be guided by the incident annex for radiological response, as well as one of the emergency support functions, that is ESF-8. The nuclear radiological incident annex calls for the Department of Homeland Security to coordinate the federal response to incidents of national significance, such as terrorism incidents involving radioactive materials and large-scale accidents or incidents. The Department of Justice will be the lead agency for criminal investigations, but the coordinating agency will be determined by the type of emergency. Consequently, the coordinating agency may be the Nuclear Regulatory Commission, the Department of Defense, the Department of Energy, the National Aeronautics and Space Administration, or the Environmental Protection Agency. The Department of Health and Human Services is considered to be a cooperating agency under this plan. Under this emergency support function, annex 8, the Department of Health and Human Services is charged with coordinating public health aspects of the federal response to any incidents of national significance involving nuclear or radiological material including coordinating public health and medical information, organizing subject matter experts, assessing medical and public health status and needs, assisting in establishment of a registry for potentially exposed individuals, performing dose reconstructions and long-term monitoring of populations, evaluating requests for deployment of the Strategic National Stockpile and serving as a member of the advisory team for environment, food and health. Much of the support under this annex has been delegated to CDC. As a reminder, these services are provided at the request of and in support of the affected state or states. For all intents and purposes, the local and state officials will need to be prepared to handle the crisis without federal assistance for at least four to six hours following the event. Thanks, Bob. Well, we've heard quite a bit about the big picture for population monitoring, the roles and responsibilities of local, state and federal partners, and the approach that L.A. County is using in its preparedness planning. But I'd like to hear now about the approach that another expert is taking with this process. Greg, we've waited a long time to hear your recommendations. Let's have it. Thanks, Sharon. It would be my pleasure. As with many processes, the devil is in the details when conducting population monitoring, and there are many details to address in this as in any disaster. Of course, one of the first goals of any response to a terrorist incident is to determine the nature of the incident. So deciding if there is a side effect like chemical, biological, radiological is important. We're talking about radiation only for this broadcast, so although we won't discuss it, we have to keep in mind that other considerations are important for a combined attack. In fact, radiation may be the least of the problems encountered. Incident commanders need to take into account the number of people potentially affected and make fast decisions to reduce their radiation dose. Research on incident response often indicates that first responders tend to corral what they believe are the affected population until they can decide what to do with them. And I believe this response most recently dramatized on the BBC the HBO film Dirty War from which we showed a brief clip tends not to be effective for a variety of reasons. The biggest being that immediate radiation dose is increased because a significant waiting period occurs due to the fact that local responders can only handle so many people at a time. The affected population will eventually become unruly if held beyond a reasonable period which varies with the level of anxiety in the event and how in control officials appear. This time is generally shorter than incident commanders might predict. A usual work practice within the health physics and radiation protection community might also complicate response. It has to do with employee monitoring from known radiation sites or work activities. This attitude and effect is wait until I make measurements and document them before decontamination. I think this is not a prudent first response policy when it comes to the general public because it also increases potential radiation dose. In the case of the general population it's much more important to get the radiation off the body than it is to measure it. Of course the key objectives of the monitoring will be to identify individuals whose health is in immediate danger and need immediate care or medical attention, whether radiation related or not. Identify people who need to receive medical treatment for contamination or exposure or be further evaluated for short-term health monitoring. Recommend and to the extent possible facilitate practical steps to minimize risk and register individuals for long-term monitoring. First responders may note that victims and others in the immediate area may be covered in visible dust. This material needs to be immediately removed if possible. Medical treatment must not be delayed. Washing is not necessarily at this point, but I think if possible having the person wipe with a moist towel, paper towel disposable wipes might be appropriate. Bag and tag all clothing that is removed and do not discard it. Two other segments of the population must be dealt with quickly. Those spontaneously evacuating and those who need some kind of monitoring before they can go home. The group that spontaneously evacuates generally goes home or to a place they feel that they are safe. We need to give guidance through the news media to that population on what to do. This might include showering and bagging of clothing worn at the time of the incident and some simple contamination control techniques. This instruction might also include returning for monitoring at a point in the future. First responders may have to deal with people who self-present asking for monitoring and decontamination, although they may not know this is what they are asking for. This could be a combination of worried well and legitimate victims. Incident commanders need to have the ability to expand monitoring and monitoring locations to handle an increasing demand. I think we need to be very cognizant of the significant challenges that we may face in dealing with people with psychosocial issues. This could place tremendous resource needs on public health and medical systems. As a first bit of guidance, we might call this a monitoring and decontamination center in our plans. I'm not sure the public at large will understand what that means. Experienced with other mass casualty incidents shows that the public will understand simpler language, so calling the area of service a wash center might work better and facilitate immediate understanding with the public. We know it's much more than that. It is also important to realize that just because a person is sent to a wash center doesn't necessarily mean they will be washed. The area chosen for monitoring and decontamination needs to be controllable with definable entries and exits. Ideally, one might choose an all-weather facility like a nearby covered sports arena or convention center, but depending on the circumstances in the weather, a nearby park or large parking lot will suffice. Security will need to be provided and media relations people will be needed to control media access. I would also recommend that there be a series of greeters at the center similar to what some large retailers use at their retail stores. These greeters could answer questions, direct people to monitoring areas, and try to pull people with special concerns out of the line for special service. The number of greeters is important because explaining what is happening immediately is important in crowd control. I would suggest there needs to be one greeter per 500 individuals per hour. In other words, one greeter should be able to pass 500 people by his or her point in an hour's time frame. Greeters who speak other language common in the area would be really helpful. For instance, a person giving instruction to Spanish would be available for those who speak Spanish and can direct them appropriately. As people begin to line up for services, these stations need to be set up in such a way to give the perception of a moving line, not a stagnant line. Even if it takes a long time to get people through monitoring and decontamination, crowd control is significantly improved if you can create the perception of a moving line. Next, if people are forming lines to be monitored and possibly decontaminated, they need to have an opportunity to partially decontaminate themselves. This would be what we'd call a gross decon, again with paper towels or some kind of disposable wipes. Parks and sports arenas generally have large 55 gallon drums set up for paper waste. And these should be enlisted for this purpose. Don't be concerned with the amount of paper trash generated at this point, but keep it under control and collected. Not everyone will want to avail themselves of this first decontamination and that's fine. They can get in line. As I mentioned, a key goal of monitoring is to get people through it as fast as possible. Identify those who are contaminated health effect levels and deal with them. Those who are contaminated below health effect levels or have no contamination should quickly be allowed to go home or to a shelter. Individuals who cannot go home because of their home is in the affected area may not be able to go to a shelter with any measurable contamination. Red cross shelters typically will not accept individuals with contamination. They're not set up to deal with it. Or with the problem of perception of danger to others housed there. Monitoring stations need to be set up to process about 100 individuals per hour. To achieve this, I think that one must assume that most of the victims presenting themselves for monitoring are not contaminated at health effect levels. As monitoring lines form, other staff should walk the line with radiation survey instruments looking for individuals who might slow the line down. This monitoring assistant is looking for individuals who are highly contaminated, who might have medical problems, who might be pregnant, or who are underage and do not have a supervisory parent or guardian with them. Other individuals who may need special assistance include people who don't speak or understand simple English, who have cultural or religious issues which might slow down monitoring, who have issues because of age or mental status that might make understanding what is happening difficult. And this screening for walking the monitoring line is the beginning of a triage system enabling the monitoring center to process individuals quickly. One staff member per line would be sufficient to do this screening and it would all be based on a judgment call. I think it's important to remember that families should never be separated. Also, if you can recruit another individual, a friend for instance, to assist with the monitoring process, then they can help in having the group remain in place. As the person gets to the head of the line for radiological monitoring, three parts of the body are monitored initially, face, hands, and feet. This should take about 30 seconds per individual. If these three areas are not contaminated, it is highly unlikely that the rest of the individual is contaminated. Using a handheld monitor for this screening will work well to screen large numbers of people fairly quickly. Portal monitors are not readily available everywhere. If you're using portal monitors for this initial screening, they must be used carefully since they are easily contaminated. You may want to use them later in the process for screening smaller numbers of individuals who have been decontaminated. I reiterate CAS's comments regarding that you should develop a close relationship with your Radiation Control and Management Specialists whether they are in your health department, environmental agency, or other organization. They have extensive expertise in this area and can help you. If a person passes through this initial monitoring, they should be sent to an out-processing center where critical information can be collected such as name, address, etc. and instructions provided in a simple form. For example, a one-page fact sheet with instructions for a shower at home and instructions to watch TV or listen to the radio for further instructions. Readability is very important with these instructions and should be prepared and reviewed prior to dissemination. Words like decontamination, monitoring, external radiation, dose, internal radiation dose are poorly understood, if at all, by the general public. The handbook prepared by the conference of Radiation Control Program Directors which CAS mentioned earlier has some sample instruction sheets that could be used. CAS, you brought these up briefly to learn more about them. Sure, Greg. The handbook provides two different sets of instructions for the public. One is on how people can perform self-decontamination at home and the other provides instructions while they're waiting in line at a decontamination or wash center. The language is simple and straightforward with a brief explanation as to why people need to perform decontamination or be monitored and an explanation of how to perform decontamination. State and local health departments can use this information sheets to prepare their own materials that are tailored to their plans and procedures and with their own logos. I think these templates provide a good template for basic informational sheets to help members of the public understand their role in such an event. Thanks, CAS. Now, if an individual is contaminated beyond a set amount, the purpose of the secondary monitoring is to see what, if any, immediate steps can be taken to reduce radiation on that person's body. This might involve removing clothing which could be bagged and tagged for further future study. This would be handled similarly to evidence sample where with similar rigor and data collection. If a person's skin or hair is contaminated a simple technique is rinse wipe, rinse wipe with paper towels depending on air temperature. No personal identification, jewelry, money, or credit cards should be taken away from any individual no matter how contaminated. If they can't be immediately decontaminated they should be returned in bags with simple instructions on how to deal with them. You'll probably need two individuals per secondary monitoring station. It may take from five minutes to an hour to process an individual and the secondary monitoring station personnel should direct more and assist less in the decontamination process. Let's take a look at this secondary monitoring process. To begin a body survey the individual should be in a standing position. Holding the probe about a half inch away from the surface to be surveyed slowly move the probe over the head and proceed to survey the rest of the body particularly the shoulders, arms, and bottoms of the feet. You should be moving the probe about one to two inches per second. Be careful not to allow the detector probe to touch any potentially contaminated surfaces. Wrapping the probe in plastic wrap will help prevent surface contamination. A consistent procedure should be followed to help prevent accidentally skipping an area of the body. Pause the probe for about five seconds at locations most likely to be contaminated. A whole body survey should monitor the tops and sides of the person's head and face, the front of the neck and shoulders, down one arm pausing at the elbow and then turning the arm over, the backside of the hands and turning them over, up the other arm again pausing at the elbow and then turning the arm over, shoe tops and inside the ankle area and shoe bottoms. Record your findings on the survey form. The most common mistakes made during the survey are holding the probe too far away from the surface. It should be about one half inch or less for a detailed survey or one to two inches away for a screening survey. Moving the probe too fast it should be about one probe diameter per second or one to two inches per second normally. Twice that is acceptable for a screening survey. Contaminating the probe the probe background should be observed and compared to initial background. If within a factor of two it is acceptable to continue to use the probe. Otherwise check with radiation control personnel. Remember heavily contaminated individuals need immediate attention. A privacy area needs to be set up and a person would be escorted there by a floating staff person, a nurse, an EMT or another volunteer. These individuals might be identified at any stage of the process but hopefully would be identified by a greeter or a person walking the line with a survey instrument. Just as in a hospital emergency room vital information is collected alongside of trying to provide a health service. A goal of this stage is to get a person out of contaminated clothing immediately and get the radioactive material off their body as soon as possible. Unlike the rinse wipe technique mentioned previously this can also mean showering. If showering is to occur replacement clothing must be nearby. People who are able to shower should shower themselves using simple soap and warm water. I have some concerns about using cold water, hydrant water, or hydrant spraying or fogger nozzles since this may produce other undesirable health effects such as heart attacks or cold shock. In some locales finding a shower facility nearby might seem initially difficult if a sports arena can't be utilized. However one suggestion is to use a nearby hotel in the affected area. Staff can escort people to rooms where showers can be quickly used with minimal damage to the hotel. If an entire hotel is needed for a large population you will need staff members to manage the floors and you may need to instruct people to wait in rooms until suitable clothing can be brought to the hotel. Allowing them to use the phone and the TV will assist in crowd control. Anyone who showers needs to be re-monitored and if sent for a second shower if contamination is still present. If this fails you may need to assess the person for internal contamination using further techniques which should probably be accomplished at a hospital with the assistance of medical personnel. Again, at no time should an individual's identification, jewelry, money, or credit cards be taken. The individual can try to wash these items as they wash themselves or they can be bagged and returned. All contaminated clothing collected in the washing process should be bagged and tagged for further study. If a large number of individuals need extensive decontamination service it may be necessary to move them by bus to the hotel area or to another area set up for decontamination. It is probably not feasible to try to prevent the bus from becoming contaminated at this stage. Large caches of clothing might be needed to allow for victims to go to home or to a shelter. Individuals going home are the easiest to clothe as the robustness of clothing is secondary. In that regard hospital scrubs, paper clothing, sweatsuits, and t-shirts perhaps with blankets for warmth can be provided. Hospital scrubs are most likely available in a large community in quantity since hospitals and other medical providers turn them over on a daily basis. And commercial laundry may have large quantities in many sizes. Research has indicated that people are willing to wear these items home in an emergency. You can also reach into the community and use large retailers for children's clothing, shoes or flip flops or sandals or odd clothing needs. Incident officials needing these items should make arrangements for payments at the time of purchase or provide information to an ICS resource unit for procurement and payment. These resources are widely available throughout the country as you can see from this graphic. Individuals going to a shelter have to remove clothing items need more robust clothing. While sweatsuits might work for patients, personal dignity may require more. Communities should have cooperating retailers identified in their local emergency response plan, and if possible emergency purchase agreements pre-negotiated. At various places in the monitoring and decontamination facility, folding chairs should be used in temporary waiting areas. Some individuals, particularly the elderly may find it difficult to stand for an hour or more until they are in the monitoring process. In addition, certain special populations may arrive at your monitoring center, some of whom we mentioned before, you may want to consider also that people might bring their pets. As we saw from the response effort following Hurricane Katrina, some people consider their pets part of their family unit which will affect their behavior in this situation. People showing up with pets, especially service animals need to have the same services applied without question. While it may be difficult to wash a pet in a monitoring location, the concern with the contamination is great and the owner needs to be apprised of the options. The concern is less about the dose of the pet and more about cross-contamination to the owner and to others. It is probably not feasible to try to collect nasal swipes, smears, or any type of biological sample for laboratory analysis in this first stage of a local response. Those consequences are important but as a guide, most communities will not be able to do anything with swipes or smears or range for analysis until federal resources arrive. CDC and others will need information on victims and workers taken throughout the monitoring system. And we will provide additional guidance on that. While a collection of this information is voluntary and may assist in future recovery services. It is much more important in the early hour to provide services than to build this facility. As time permits, upgrade the facility and this would include adding a plastic floor covering and critical high traffic areas or relocating station by station to areas that can be set up properly. If the first monitoring area is temporary until a better facility can be built and people are available to do that, first responders should not worry so much about contaminating a park or building at the expense of an individual's health. I think that portal gamma radiation monitors can be used in population monitoring if you use them carefully. A community having a limited amount of portal monitors may want to consider using them at the end of other monitoring as one final pass before a person goes home. Portal monitors used too early in the monitoring process could become contaminated and could actually slow the monitoring process down. So we just need to be aware of the possibility of setting up this type of system. As Bob mentioned earlier in the program, staffing requirements will be a major challenge and the work will be quite strenuous and exhausting. You should consider shifts with workers rotated four to six hour intervals and given frequent breaks. Additionally, as the monitoring center becomes more functional, additional needs are protecting worker health and safety. As the federal government arrives to assist, many of the services provided will be augmented. As days and weeks progress, individuals may be asked to return for additional monitoring services including bioassays that might establish an internal dose. These analyses would be used for later dose reconstruction which would assist in assessing the need for long-term monitoring. At no time should the first monitoring effort give the impression that it is the last monitoring effort to be done on a person. Thanks, Greg. Well, this certainly gives us a better sense of the actual process of population monitoring, which I believe should be helpful to our viewers. Now, you mentioned the arrival of federal assistance at this point in the event, so I'd like to go back to Bob once more to tell us some of that support and assistance that CDC will be able to provide. I mean, Bob, what is CDC doing for its role in population monitoring and is it looking to provide some sort of guidance for local officials? Well, yes, we're doing quite a bit, Sharon. One thing we're doing, most importantly, is we're preparing a draft on radiological population monitoring guidelines right now, and we hope to have a final version within the next 12 months. Now, developing guidance, I would think, would be a pretty big undertaking. How did CDC go about determining which processes would be most useful in radiological population monitoring? Well, Sharon, let me say that we did not do it on our own. We started by holding a roundtable on population monitoring in January of 2005. This roundtable was designed to open the lines of communication between CDC and our partners and constituents to come up with practical radiation monitoring strategies for public health officials. We also included other participants from federal agencies, state and local health departments, academia, and professional organizations for health physics, epidemiology, health communications, psychology, radiological dosimetry, laboratory, social work, and contingency planning. The participants spent two days conducting 16 breakout sessions ranging from psychosocial issues to vaccination. When we then compiled a summary report of the roundtable and started to work on developing CDC's guidelines based on discussions by the participants, as you said, population monitoring is a very complex process. So we've been drafting and redrafting this material very carefully. Once the guidelines are drafted, and we expect this to be within the next few months, the draft guidance will be posted on our website for review and comment. And we will continue to work with our partners and other interested individuals and organizations to address this important issue. We've considered a variety of approaches, including the ones you've heard about today, and hope to be able to provide a broad framework from which local communities can develop or add to their plans. Sounds like a great plan, and it seems it will be quite helpful for future population monitoring, but what about now? Are there other resources available at this moment? Yes, there are, Sharon. On CDC's Ray Logical Emergency Preparedness Website, we have a number of materials that we hope you'd find useful, as well as links to other agencies and organizations that have information and expertise about Ray Logical Emergency Response, including population monitoring. Some of the CDC materials include a previous training for public health officials on the role of public health in a nuclear and biological terrorist event, as well as several components of a Ray Logical Terrorism Preparedness Toolkit for Clinicians. This toolkit includes CDC's Satellite Broadcast Training on Medical Response to Nuclear and Ray Logical Terrorism, which discusses basic radiation information for clinicians, medical management of Ray Logical Injuries, and decontamination procedures and staff protective measures for emergency services and other clinicians. This is a one-hour presentation. Just-in-time training is designed to provide a brief overview of basic clinician skills for Ray Logical Emergency involving mass casualties. In a moment, we're going to see a clip from a 15-minute-long training video that was created to address basic principles of radiation and procedures such as donning and removal of protective equipment and clothing, proper Ray Logical Survey techniques, and patient decontamination, followed by application of this information in several hypothetical patient care scenarios. And now, let's take a look at the clip from the just-in-time training video. A critical contaminated patient with a pneumothorax. Okay, out! It's the patient we called you about with a sucky chest wound. We got contamination here. Looks fairly low level. BP is 90 over 60, respirations 30 per minute, and shallow with retractions. He was made to be 50 feet from the dirty bomb explosion. He's got a deep wound on the right calf, sinus tachycardia around 130. He needs a protective step. Let's get his clothes off before we get him into trouble. Remove clothes as soon as possible, carefully rolling them away This may remove as much as 90% of the external contamination. For patients with life-threatening injuries, medical stabilization should take priority over radiological decontamination. You're going to tell me, let's get him on his way. Your hospital should have a policy and procedure for performing radiological decontamination inside the facility. Note that in this last scenario the decontamination team was still wearing all hazards PPE since the hospital had just received confirmation that radiation was the only contaminant. Mr. Jones, are you breathing better? This program may be used for basic pre-event staff training or just-in-time training of hospital staff assigned to support emergency services in an event. Now, also included in the toolkit are an emergency management pocket designed to accompany the just-in-time training. The guide provides a brief reference document for clinicians summarizing the key points of the training. A CD-ROM based training titled Rheological Terrorism, Medical Response to Mass Casualties should be available within the next month. It is intended for clinicians with some basic understanding of radiation injury and provides more detailed information about management of mass casualties or following a Rheological Terrorist event. Continuing education credit may be obtained for this training as well as the previous satellite broadcast training and just-in-time training. And three physician brochures provide diagnosis and treatment information about radiation injury including acute radiation syndrome, cutaneous radiation injury and prenatal exposure to radiation and can be used as reference material for emergency services as well as other physicians. You can request copies of these materials or submit questions about them to our email box at rsb.cdc.gov or you can visit our website at www.bt.cdc.gov I'd like to specifically solicit input from all our viewers and your colleagues about our materials this broadcast and any gaps you believe we could fill in this area in the future. We will continue to work with our partners to develop supportive products so it's essential to hear what is useful to you and what isn't. Now it's time for our question and answer session and let's begin with our first question Ladies First. Cass, this one I think is for you. Do you expect issues with portal monitors regarding background radiation from approaching individuals? Well it's a good question Sharon because you do need to be quite careful that you set the portal monitors a sufficient distance from each other so that you don't pick up radiation from other people and in addition the person waiting to go through the monitor also has to be at some distance from the monitor itself. It's a large issue when setting up portal monitors. All right Greg I think thanks Cass I think this question is for you Greg it's from Chris in California he wants to know what your recommendation is for handling the contaminated water that comes from rinsing individuals. Well in many cases right at the beginning you may not be able to do anything with it other than to let it go if it goes into a sanitary sewer we can deal with it later and a lot of guidance from the Environmental Protection Agency you know if you're trying to do this and you're trying to do it as a good Samaritan it's all right to let it go into the sanitary sewer early on but some departments will try to control it if they can but it really depends on the situation and what you can do quickly. All right thank you. During one of our exercises we realized what a problem it was for people to try and contain water because the firefighters contained the water and what we ended up with were very large pools of water that would have had radioactive contamination and it meant that the first responders were wading through six inches of contaminated water and so generally speaking if it's a large event it's probably going to be much better to just let the water go ahead and run off. It's amazing how many issues you all have to think about and I wasn't aware of. Now this question comes from Steven in Philadelphia and Bob I think it's best suited for you. When a patient is being treated for internal contamination is it recommended to collect urine or stool samples to monitor the effectiveness of the treatment? Well Steven it's very important to monitor the person's health anyway. For this instance for an internal radiological contaminating incident it's really important to know what you're treating. If it happens to be cesium for example Prussian blue will bind cesium in the gut allowing it to pass through to the feces so in that instance you'd want to collect feces to determine that the material and the removal processes are working appropriately. You'd also want to follow up and monitor the person. Again it's also helpful if it isn't a hospital situation that the hospital attending physicians and nurses bring in and ask for the help of the radiation control within their hospital. Alright thanks Bob. This is from CJ in California and Greg I think it's best suited for you but any of you that want to chime in on these answers please feel free. Regarding special populations in urban areas for example non-English speakers are the current guidelines or outreach activities targeting these special populations and trying to educate and perhaps better prepare them? Well we've seen some cases where yes this is happening a little bit but it really depends on the community if your community is diverse I think this is incumbent upon you as the first response person or preparer of the media information to look into your community and say well I've got these language issues I've got these cultural issues and I need to address these particular concerns so you can do this a lot and I hope in the future there'll be more guidance from the federal level to do this but right now it's going to happen at a local level. Alright thank you sir. Next question I think Cass is best directed to you it's from Chris in South Carolina writes we understand that stabilizing a patient takes priority over radiological contamination control but is there a point at which radiation health may be deemed dangerous and decontamination measures should be required before any admittance to the hospital? Yeah that's a really good question Sharon Well from an RDD event it is unlikely that any one person is going to have enough contamination on them that they will represent a threat to another person but the exception to that is if someone has fragments for example if there's an explosion and they have fragments embedded on their person those fragments could be quite radioactive and those fragments should only be handled by the use of tongs or something like that that no one should with their hands try and remove that type of a fragment Alright Cass thanks This next question is from Steven in Philadelphia and Bob I think it's probably for you since it's got CDC in the question Does CDC have a lab capacity to analyze bioSA samples in a rapid manner and if not is there a lab that does that kind of testing? Well Steven there are capabilities in the country at this time to do some of this bioSA analysis However what I can tell you the CDC is working very very diligently producing methods rapid detection methods in human samples collected from individuals for monitoring individual contamination and also the treatment to monitor the effectiveness of the treatment with the radiological countermeasures contained in the stockpile What's important here is as the CDC increases its capability of detecting this through laboratory processes we're also going to be working with the state and local labs to help them with the methods and increasing the network of labs across the country so that we can rapidly assess a large number of people Thank you Bob This next question I think is probably a tough one It's from John in New York and I'm going to let you all weigh in what would be considered an appropriate time frame for activation of federal assistance and which emergency support functions should be activated Have at it guys Greg you want to start? Well a lot of it depends on where you are, where we are and how fast we can get to you and the other things that are going on around the accident so if there's a multiple incident and they're across the country and as we saw in September 11 the airlines would have been all the airlines would have been put on the ground so that can complicate response but most of the departments in the federal government try to get under way sometime between four and six hours and the mobile assets and things that would be driven like mobile laboratories and things like that can take longer to get there and obviously once you put something on the road it takes a while to drive to wherever you are so that's a complicating factor too What would you say to that? Well CDC would respond as the other federal agencies would respond to this under the national response plan we have an emergency operations center at CDC that would activate immediately upon notification of a major event such as a radiological or nuclear terrorism event we have people that would as I mentioned earlier in the program that are part of the advisory team for environment food and health and their activities are looking at protective action recommendations to assist and support the states in that process so although we may not be on the ground immediately to assist and support the states we will be able to assist and support them through the emergency operations center which has direct links to all the health public health departments across the country so I think we can assist very early being on the ground will take some time especially with the large federal assets that have to come to bear Alright Bob thanks for that as you are sitting in a large metropolitan area what would you consider an appropriate time frame as somebody who may be frantically waiting? Yes Sharon from a local perspective the real issue is has the incident exceeded your local resources because if you can handle it on your own then you may not need federal support but if you do need federal support really they can't get there quickly enough so the time frame is going to be a critical issue as Bob mentioned there will be a lot of support just by telephone and email and that kind of electronic communication and so I think the important thing for people to remember is that they're not out there on their own there are any number of agencies and individuals who will be willing to provide support either by trying to get to the scene or by trying to communicate electronically Alright thank you much here's an interesting question Greg I'm going to throw it to you communities around nuclear power plants already have plans in place that exercise every six months why can't they just use those? Well I'd say it's a great place to start basically nuclear power plants by and large are located in lower population areas and that's an example of a good scale to start with you know how many people can be monitored and decontaminated but I would say maybe what you need to add to plans like that is to be able to handle large amounts of population in urban centers which typically we haven't planned for so we've got to think a little bit further on this and say ok here's a good place to start with the nuclear power plant plans and we can scale those up to handle even bigger events Alright thank you Kim from Virginia wants to know CAS How will the CRCPD manual differ from the NCRP 1380 138 I guess First of all let me mention that there is a National Council on Radiation Protection report number 138 that has been around for some years and it has been extremely helpful but they're also in the draft format of a commentary to 138 which adds some additional and more specific guidance our document does not differ greatly from the NCRP report or the commentary in fact we used the existing 138 as guidance when we developed our handbook there are some differences but not by orders of magnitude and so frankly the guidance from these agencies is quite similar and in either guidance would be appropriate for responding to an event And since you're already on camera here where can people get the public announcements prepared by LA County they can get those documents by contacting the Centers for Disease Control and they can send them an email at rsb at cdc.gov Alright thank you CAS Bob I think this next question best goes to you but again any of you can weigh in if you want When will the federal authorities be able to take over the response and population monitoring for a radiological event that would be a loaded question because I guess sometimes you just don't know Well it's a good question let me first say that the federal government would not come in and take over the emergency response Back to the original information that's already been presented in the satellite webcast we know that all events start out local and that request from the local authorities would come and provide the federal support and assistance that we would bring to bear emergency support functions in support of the national response plan so we would not come in and take over however we would be ready to assist and support the states and whatever activities they would like us to help them with Alright Bob thank you I'd like for all of you to weigh in on this next question because I've often wondered about this what if people don't want to be monitored or decontaminated either because they don't trust the government or because they have religious issues I mean this could be a real issue how do you handle that I'll let you start there I think basically if they don't want to be monitored they're not monitored but you as a first response official need to say look here is the problem here are some things that you need to do when you get home when you get somewhere where you can do this because if we think your health is at risk you need to do something about it and those things need to happen fairly quickly Yes we would never force anyone to undergo monitoring or decontamination and one point that I also wanted to make was that when we talk about removing the person's clothing we are talking about their outer garments so people don't need to be stripped naked for something like this but if they prefer to go home that is our guidance is to let them go home and do self decontamination at home and Bob I'm a little surprised by that because are they not a danger to other people if they're very contaminated it would probably not be likely they'd be an immediate danger or threat to others however as Cass and Greg both pointed out allowing them to go home to self decon would be preferable if they did not want to be monitored or decon at a relocation or reception center the important aspect is getting them critical information they can take home with them allowing them the opportunity to self decon themselves in an appropriate manner whether they could bring back their clothing or bring back their pet or whatever for monitoring later if they so choose so allowing them that option but also giving them the information they need to make the appropriate self protection measures alright thanks Bob now this next question comes from Mary in Florida and it's for you Cass she wants to know if there are any lessons that you gained from Operation Televera yes Sharon we learned a lot from all of our exercises and especially Operation Televera one of the things I mentioned earlier was the issue about damming the water so that it doesn't flow away there was just 6 or 7 inches of water that we were all trying to wade through and had it been a real event that water would have had radioactive contamination in it so it's an important point to perhaps not try and maintain water if it's a large event and a lot of water is being utilized another issue had to do with other agencies recognizing radiation experts and allowing them to participate in the event this has been an issue in all of our exercises as well even though we have done tremendous outreach trying to get our fire and police officers to know who we are and what we do and how we can help them that has been an issue at each of our exercises and that's why I mentioned it is so important to contact your local radiation control programs or state radiation programs now before an event and assure that there's a method to integrate them into your response plans they should actually be in your written plans so that if there's a radiation event the people with radiation expertise are on the scene and individuals know that they should pay attention to what they're saying and they should probably follow their guidance alright Cass, thanks now this is not a question it's actually a comment from Will in Kentucky Will wants to remind viewers that there are civil support teams that can be mobilized in states in one to two hours and can reach surrounding states in four to five hours so that's something to keep in mind too nice to know this next question is for Bob Bob, can CDC funding to states be used for preparedness activities related to population monitoring? oh that's a very good question we get that question quite a bit from our state public health partners the answer is basically yes the bioterrorism grant funding that's out there for now for states to take advantage of specifically talks about bioterrorism events for their BT grant funding application but it also mentions other emergencies and we feel strongly that radiation is one of those other emergencies and it is one of which you can use the BT grant funding for we do know that some of our state public health agencies have received funding and have enhanced their preparedness and response activities and planning activities with that BT grant funding what's important to remember as most of this funding goes to public health departments within the states if the radiation control program is not in your public health department within your state you should seek out their assistance in applying for these fundings because the information, the language the terminology they use will help better your application through the process for receiving these funds Cass, I think this next question goes to you you mentioned that people who are critically injured should not be decontaminated before being treated with life-saving measures but that's not what clinicians have been taught why change the policy very good question this is an ongoing issue it's an enormous training issue most clinicians have not had extensive training on handling radioactively contaminated people and even fewer actually have experience with handling these people it is just so unlikely that any person is going to have an amount of radiation on them that would represent a risk to their own person or to those working with them that handling their life-saving issues takes precedence over decontaminating always and it is the issue is if you try and decontaminate them and you may have saved them and yourselves a very small amount of radiation does in the meantime that person has died and so life-saving efforts always take precedence over decontaminating someone now if they don't have life-threatening injuries if we're talking about a broken arm then they should be decontaminated prior to being sent to a hospital but if they have life-threatening injuries those injuries should be treated prior to even worrying about contamination issues alright Cass thanks Greg let's send this next one your way how do you address surveying for alpha contamination well that's a tough one basically one of the things that we recommend is that when you first go to a scene you find out if you have radiation there you look for both beta and gamma radiation which are the easiest to measure and then you also look for alpha contamination also and you need specialized survey equipment to do this and then the only event it kind of changes the ball game completely because you've got a lot of potential for internal contamination and we really need to look at that as a special kind of event and look at it a lot in a different way than we have some of the other traditional radiation events but again a lot of it is monitoring internal contamination and there are all kinds of additional problems that we might have to deal with in the future so I'm going to send this one to you in Washington thanks Sam this is from Brian in Ontario and I think Cass perhaps you are best suited to answer this do you have any alarm trigger set point values for your portal monitors and if so what are they our specific portal monitors are established so that you can set them to alarm at any number of standard deviations above background at two times standard deviations above background or three times so there is not a specific number and this is something that we're going to handle the event specifically so that we'll know what the background level is and then we'll set it accordingly again the monitors must be set at some distance from each other and from other people so that they don't pick up contamination or radiation levels from adjacent people do you have something to add to that? the contamination monitors that you have the portal monitors that you have are really nicely designed because traditional portal monitors typically have a foot monitor on them also and if you have a bunch of people going through and someone stands on it and they had something on their shoes they can contaminate the portal monitor and so that may make it to where you have to stop clean it up, get it ready to go again the things that you have are better in that regard because they only monitor over the top and that's the big assessment that we need to make we have one more question and Bob I think it ought to go to you should we be distributing KI at the monitoring centers I don't even know what KI is KI is one of the substances I mentioned when I was discussing the material that's in the strategic national stockpile it's a nuclear counter measure that is normally referred to as potassium iodide KI for short which is usually distributed and available to states that have nuclear power plants and they have plans in place for it and in the nuclear power plant situation the KI distribution policies are usually in supplement to the normal protective measures of evacuation and sheltering for radiological terrorism events in an RDD situation radioactive iodine to be present in these kind of events and therefore potassium iodide may not be useful for the IND or nuclear detonation scenario there may be a plume of material that travels many miles down wind if KI is available that can be distributed early enough before that plume arrives one of the problems that we've noted with KI is that it has to be distributed or taken just before or very shortly after exposure to radioactive iodine the things to consider about potassium iodide use is it's only available for one radionuclide which is iodine 131 it only protects one organ of your body which is the thyroid and it has to be used shortly before or very shortly after exposure so it has very much limitations and it's received a lot of press about being a radiation and anti-radiation pill so as you can see from what I've described on these limitations it is really not and we need to use it appropriately alright good to know thanks Bob well unfortunately that's all the time we have for your questions but thank you so much for your calls your faxes and your emails and remember if you did not have your question answered during this program we will post all our answers on our website that's www.bt.cdc.gov slash radiation April 2006 well it has been my pleasure being your moderator for this program and I'd like to thank our distinguished panel of experts you guys have been a joy to work with especially we'd like to thank you our viewers for participating in today's program preparing for radiological population monitoring and decontamination this is Sharon Collins wishing you a great day from Atlanta