 Use of trade names or commercial sources is for informational purposes only and does not constitute an endorsement by the United States Department of Health and Human Services or the Public Health Service. Views expressed by guest participants are not necessarily the views of the Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The CDC designates this educational activity for 1.0 Category 1 credit toward the AMA Physicians Recognition Award. Each physician should claim only those credits that he or she actually spent in the activity. This activity for 1.2 Contact Hours is provided by the Centers for Disease Control and Prevention, which is accredited as a provider for continuing education in nursing by the American Nurses Credentialing Centers Commission on Accreditation. The Centers for Disease Control and Prevention has been approved as an authorized provider of continuing education and training programs by the International Association for Continuing Education and Training and awards 0.1 Continuing Education Units. The Centers for Disease Control and Prevention is a designated provider of continuing education contact hours in health education by the National Commission for Health Education Credentialing Incorporated. This program is a designated event for the Certified Health Education Specialist to receive 1.0 Category 1 Contact Hour in Health Education, CDC Provider Number GA0082. CDC and our presenters wish to disclose that they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. Presentations will not include any discussion of the unlabeled use of a product or a product under investigational use. The website to receive continuing education credits is www.phppo.cdc.gov.phtn.webcast.nuclear05.default.asp. The origination date for this satellite broadcast and webcast is February 3, 2005. Continuing education credit for these live activities will expire on March 7, 2005. Live CE activity numbers are SB0168 and WC0068. If you would like to view this program after March 7, 2005 as an archived webcast, the course number will be WD00062. Continuing education credits will expire on March 7, 2008. A complimentary videotape or CD-ROM of this program may be obtained by sending an email to rsb.cdc.gov. Hello everyone, welcome to the role of public health in a nuclear or radiological terrorist incident. I'm Kisa Daniels, I'm your moderator for this program, which is being broadcast from the Centers for Disease Control and Prevention in Atlanta, Georgia. The program is sponsored by CDC and the Public Health Training Network. The goals of the program are to provide the public health workforce with information related to radiation, including the difference between ionizing and non-ionizing radiation, types and penetrating abilities of radiation, possible nuclear and radiological threats, radio protective measures, contamination with radioactive materials versus exposure to radiation, and protective action guides. Another goal is to provide the public health workforce with the following information related to the role of public health in a nuclear or radiological incident, such as the basic roles and responsibilities of public health, initial and long-term response roles, the national response plan, role of health and human services, HHS, and the role of CDC. At the completion of this broadcast, participants should be able to, number one, explain the basic principles of radiation, describe protective action guides for a radiological incident, describe the responsibilities of CDC in a radiological incident under the national response plan, explain the roles of CDC in a radiological incident, discuss the initial response roles of public health in a radiological incident, and describe long-term response roles of public health in a radiological incident. If you'd like to receive continuing education credit, you must register with the CDC ATSDR Training and Continuing Education Online System. You can access that information at www.phppo.cdc.gov forward slash phtn online. Once you've registered, you must complete an evaluation for the activity. And now that we've gotten some of our housekeeping out of the way, let's set the stage for our upcoming discussion by viewing one possible terrorist scenario. It's a beautiful, chilly fall day at your local university. A great day for football. The sun is shining as a capacity crowd cheers on the local team competing for a conference playoff spot against their biggest rival. Just as the home team makes a first down on the 30-yard line, the fans go wild. There is a horrific explosion from the other end of the stadium. A split second of silence follows. Before panic screams are heard, people begin jamming the exits to escape the scene while others are trapped in debris beneath the stadium. Within minutes, sirens are heard as first responders begin racing towards the stadium. Police and fire vehicles as well as ambulances fill the roadways outside the stadium as thousands of people covered in dust and debris flee the scene. First responders arrive at the stadium and check for biological, chemical, and radiological agents but find none and continue to work in the area. Within a few hours, hazmat teams arrive and survey the scene using more sophisticated radiological instruments and discover that a significant amount of radiological material is present. The explosion at the stadium was a dirty bomb. Those who left the scene may have been contaminated with radioactive material and have by now spread that material all over the city and possibly the country. What do you do? That's a poignant question and here to help us define our roles in such a scenario are James M. Smith, Ph.D., a Biophysicist and Associate Director for Radiation with the Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention. Charles W. Miller, Ph.D., a Health Physicist and Chief of the Radiation Studies Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention. And Debra McBoss, CHP, from the Washington State Department of Health, also a Health Physicist and Head of the Environmental Radiation Section, Department of Health, Washington. And a big welcome to all of you and Dr. Smith. We're going to get started with you first. Thank you, Kisa. Well, first I think it's important for us to define what we mean when we say radiation. The term can be associated with a variety of sources, nuclear sources, for example, radio and television signals, energy from the sun, light, heat, and microwaves. If we look at the electromagnetic spectrum, we see that radiation generally can be divided into two very broad categories. The higher energy radiation on the right side of the spectrum has sufficient energy to eject electrons from atoms and molecules when it interacts with matter. Now, this reaction creates highly reactive atomic and molecular species. And we refer to this process as ionization, and therefore we call this ionizing radiation. Now, on the lower energy part of the spectrum to the left, we of course refer to that as non-ionizing radiation, and this includes electrical power, microwave energy, light and radio, and television signals. What we are discussing today involves ionizing radiation exclusively. They hire energy part of the spectrum. Now, in addition to x-rays and gamma radiation, which are a part of the electromagnetic spectrum, there are three other common types of ionizing radiation emitted during radioactive decay or nuclear fission. These are alpha and beta particles as well as neutrons. Each type of ionizing radiation has a different ability to interact with and penetrate matter. These properties can significantly influence not only the potential health effects of each type of radiation, but also the actions we should take to protect ourselves and others. Alpha particles may be ejected from the nucleus of an atom during radioactive decay. They are relatively heavy and travel only about an inch in air. They can also be easily shielded by a single sheet of paper, for example, and cannot even penetrate the outer dead layer of skin. So they pose no danger when their source is outside the human body. Beta particles are essentially electrons emitted from the nucleus of a radioactive atom. They are lighter than alpha particles and can travel farther in air up to several yards. Very energetic beta particles can penetrate up to half an inch through skin and into the body. They can be shielded with less than an inch of material, such as plastic. In the case of lower energy beta particles, the outer layer of clothing can act as an effective shield. Gamma rays, the most energetic part of the electromagnetic spectrum, can be emitted from the nucleus during radioactive decay. They are able to travel tens of yards or more in air and easily penetrate the human body. Shielding this penetrating type of radiation requires thick, dense material, such as several inches of lead or concrete. Neutrons can be released from the nucleus of an atom during a fission reaction, such as within a nuclear reactor or upon detonation of a nuclear weapon. Neutrons, like gamma rays, are very penetrating and several feet of concrete is needed to shield against them. When we speak of radioactive materials, we mean those substances that contain nuclides or isotopes that spontaneously emit ionizing radiation through radioactive decay. Some common examples include those that are naturally occurring, such as carbon-14, potassium-40, uranium-238, and those manufactured for use in medicine, such as technetium-99M, iodine-131, and thallium-201, and those from nuclear weapons fall out, such as cobalt-60, cesium-137, and plutonium-239. One of the most confusing aspects of radiation is the notion of someone being contaminated versus being exposed. Now, simply put, contamination refers to having radioactive material on or inside of the body. Exposure, on the other hand, refers to radiation energy 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. In general, we measure radiation exposure in terms of absorbed dose, that is the amount of radiation energy absorbed by an object divided by the mass of the object. In the U.S., the unit we use is the rad. However, internationally, the unit is the gray. Fortunately, it's easy to convert, one gray is equal to 100 rads. Now, the biological and health effects from radiation exposure depend directly on the absorbed dose, but are modified by biological factors as well as the type of radiation. When we calculate the biologically effective dose, it is common in the U.S. to use the unit of REM. Internationally, the unit sievert is used. Again, an easy conversion, one sievert, is equal to 100 REM. To get a feel for this measurement, note that a chest x-ray is about one one-hundredth of a REM, or 10 millirem. It's important to point out here that radiation is all around us. For example, we're exposed daily to radiation from cosmic sources throughout the universe, to naturally occurring radioactive isotopes in our body, and even the radioactive gas radon in the air we breathe. Each year, we are exposed to about one-third of a REM from all sources combined. As you can see from this graph, we receive most of our annual dose from breathing radon, but we also receive some from medical exams such as diagnostic x-rays and from radioactive nuclides in the soil such as isotopes of radium and uranium. The basic mechanism by which radiation expresses biological effects is through interaction with the DNA found in the cells of our body. Damage to DNA can result in cell death, and if sufficient numbers of cells die, the result can be injury to tissue or organs. But even if the cell survives the damage, it can still be transformed or mutated in some way. So, either cell death or cell transformation can lead to a variety of possible health consequences. We should note here that although we have learned much about these mechanisms through decades of basic research, the complete picture of how radiation causes biological effects has yet to emerge. More research is needed. Now, people are often quite concerned about radiation exposure because of the known health effects associated with it. Some of these include death at very high doses, mutagenic effects which can lead to genetic changes in subsequent generations, carcinogenic effects, and other biological effects especially at high doses. First, let's consider the early acute effects from high doses. Now in the range of about 100 to 400 REM, most people exposed will survive with appropriate medical care. The symptoms in this dose range include nausea and vomiting, fatigue, loss of appetite, and general malaise. In the 400 to 600 REM range, about 50% of those exposed will die. The symptoms include all of the above plus diarrhea, fever, hemorrhage, inflammation of the mouth and throat, and emaciation. In general, these symptoms may begin within minutes to days after exposure and the higher the dose, the earlier the symptoms will appear. As the dose increases above 600 REM, the probability of survival rapidly decreases. The cause of death in most cases is destruction of the person's bone marrow which results in infection and internal bleeding. In addition to acute effects from doses above 100 REM, there can be adverse health consequences that occur at not only lower doses, but are delayed for years or decades following exposure, the primary late effect that has been identified is cancer. However, it is important to note that the occurrence of a radiation induced cancer is highly influenced by a variety of factors, primarily the radiation dose, but also the age and gender of the person exposed, as well as the specific organs irradiated. Now some examples of the more radio-sensitive organs include the bone marrow, the digestive system which includes stomach and intestines, and the thyroid gland. Also note that the female thyroid and breast are more sensitive to radiation induced cancer than those of the male. And in general, children are more sensitive to carcinogenic effects of radiation than adults, older adults are the least sensitive. Well, I'll wrap up here with some practical suggestions on reducing one's exposure to radiation in the case of a radiological or a nuclear event. The easiest and most effective way is through the use of time, distance and shielding. Simply put, to reduce your radiation exposure, decrease the time spent near the radiation source. Increase the distance between you and the source, that is, get as far away as possible. And finally, provide as much physical shielding between you and the source as practical. With regard to physical shielding, the Environmental Protection Agency's Manual of Protective Action Guides gives these estimates of the effectiveness of a variety of shelters. As you can see, within a large building where people may be able to move to the center, away from a source located outside the building, people can reduce their doses by up to 80%. On the other hand, a wood frame structure in which people are sheltered on the first floor only offers about a 10% reduction in dose. So, Kisa, it's important to remember that any reduction in exposure that can be practically achieved, whether through time, distance or shielding, is the safest way we can protect ourselves and others from any potential harmful effects of radiation exposure that is not desired. Dr. Smith, thank you so much for helping us understand some of the basic concepts associated with radiation. Appreciate you. We turn now to Dr. Charles W. Miller, who will discuss some potential terrorist nuclear and radiological scenarios and the role of CDC in such an incident. Dr. Miller. Thank you, Kisa. When we discuss how radioactive material could be released into the environment by terrorists, we're talking about two basic categories of events. A radiological incident or a nuclear 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. 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. Now 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 a high energy radioactive source in an area where people would be exposed to radiation without their knowledge. Examples of nuclear incidents, on the other hand, include a targeted attack on a nuclear facility, a nuclear weapon detonation, or an improvised nuclear device, sometimes called an IND. Nuclear facilities are heavily guarded and have many built-in safety features. Also, modern nuclear weapons are very carefully controlled, reducing the ability of terrorists to obtain one. But what is an improvised nuclear device and how destructive could such a device be? Now, when I hear that something is improvised, I often assume that we are talking about something crude and not very efficient. In 1945, the United States dropped two atomic bombs on Japan. The device dropped on Hiroshima was nicknamed Little Boy. This bomb resulted in over 120,000 casualties, both dead and injured, and widespread physical destruction. The design of Little Boy was so simple that this design was never tested before the bombing of Hiroshima. From a physics and engineering point of view, Little Boy was an improvised nuclear device. If terrorists were able to obtain the right radioactive materials, they could potentially build a weapon of this magnitude. Now, the Department of Homeland Security is aware of this fact. In 2003, they released a report noting that for an improvised nuclear device greater than 100,000 patients could require evaluation and treatment. However, most experts consider an RDD or other malicious use of radioactive source to be a more likely scenario. This scenario is more feasible because of the wide availability of radioactive sources. Currently, there are 157,000 licensed users of radioactive materials in the United States. Two million devices containing radioactive sources are in use around the country. And each year, about 400 sources are lost or stolen in the United States. Now, most of these sources are small. Others, however, are much larger and more radioactive, such as sources found in food irradiators and radiotherapy machines. Furthermore, many radioactive sources that are physically small are strong enough to injure people if the source is not properly shielded. In addition to radioactive sources in the United States, these types of sources are found all over the world. In the former Soviet Union, some sources still remain unaccounted for and unsecured. The International Atomic Energy Agency, or the IAEA, is working to locate and secure as many of these sources as they can. The photo on the left shows a battered radioactive source container that was recovered by the IAEA. The photo on the right shows four of those devices used to irradiate agricultural seeds. Each of these irradiators, which were widely used in the former Soviet Union, contained a large amount of radioactive cesium-137. Radioactive material from any of these containers could be used to build a radiological dispersal device. Now, as I mentioned a moment ago, a radiological dispersal device does not necessarily need to use explosives to spread radioactive materials. For example, terrorists could covertly plant radioactive sources in order to contaminate people and the environment, or such materials could simply fall into the wrong hands. The most notable incident involving the release of a radioactive source occurred in Goiania, Brazil in September 1987. Though this was an accidental release of radioactive material, it is a notable example of the impact that a radiological dispersal device could have. In this incident, people seeking scrap metal to sell entered an abandoned cancer clinic and removed a discarded radiotherapy machine containing 1,375 curies of radioactive cesium-137. Now, this is less than half of the cesium-137 found in one of the seed radiators shown previously. Junkyard workers opened the canister and found a blue powder inside, which they took home to their families and neighbors. People in the community admired this powder because they found that it glowed when they spread it on their skin. As a result of this accidental radiological dispersal event, 249 people were exposed to radiation or contaminated with cesium-137. 54 people were hospitalized, eight with radiation sickness, four of whom died. However, the important public health message to remember from this incident is that although only 249 people in the city of Goiania were affected by this incident directly, 112,000 people demanded to be monitored for contamination and screened for exposure. That is more than 10% of the total population of Goiania. Furthermore, it is interesting to note that this event was first identified approximately 10 days after the powder was first released from the unit and the person who made the discovery was a physician working in a public health clinic when a patient with radiation sickness came to him seeking treatment. Now, if such a radiological incident occurs in the United States, CDC will be a part of the response. But before we discuss CDC's specific roles, it is important to understand how CDC fits into the government response structure. First of all, I think that it is important to remind ourselves that all emergencies are local. If a terrorist attack occurs, it will be the responsibility of local public health response organizations to determine if they need the assistance of the state public health organizations. In turn, it will be the responsibility of the state agencies to determine if they need the assistance of federal public health response organizations. Now, obviously, many agencies other than public health will be involved, too. But we must never forget that protecting people's health is the overarching goal of all emergency response activities. While all incidents are local, if you deem that you need assistance, CDC will respond. Remember, you are not alone. Now, as you are undoubtedly aware, the Federal Response Plan is being replaced by the National Response Plan or NRP, which is currently being phased in. You may view and download the NRP from the Department of Homeland Security website at www.dhs.gov. Now, the NRP includes the base plan plus emergency support functions, support and incident annexes, and appendices. Now, 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 that group capabilities and resources into functions most likely needed during an incident. These ESFs describe the responsibilities of primary support agencies that are involved during incidents of national significance. The support annexes provide the procedures and administrative requirements common to most incidents, such things as public affairs, financial management, and worker safety and health. Now, the incident annexes describe the procedures and roles and responsibilities for specific contingencies such as terrorism, radiological response, and catastrophic incidents. These annexes are typically supported by more detailed supporting plans. Now, the appendices offer other relevant information, such as terms and definitions. The Department of Health and Human Services, or HHS, is designated as the coordinating agency for public health and medical services, which is emergency support function number eight. In turn, HHS has tasked the centers for disease control and prevention to coordinate with state health agencies on issues related to health surveillance, worker health and safety, public health information, vector control, and all hazard public health and medical consultation, technical assistance, and support. Now, as I mentioned previously, in addition to emergency support functions, the NRP includes annexes that address specific emergencies, one of which is the nuclear radiological incident annex. Under this annex, the Department of Homeland Security coordinates the federal response to incidents of national significance, such as terrorist incidents involving radioactive materials and large-scale accidents or incidents. The Department of Justice is 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, if it's a nuclear regulatory licensed event, the Department of Defense, the Department of Energy, the National Aeronautics and Space Administration, or the Environmental Protection Agency. Under this annex, HHS is a cooperating agency. That is, through our responsibilities as defined in ESF number eight, HHS will coordinate public health aspects of the federal response to any incident of national significance involving nuclear or radiological material. As part of the nuclear radiological incident annex, HHS will aid state and local public health agencies in inspecting production, processing, storage, and distribution facilities for human food and animal feeds, collecting samples of agricultural products to monitor and assess the extent of contamination, providing advice on proper medical treatment, and providing advice and guidance in assessing the impact of the health effects of radiological incidents. In addition, CDC, as an agent of HHS, will assist in the management of long-term public monitoring in support of the affected population, collecting and processing blood samples, body fluids and matter samples, and advising on medical assessment and triage of victims. CDC and HHS will also assist states in tracking victims' treatments and long-term health effects, and provide assessment and treatment teams for those exposed to radiation or contaminated with radioactive materials. CDC will respond if and when to determine that we are needed. CDC will not come to your city or county and take over from the people who know the area and the residents best. That is why it is especially important for state and local public health professionals to understand their roles in response to a nuclear or radiological incident. Now, I'm going to let Ms. Deborah McBaw cover the local response roles in the next section of this presentation. Thank you, Dr. Miller. We have heard public health professionals express a lot of confusion regarding their particular roles during a nuclear or radiological incident. During 2003 and 2004, the Association of Schools of Public Health conducted focus groups with a variety of people from around the United States. As part of this work, 13 focus groups were conducted with members of state and local public health agencies. During these focus groups, public health workers expressed concern with their roles in response to a nuclear or radiological incident. One participant stated, I haven't heard that I am involved and I don't want to be involved. And another participant added, right now the lab has no plans and is not directly involved. We're more involved if there is a biological attack. But the truth is that should a nuclear or radiological incident occur, everyone in the public health system will have a role. But are we ready to respond? Despite the increase in federal aid to prepare the public health workforce, we still have much to do to be ready to respond to an incident. Some things that public health professionals should do in preparation include developing partnerships with other state and local agencies. Communicate with agencies and stakeholders from inside and outside the public health community. Make plans and conduct drills with these stakeholders. The more prepared we are to work together, the smoother operations will run during an actual event. Identify team roles and people within the community who can fill these roles. Determine public health roles within the incident command structure and identify who will fill those roles. Develop communications messages for a variety of scenarios and keep them on hand for tailoring post-event. It is much easier to develop messages in advance than during the confusion that follows a major incident. Find out who is responsible for what actions in your state and how to contact these people. And develop a list of resources available within your state and community. Include websites such as the CDC Radiation Emergencies website and contact information for several groups, including local fire departments, EPA regional office, hazmat teams, local nuclear medicine staff and radioactive material licensees, both of which have radiation detectors and people familiar with radiation and how to handle radioactive materials. Most importantly, I encourage you to have the name and contact information for your state Radiation Control Program Director. This person is vital in both planning for and responding to a nuclear or radiological incident. In planning, remember, assistance is also available from federal agencies. The CDC will assist you in responding and resources such as the Federal Radiological Monitoring and Assessment Center, known as VIRMAC, are available through the Department of Homeland Security for surveying the scene and determining radiation levels. This assistance must be requested by the governor or tribal leader. Until this request is made, community leaders are responsible for coordinating the response. Remember, even when CDC and other federal agencies arrive, they will provide assistance and recommendations only. Most of the major response roles and certainly the responsibility for them will still fall to the local public health professionals. Within the local government, the chief executive officer, that is the mayor or city or county manager, is responsible for coordinating the local response and resources. If necessary, he or she may suspend local laws, for example, establishing a curfew or directing that an area be evacuated. They are also responsible for communicating with the public. The tribal chief executive officer has all of the same responsibilities as the local, and in addition, may communicate directly with federal officials to request assistance without going through the state's governor. Should a nuclear or radiological incident occur, state and local public health need to be prepared to do many things. Some things to keep in mind as you prepare are that the workforce will be responsible for monitoring workers' health and safety, assuring there are plenty of safe shelters and healthy food and water supplies, coordinating sampling and laboratory analysis of biological and environmental samples, conducting field investigations and monitoring people who are possibly contaminated with radioactive materials or exposed to radiation, developing criteria for entry and operations within the incident site, and recommending disease control and prevention measures. If requested, CDC will assist in these tasks. There is also federal guidance available from EPA and DHS. Medical support will both be needed in the short term and the long term. The state and local public health agencies, with assistance from federal partners, will evaluate the health and medical impacts on the public and emergency personnel. They will develop medical interventions, recommendations, treat impacted citizens, and, if necessary, request that CDC deploy the Strategic National Stockpile, formally known as the National Pharmaceutical Stockpile. State and local public health professionals also will be responsible for implementing protective action guides, including recommendations for sheltering, evacuation, relocation, which is permanent evacuation, decontamination, and worker personal protective equipment. These are outlined in federal guidance, such as EPA's manual of protective action guides and protective actions for nuclear incidents, which is EPA document number 400. CDC will also offer advice and assist in developing these recommendations if requested to do so by state and local governments. Nonetheless, we should be prepared within our communities to give immediate protective action recommendations in the event of a nuclear or radiological terrorist attack. As an example, if we consider the most likely radiological terrorist incident, a dirty bomb, the presence of radiation may not be immediately apparent. However, if an explosion occurs in the community, there are some simple protective action recommendations that the local chief executive officer or public health official can give to people in the affected area. Even before people know whether or not radioactive materials were present, following these simple steps can help reduce their injury from radiation or chemicals that might have been present in the blast. If you are inside, you should shelter in place. This means stay inside, turn off ventilation systems that bring in air from the outside and use recirculated air. Close all windows, doors, and fireplace dampers. Sheltering will generally be in effect for less than 24 hours, at which point safe paths of egress will be determined by public health agencies. For an RDD, evacuation may never be necessary. If you are outside, cover your nose and mouth with a cloth. This will reduce the chances of inhaling or ingesting radioactive materials. Leave the immediate area and go inside the nearest building. Stay inside and follow the steps recommended for sheltering. Staying inside will reduce people's exposure to any radioactive material that may be on dust at the scene. If you think you may be contaminated, remove your outer layer of clothing as soon as possible. Place them in a plastic bag and seal it. As Dr. Smith told us earlier, removing clothing can remove a significant portion of external contamination. Saving the clothing in a plastic bag will allow for testing for radioactive contamination later. Take a shower or wash as soon as possible. Washing will reduce the amount of radioactive contamination on the body and effectively reduce total exposure. Tune in to your local emergency broadcasting system, if possible. Be on the lookout for information. Once emergency personnel can assess the scene and the damage, they will be able to tell people whether radiation was involved. And most importantly, encourage people to seek medical attention only for severe injuries, not for contamination. In the event of an emergency medical system, could quickly become overwhelmed with patients, and we want to be sure that the severely injured get treated first. Assure people that monitoring stations will be set up as soon as possible to deal with possible exposure and contamination. Over the course of the cleanup and recovery, state and local public health agencies will collaborate with federal agencies, such as DHS, EPA, and the Food and Drug Administration to apply protective action guides for food and water, for non-food use of agricultural products, and recovery operations. As part of this, they will develop long-term plans for decontamination, for re-entry into contaminated areas, and for final recovery of the incident site and the surrounding areas. They will also conduct long-term surveillance and epidemiological studies. Assist in the establishment of an exposure registry to monitor long-term health impacts from the incident, and provide information to the public and responders on long-term health effects associated with exposure to radiation. For more information on radiation protection, you can visit the CDC Radiation Emergencies website where you can find fact sheets on radiation, medications to treat internal contamination, various radioisotopes, and evacuation and sheltering. You can view and download the National Response Plan from the Department of Homeland Security's website. Other guidance on response and recovery will also soon be available. The Environmental Protection Agency's Radiation Protection page offers recommendations for protecting people and the environment. And the Nuclear Regulatory Commission offers radiation protection and regulatory guidelines at its website. While it may seem that as state and local public health professionals, we are tasked with enormous responsibilities in response to a nuclear or radiological event. It is important to re-emphasize something that Dr. Miller said earlier. And that is, you are not alone. If such an event occurs, CDC, HHS, DHS, and other federal agencies are ready to respond and assist your community in dealing with and recovering from a nuclear or radiological terrorist attack. And we are going to want that assistance. Ms. McBeth, thank you so much. Your information and, of course, all of the information provided today will certainly go a long way in helping healthcare workers lay a foundation for preparing and responding to any such radiological or nuclear incident. Now, for the rest of the broadcast, we'd like to address some of your questions that you submitted. If you do not have your question answered, during today's broadcast, we'll contact you later with a personal follow-up. The question today is for you. Dr. Miller, it's from Paul in Haida, home. He asks, can funds from the CDC Cooperative Agreement on Public Health Preparedness and Bioterrorism be used for nuclear slash radiological preparedness and response? Well, Paul, that's a very interesting question. In fact, it's probably one I receive more often than any other when I'm out talking with state and local public health officials. Now, I'm not an active participant in administering the Cooperative Agreement. And I do know that there is nowhere in the guidance that I've been able to find whether words nuclear or radiological are mentioned. However, there is a statement in there that the grant and the agreement can be used for other potential public health emergencies, besides those that are listed specifically. And I do know of at least one or two other states who have used the Cooperative Agreement funding to support radiation preparation efforts. And in asking up the chain here at CDC, it is my understanding that, in fact, that is perfectly acceptable. It is up to the states to decide how they disperse those funds within the guidance given and nuclear and radiological preparation can be included. All right, good deal. Dr. Smith, Marcel from Ohio wants to know two-part question. The FDA recently approved DTPA for use in treating internal contamination. What is the role of this medication? Also wants to know should cities and states stockpile this medication? Okay, well, that's certainly a relevant and a timely question. Thank you for that. Yes, DTPA has been approved recently for use for people who have been very heavily contaminated with a certain class of radioactive substances. The calcium and zinc salts of DTPA bind within the body to these substances and accelerate the excretion of the substances from the body through the urine. Now, of course, administration of such a drug should only be done under the supervision of a physician. And the drug, as I say, can only be used on a certain class of substances, and that's important to keep in mind. We have more general information about that on our CDC website, and we also have links there to the FDA website and other relevant websites, which have a lot more specific information about DTPA and other types of drugs like that. Now, with regard to the question of state and local government stockpiling DTPA or any other type of medication, that's really a local decision. However, I would point out, Kisa, our Strategic National Stockpile is currently working with FDA to acquire and stockpile this recently approved DTPA. Good deal, too. David of California has a question he wants to know, or he says, I'm located in a small community one hour from a major metropolitan area. How will I be affected by a terrorist attack in that city? Bob, can you answer that? Yeah. It's very likely that many people will self-evacuate from that large city, and many of them could potentially be contaminated. So it would be very good as a small community to talk with all those people that could potentially help. Talk to your hospitals, your nuclear medicine clinics, and to fire departments, anyone that can help you in this area and build relationships with them so that you can interact together. It's very possible that many of your procedures that you normally deal when you're dealing with people that need shelter or medical care, those procedures will be the same with the added aspect of having potential radioactivity involved. Doing some simple tabletop exercises with all of those people that can help you ahead of time would be very helpful to add that aspect to your plans. Okay. Dr. Miller, we have about a minute left, but Glen of Maryland wants to know what guidelines would you recommend for first responders to an explosion with radiation levels significantly above background? Good question, Glenn. The federal government has put out some guidance in that issue, such as EPA document number 400, that Ms. McBall referred to a minute ago, and there are other places where you can go. But ultimately, the limits for responders to any kind of event like this is up to the state and local responding organizations to set. So I would encourage state and local responders to go look at the guidance and then work together to determine what those limits might be. All right. You did that very quickly. So quickly we have time for one more question. Dr. Smith, Wesley from Georgia wants to know. He said, you mentioned that children are more sensitive to radiation than adults. How much more sensitive than adults? Good question, Leslie. We get that type of question often. Well, just a brief answer to that. Let's take, for example, a five-year-old child and a 35-year-old adult, and let's say they get the same significant level of a whole-body acute radiation dose. We would expect the five-year-old child to have about double the risk of eventually getting a radiation-induced cancer than would the adult. Wow. All righty. Unfortunately, we are out of time. I'm entering your questions during this broadcast. If you've submitted a question, we will contact you again personally with an answer. The email is rsb at cdc.gov. You may also use this address to email questions, comments, and address for further information. Finally, an archive of this program will be available for viewing at this website, www.phppo.cdc.gov.gov slash phtn slash default.asp. Also, CE credits for the archive webcast will expire on March the 7th of 2008. In addition, videotapes and CD-ROMs of this program soon will be available at no cost at rsb at cdc.gov. If you wish to receive continuing education credit for today's program, you must register and complete an evaluation. CME, CNE, CEU, and CECH health educators are available for this program through the CDC, ATSDR, Continuing Education, and Training Online System. We want everyone to register and complete the course evaluation even if you're not taking the program for continuing education credit. For those of you who do not wish to receive CE credit or certificate of attendance, we'll be forwarded to award it rather to participants who register and complete the course evaluation. You may receive one hour of continuing education credit at no charge by visiting www.phppo.cdc.gov slash phtn online. Be certain to jot down the verification code that you'll see in just a moment since you will need this to gain access to the CE credit. And to receive continuing education for this program, you need to know two important pieces of information. The first is the course number, and the course number for this satellite broadcast is SB0168. The course number for this webcast is WC0068. And the course number for Web on Demand is WD0062. You will need one of these course numbers to identify the correct evaluation in the CDC-ATSDR online system, so please jot it down right now. Also, the second critical item is the course verification code. Everyone must have this verification code, and it is RADTerrorism. The code must be entered in uppercase, and be careful because it is case sensitive, so please write it down right now and enter it in uppercase letters when prompted. The evaluation for this program will be active on the online system for 30 days after the live broadcast. Registration and evaluation must be completed no later than March the 7th of 2005 to receive CE credit. Now, many of you are already familiar with using the CDC-ATSDR online registration and evaluation system. If you've not used it before, you can receive instructions through our fax-back system. Call our toll-free number using a touch-tone telephone, and the number to dial is 888-CDC-FAXX. When prompted for a document number, request document number 130026, then enter your fax number. The document will be faxed to you in only a few minutes after you do that. And here is the address for the CDC-ATSDR training and continuing education online system. www.phppo.cdc.gov-slash-phtn-online. When you get to the website, an extensive help function can also assist you in the registration process. Rather than go through all of the details of using the online system, you should use the instructions on the website or order the instructions from our fax-back system. In addition to the online help function, you can receive assistance the old-fashioned way by telephone. If you have any problems with the online system, you can call us toll-free at 800-411-TRAIN. You can also call us at 404-639-1292. CE unit personnel are available Monday through Friday from 8 a.m. until 4.30 p.m. and that is Eastern Time. You can also receive assistance by email. Our address is ceatcdc.gov. The continuing education staff will be happy to assist you with the login and registration process. And finally, I'd like to thank our guest one last time, Dr. Smith, Ms. McBaw, and Dr. Miller. We appreciate all of the information that you gave us. Again, it's going to go a long way in helping us to be prepared. And I'd also like to thank our viewers for submitting your questions for the guest during today's program. Many thanks to you. And so that brings us to the close of the role of public health in a nuclear or radiological terrorist incident. I'm Kisa Daniels, and it certainly has been my pleasure to be your moderator today. Goodbye.