Emergency planning and preparedness against chemical, biological, radiological and nuclear terrorism.

1. CBRN Terrorism and
Emergency Preparedness
David Alexander
University College London

2. The problem

3. Principal objectives of terrorism
• obtain political concessions
by negotiation
OR
• injure or kill many people
or create great destruction
or chaos (reprisals).

4. • modern society changes so fast
that historical analysis may not
be useful for scenario building
• past events may not necessarily be the
best guide to future planning scenarios
• there is an infinity of possible event
scenarios - will 'orthodox' thinking help
in the face of a terrorist's creativity?
• palliative and analytical capabilities are
expensive but not necessarily effective.
The CBRN problem

5. • unanticipated, unfamiliar threat to health
• lack of sensory cues
• prolonged or recurrent aftermath
• potentially highly contagious
• produces observable casualties.
A CBRN incident:-

6. • a small, concentrated attack
with a highly toxic substance: 210Po
• 30 localities contaminated
• tests on hundreds of people
• a strain on many different agencies
• problems of determining who was
responsible for costs of clean-up.
The case of Alexander Litvinenko

8. Laboratory
error with
CBR emissions
Sabotage with
poisonous agent
Nuclear
emission (NR)
Disease
epidemic or
pandemic (B)
Terrorist
attack with
C, B, R or N
contaminants
Industrial
or military
accident
with CNR
emissions
Chemical,
biological
or nuclear
warfare
(CBN)

9. Industrial
accident
Medical
accident
Nuclear
accident
Epiphytotic
(food chain)
Epizootic
(food chain)
People
(victims)
CBRN
attack

10. Psychological reactions:-
• acute stress disorder
• grief
• anger and blame
• contagious somatization
...but not panic?
Physical effects:-
• cancer
• birth defects
• neurological, rheumatic,
and immunological diseases.
Possible effects of chemical attack

11. The instruments
of attack

12. Some possible means of attack:-
• viral or bacterial pathogens
• chemical toxins
• radioactive substances
• nuclear weapons.

13. Possible means of dispersion of
a chemical or biological agent
• aerial dispersion or launch
• bomb
• missile
• dispersion by hand.

14. Possible events
• delivery of a weaponized
biological or chemical agent
• use of a common pathogen
• contaminated missile or bomb
• hoaxes or false alarms.

15. What determines the risk levels
associated with a given substance?
• lethality
• particle size
• purity and durability (+ persistence)
• how easy the substance is to
transport and disseminate
• whether victims are able
to survive the attack.

16. Possible source pathogen in a
biological attack - epidemics
• anthrax (Baccilus anthracis)
• plague (Yersinia pestis)
• smallpox (variola)
• Escherichia coli or salmonella
• dengue or ebola haemorrhagic fevers
• botulism (Clostrudium).

17. Possible impact of a biological attack
on the food chain - epizootics
• bovine spongiform encephalopathy
• foot and mouth disease
• mass poisoning.

18. • Karnal Bunt fungus
• Puccinia graninis avenae pathogen
• fungal infections of rice or other grains.
Possible impact of a biological attack
On the food chain - epiphytotics

19. Examples of
incubation periods
• anthrax: 1-6 days
• smallpox: 12 days
• plague: 2-3 days.

20. Biological
agent
Chemical
agent
Origin natural anthropic
Production difficult,
small scale
industrial
scale
Volatile? no yes
Toxicity more less
Effects
on skin
not active active

21. Biological
agent
Chemical
agent
Taste/smell none sensible
Toxic
effects
many few
Immunogens often
generated
rarely
generated
Delivery by aerosol aerosol cloud
or droplets

22. Botulism Nerve gas
Symptoms in 1-3 days minutes
Deaths in 2-3 days minutes
Effects
on nerves
progressive
paralysis
convulsions,
spasms
Cardiac
rhythms
normal reduced
Respiration normal difficult

23. Botulism Nerve gas
Gastro-
intestinal
reduced
motility
increased
motility, pain
Ocular eyelids
droop
pupils
contract
Saliva difficulty
swallowing
watery
Responds to
atropine?
no yes

24. The response

25. • injuries and illnesses
caused by the toxic agent
• risks to reproduction
and human fertility
• psychological and psychosomatic effects
multiple idiopathic physical symptoms.
Consequences of an attack

26. Elements of emergency
response to plan
• recognize the scope and
nature of the attack
• management of large numbers of dead
• limit access to site of attack.
• mass prophylaxis
• management and security of the public

27. Elements of emergency response to plan
• quarantine
• specialised equipment
• safety of emergency workers
• apportion roles and tasks.
• diagnose and decontaminate
the site and victims

28. Situation monitoring requirements
• nature of symptoms
• rapid diagnosis
• number of sick people
• anti-microbe or anti-toxin therapies.
• mass casualty
management procedures

29. Analysis of samples taken
from site or from victims
• special transport is required
for dangerous samples.
• rapid and timely alarm-raising
and analysis is essential

30. • use only specialised and highly
qualified laboratories with
- specialised analytical
equipment
- a staff of experts
- ability to discern minute
traces of pathogens
or toxins
- procedures designed to
avoid contamination.

31. Role of scenarios
in indicating
preparedness needs

32. The knowledge problem
• cause, agent & effects unknown
• cause known, agent & effects unknown
• cause & agent known, effects unknown
(i.e. diffusion mechanism unclear)
• cause, agent & effects known
• social reaction predictable or not
(dynamic evolution of the event)

33. 20 March 1995 attack on
five Tokyo metro trains:-
• 5,510 people affected
• 278 hospitals involved
• 98 of them admitted 1,046 inpatients
• 688 patients transported by ambulance
• 4,812 made their own way to hospital.
Aum Shinrikyo
(the "Religion of Supreme Truth")

34. Dead: 12
Critically injured: 17
Seriously ill: 37
Moderately ill: 984
Slightly ill: 332
• 110 hospital staff and 10% of
first responders contaminated
• "Worried well": 4,112 (85% of patients).
Aum Shinrikyo attack (1995)

35. Mythmongering:
"Problems with crowd control, rioting,
and other opportunistic crime could
be anticipated" (Staten 1997)
The assumption of panic reflects
the hiatus between sociological and
psychological views of the phenomenon.

36. First
responders

37. • possible contamination of
responders and medical staff
• physical and mental state
of victims and patients
• uncertainty (nature of the contaminant,
degree of contamination, effects).
What problems will volunteers, first
responders and hospital staff have
to deal with in a CBRN incident?

38. What problems will volunteers, first
responders and hospital staff have
to deal with in a CBRN incident?
• lack or inadequacy of
protective equipment
• lack of training and exercising
(to know what to do)
• lack of familiarity with
equipment and procedures.

39. In the London Underground tunnels
on 7 July 2005 rescue operations
by London Fire Brigade were
delayed by 15-20 minutes by
the need to ascertain whether
CBRN contaminants had been
used in the attacks. Meanwhile,
victims died of their injuries.

40. • ascertaining level of contamination
takes specialised equipment & training
• can slow down rescue in critical incidents
• risk aversion may lead to failure
to commit staff to rescues
• long-term liability for rescuers'
injuries is a serious problem
• is it time to rethink the
"rules of engagement"? .
Delays in responding to incidents
lead to heavy criticism by the public

41. • requires specialised procedures
• must avoid contamination of staff
• requires ionising radiation dosimeter
• biological symptoms may be
delayed by 3 minutes - 3 weeks.
Triage problems:-
Level 1 - on-site triage
Level 2 - medical triage
Level 3 - evacuation triage
Mettag CB-100

42. Decontaminate:
• people
• internal environments
• external environments.

43. 'Hot' area
(contaminated)
'Warm' area
(decontamination)
'Cold' area
(clean treatment)
>300 m upwind
PPE level A
(contaminant unknown)
PPE level B
(contaminant known)
PPE level D
Medical
staff and
first
responders
PPE level C
PPE=personal protection equipment

44. Very considerable uncertainty surrounds
the practice of decontamination,
regarding protocols, practices
effects, efficiency and timespans.

45. • risks of secondary contamination
of responders and hospital staff
• shortage of personal protection
equipment & expertise on how to use it
• shortage of isolation facilities.
Contaminated patients

46. In the case of a chemical attack, the
following aspects of decontamination
protocols are highly debatable:
• the use of chemical agents
to neutralise toxic substances
• whether to strip naked before treatment
• what decontamination technique
should be used if the toxic agent
has not been identified
• how many people can be
decontaminated per unit time.

47. • restriction of physical activity
(manual dexterity, hearing)
• communication problems
• dehydration
• heat-related illness
• psychological effect
(e.g. claustrophobia).
Limitations on use of PPE:-

48. • chronic injuries and diseases
directly caused by the toxic agent
• questions about adverse
reproductive outcomes
• psychological effects (persistent)
• increased levels of somatic symptoms.
Health concerns following a CBRN attack

49. A study by Hantsch et al.* suggested that
one third or more of emergency personnel
would not respond to a CBRN incident
(absentee rate in natural disaster
are lower than one in seven)
• The greatest enemies are
uncertainty and unfamiliarity
• The only antidotes are information
and authoritative reassurance.
2004, Annals of Emergency Medicine

50. Conclusions

51. Conclusions
• a great many different scenarios
and outcomes can be hypothesized
• the most significant, prolonged
and costly impacts could well be
those associated with human
behaviour and mental health.

52. • emergency medical and
psychological assistance
• long-term healthcare
and health surveillance
• extensive medical information
and risk assessment.
Medical personnel have the same
vulnerabilities and preoccupations as
the general public: they may need...

53. • work in a contaminated environment
• identify possibly contaminated scene
• recognise symptoms of nerve agents,
blister agents and asphyxiants
• inform mass media about CBRN event.
Training needs - how to...

54. • "gas mania" (influx of the worried well)
• a complex and unfamiliar situation
• balance between action and precautions
• shortage of equipment and training
• the worry caused by uncertainty.
We need to know how to deal with:-

55. "The onset of mild to moderate signs and
symptoms following dermal exposure to
VX* may be delayed as long as 18 hours."
(Sidell 1997, Garahbaghian & Bey 2003)
*organophosphorus nerve agent chemical weapon,
lethal dose: 10 milligrammes
Think about the implications for
CBRN intervention...