CBRN Terrorism and Emergency Preparedness


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CBRN Terrorism and Emergency Preparedness

  1. 1. CBRN Terrorism and Emergency Preparedness David Alexander University College London
  2. 2. The problem
  3. 3. Principal objectives of terrorism • obtain political concessions by negotiation OR • injure or kill many people or create great destruction or chaos (reprisals).
  4. 4. The CBRN problem • 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.
  5. 5. A CBRN incident:• unanticipated, unfamiliar threat to health • lack of sensory cues • prolonged or recurrent aftermath • potentially highly contagious • produces observable casualties.
  6. 6. The case of Alexander Litvinenko • 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.
  7. 7. Laboratory error with CBR emissions Industrial or military accident with CNR emissions Nuclear emission (NR) Terrorist attack with C, B, R or N contaminants Disease epidemic or pandemic (B) Chemical, biological or nuclear warfare (CBN) Sabotage with poisonous agent
  8. 8. Industrial accident Medical accident Nuclear accident People (victims) Epizootic (food chain) Epiphytotic (food chain) CBRN attack
  9. 9. Possible effects of chemical attack Psychological reactions:• acute stress disorder • grief • anger and blame • contagious somatization ...but not panic? Physical effects:• cancer • birth defects • neurological, rheumatic, and immunological diseases.
  10. 10. The instruments of attack
  11. 11. Some possible means of attack:• viral or bacterial pathogens • chemical toxins • radioactive substances • nuclear weapons.
  12. 12. Possible means of dispersion of a chemical or biological agent • aerial dispersion or launch • bomb • missile • dispersion by hand.
  13. 13. Possible events • delivery of a weaponized biological or chemical agent • use of a common pathogen • contaminated missile or bomb • hoaxes or false alarms.
  14. 14. 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.
  15. 15. 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).
  16. 16. Possible impact of a biological attack on the food chain - epizootics • foot and mouth disease • bovine spongiform encephalopathy • mass poisoning.
  17. 17. Possible impact of a biological attack On the food chain - epiphytotics • Karnal Bunt fungus • Puccinia graninis avenae pathogen • fungal infections of rice or other grains.
  18. 18. Examples of incubation periods • anthrax: • smallpox: • plague: 1-6 days 12 days 2-3 days.
  19. 19. Origin Production Volatile? Toxicity Effects on skin Biological agent natural difficult, small scale no more not active Chemical agent anthropic industrial scale yes less active
  20. 20. Taste/smell Toxic effects Immunogens Delivery Biological agent none many Chemical agent sensible few often generated by aerosol rarely generated aerosol cloud or droplets
  21. 21. Symptoms in Deaths in Effects on nerves Cardiac rhythms Respiration Botulism 1-3 days 2-3 days progressive paralysis normal Nerve gas minutes minutes convulsions, spasms reduced normal difficult
  22. 22. Gastrointestinal Ocular Saliva Responds to atropine? Botulism reduced motility eyelids droop difficulty swallowing no Nerve gas increased motility, pain pupils contract watery yes
  23. 23. The response
  24. 24. Consequences of an attack • injuries and illnesses caused by the toxic agent • risks to reproduction and human fertility • psychological and psychosomatic effects multiple idiopathic physical symptoms.
  25. 25. Elements of emergency response to plan • recognize the scope and nature of the attack • mass prophylaxis • management of large numbers of dead • management and security of the public • limit access to site of attack.
  26. 26. Elements of emergency response to plan • diagnose and decontaminate the site and victims • quarantine • safety of emergency workers • specialised equipment • apportion roles and tasks.
  27. 27. Situation monitoring requirements • number of sick people • nature of symptoms • rapid diagnosis • mass casualty management procedures • anti-microbe or anti-toxin therapies.
  28. 28. Analysis of samples taken from site or from victims • rapid and timely alarm-raising and analysis is essential • special transport is required for dangerous samples.
  29. 29. • 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.
  30. 30. Role of scenarios in indicating preparedness needs
  31. 31. 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)
  32. 32. Aum Shinrikyo (the "Religion of Supreme Truth") 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.
  33. 33. Aum Shinrikyo attack (1995) Dead: Critically injured: Seriously ill: Moderately ill: Slightly ill: 12 17 37 984 332 • 110 hospital staff and 10% of first responders intoxicated • "Worried well": 4,112 (85% of patients).
  34. 34. 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.
  35. 35. First responders
  36. 36. What problems will volunteers, first responders and hospital staff have to deal with in a CBRN incident? • possible contamination of responders and medical staff • physical and mental state of victims and patients • uncertainty (nature of the contaminant, degree of contamination, effects).
  37. 37. 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.
  38. 38. 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.
  39. 39. Delays in responding to incidents lead to heavy criticism by the public • 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"? .
  40. 40. Triage problems:Level 1 - on-site triage Level 2 - medical triage Level 3 - evacuation triage • requires specialised procedures • must avoid contamination of staff • requires ionising radiation dosimeter • biological symptoms may be delayed by 3 minutes - 3 weeks. Mettag CB-100
  41. 41. Decontaminate: • people • internal environments • external environments.
  42. 42. PPE level A (contaminant unknown) PPE level B (contaminant known) Medical staff and first responders 'Hot' area (contaminated) 'Warm' area (decontamination) PPE level C 'Cold' area PPE level D (clean treatment) >300 m upwind PPE=personal protection equipment
  43. 43. Very considerable uncertainty surrounds the practice of decontamination, regarding protocols, practices effects, efficiency and timespans.
  44. 44. Contaminated patients • risks of secondary contamination of responders and hospital staff • shortage of personal protection equipment & expertise on how to use it • shortage of isolation facilities.
  45. 45. 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.
  46. 46. Limitations on use of PPE:• restriction of physical activity (manual dexterity, hearing) • communication problems • dehydration • heat-related illness • psychological effect (e.g. claustrophobia).
  47. 47. Health concerns following a CBRN attack • chronic injuries and diseases directly caused by the toxic agent • questions about adverse reproductive outcomes • psychological effects (persistent) • increased levels of somatic symptoms.
  48. 48. 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
  49. 49. Conclusions
  50. 50. 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.
  51. 51. Medical personnel have the same vulnerabilities and preoccupations as the general public: they may need... • emergency medical and psychological assistance • long-term healthcare and health surveillance • extensive medical information and risk assessment.
  52. 52. Training needs - how to... • work in a contaminated environment • identify possibly contaminated scene • recognise symptoms of nerve agents, blister agents and asphyxiants • inform mass media about CBRN event.
  53. 53. We need to know how to deal with:• "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.
  54. 54. Think about the implications for CBRN intervention... "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