CBRN Terrorism and Emergency Preparedness

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  • 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. 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. A CBRN incident:• unanticipated, unfamiliar threat to health • lack of sensory cues • prolonged or recurrent aftermath • potentially highly contagious • produces observable casualties.
  • 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. 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. Industrial accident Medical accident Nuclear accident People (victims) Epizootic (food chain) Epiphytotic (food chain) CBRN attack
  • 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. The instruments of attack
  • 11. Some possible means of attack:• viral or bacterial pathogens • chemical toxins • radioactive substances • nuclear weapons.
  • 12. Possible means of dispersion of a chemical or biological agent • aerial dispersion or launch • bomb • missile • dispersion by hand.
  • 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. 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. 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. Possible impact of a biological attack on the food chain - epizootics • foot and mouth disease • bovine spongiform encephalopathy • mass poisoning.
  • 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. Examples of incubation periods • anthrax: • smallpox: • plague: 1-6 days 12 days 2-3 days.
  • 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. 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. 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. Gastrointestinal Ocular Saliva Responds to atropine? Botulism reduced motility eyelids droop difficulty swallowing no Nerve gas increased motility, pain pupils contract watery yes
  • 23. The response
  • 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. 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. 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. Situation monitoring requirements • number of sick people • nature of symptoms • rapid diagnosis • mass casualty management procedures • anti-microbe or anti-toxin therapies.
  • 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. • 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. Role of scenarios in indicating preparedness needs
  • 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. 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. 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. 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. First responders
  • 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. 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. 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. 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. 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. Decontaminate: • people • internal environments • external environments.
  • 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. Very considerable uncertainty surrounds the practice of decontamination, regarding protocols, practices effects, efficiency and timespans.
  • 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. 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. Limitations on use of PPE:• restriction of physical activity (manual dexterity, hearing) • communication problems • dehydration • heat-related illness • psychological effect (e.g. claustrophobia).
  • 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. 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. Conclusions
  • 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. 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. 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. 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. 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