cbrn terrorism and emergency preparedness
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CBRN Terrorism andEmergency Preparedness
David AlexanderUniversity College London
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The problem
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Principal objectives of terrorism
• obtain political concessionsby negotiation
OR
• injure or kill many peopleor create great destructionor chaos (reprisals).
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• modern society changes so fastthat historical analysis may notbe useful for scenario building
• past events may not necessarily be thebest guide to future planning scenarios
• there is an infinity of possible eventscenarios - will 'orthodox' thinking helpin the face of a terrorist's creativity?
• palliative and analytical capabilities areexpensive but not necessarily effective.
The CBRN problem
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• unanticipated, unfamiliar threat to health
• lack of sensory cues
• prolonged or recurrent aftermath
• potentially highly contagious
• produces observable casualties.
A CBRN incident:-
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• a small, concentrated attackwith a highly toxic substance: 210Po
• 30 localities contaminated
• tests on hundreds of people
• a strain on many different agencies
• problems of determining who wasresponsible for costs of clean-up.
The case of Alexander Litvinenko
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Laboratory error with
CBR emissions
Sabotage with poisonous agent
Nuclearemission (NR)
Diseaseepidemic orpandemic (B)
Terroristattack withC, B, R or Ncontaminants
Industrial or militaryaccident with CNRemissions
Chemical,biological
or nuclear warfare(CBN)
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Industrialaccident
Medicalaccident
Nuclearaccident
Epiphytotic(food chain)
Epizootic(food chain)
People(victims)
CBRNattack
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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
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The instruments of attack
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Some possible means of attack:-
• viral or bacterial pathogens
• chemical toxins
• radioactive substances
• nuclear weapons.
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Possible means of dispersion ofa chemical or biological agent
• aerial dispersion or launch
• bomb
• missile
• dispersion by hand.
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Possible events
• delivery of a weaponizedbiological or chemical agent
• use of a common pathogen
• contaminated missile or bomb
• hoaxes or false alarms.
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What determines the risk levelsassociated with a given substance?
• lethality
• particle size
• purity and durability (+ persistence)
• how easy the substance is totransport and disseminate
• whether victims are ableto survive the attack.
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Possible source pathogen in abiological attack - epidemics
• anthrax (Baccilus anthracis)
• plague (Yersinia pestis)
• smallpox (variola)
• Escherichia coli or salmonella
• dengue or ebola haemorrhagic fevers
• botulism (Clostrudium).
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Possible impact of a biological attackon the food chain - epizootics
• bovine spongiform encephalopathy
• foot and mouth disease
• mass poisoning.
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• Karnal Bunt fungus
• Puccinia graninis avenae pathogen
• fungal infections of rice or other grains.
Possible impact of a biological attackOn the food chain - epiphytotics
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Examples ofincubation periods
• anthrax: 1-6 days• smallpox: 12 days• plague: 2-3 days.
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Biologicalagent
Chemical agent
Origin natural anthropic
Production difficult,small scale
industrial scale
Volatile? no yes
Toxicity more less
Effectson skin
not active active
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Biologicalagent
Chemical agent
Taste/smell none sensible
Toxic effects
many few
Immunogens often generated
rarely generated
Delivery by aerosol aerosol cloud or droplets
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Botulism Nerve gas
Symptoms in 1-3 days minutes
Deaths in 2-3 days minutes
Effectson nerves
progressiveparalysis
convulsions, spasms
Cardiac rhythms
normal reduced
Respiration normal difficult
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Botulism Nerve gas
Gastro-intestinal
reduced motility
increased motility, pain
Ocular eyelidsdroop
pupils contract
Saliva difficulty swallowing
watery
Responds to atropine?
no yes
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The response
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• injuries and illnessescaused by the toxic agent
• risks to reproductionand human fertility
• psychological and psychosomatic effectsmultiple idiopathic physical symptoms.
Consequences of an attack
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Elements of emergencyresponse to plan
• recognize the scope andnature of the attack
• management of large numbers of dead
• limit access to site of attack.
• mass prophylaxis
• management and security of the public
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Elements of emergency response to plan
• quarantine
• specialised equipment
• safety of emergency workers
• apportion roles and tasks.
• diagnose and decontaminatethe site and victims
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Situation monitoring requirements
• nature of symptoms
• rapid diagnosis
• number of sick people
• anti-microbe or anti-toxin therapies.
• mass casualtymanagement procedures
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Analysis of samples takenfrom site or from victims
• special transport is requiredfor dangerous samples.
• rapid and timely alarm-raisingand analysis is essential
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• use only specialised and highlyqualified laboratories with
- specialised analytical equipment
- a staff of experts- ability to discern minute
traces of pathogensor toxins
- procedures designed toavoid contamination.
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Role of scenariosin indicating
preparedness needs
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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)
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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")
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Dead: 12Critically injured: 17Seriously ill: 37Moderately ill: 984Slightly ill: 332
• 110 hospital staff and 10% offirst responders intoxicated
• "Worried well": 4,112 (85% of patients).
Aum Shinrikyo attack (1995)
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Mythmongering:"Problems with crowd control, rioting,and other opportunistic crime could
be anticipated" (Staten 1997)
The assumption of panic reflectsthe hiatus between sociological and
psychological views of the phenomenon.
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First responders
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• possible contamination ofresponders and medical staff
• physical and mental stateof 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?
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What problems will volunteers, first responders and hospital staff have to deal with in a CBRN incident?
• lack or inadequacy ofprotective equipment
• lack of training and exercising(to know what to do)
• lack of familiarity withequipment and procedures.
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In the London Underground tunnelson 7 July 2005 rescue operationsby London Fire Brigade weredelayed by 15-20 minutes bythe need to ascertain whetherCBRN contaminants had beenused in the attacks. Meanwhile,victims died of their injuries.
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• ascertaining level of contaminationtakes specialised equipment & training
• can slow down rescue in critical incidents
• risk aversion may lead to failureto 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 incidentslead to heavy criticism by the public
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• requires specialised procedures
• must avoid contamination of staff
• requires ionising radiation dosimeter
• biological symptoms may bedelayed by 3 minutes - 3 weeks.
Triage problems:-Level 1 - on-site triageLevel 2 - medical triageLevel 3 - evacuation triage
Mettag CB-100
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Decontaminate:
• people
• internal environments
• external environments.
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'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
Medicalstaff and
firstresponders
PPE level C
PPE=personal protection equipment
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Very considerable uncertainty surroundsthe practice of decontamination,regarding protocols, practices
effects, efficiency and timespans.
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• risks of secondary contaminationof responders and hospital staff
• shortage of personal protectionequipment & expertise on how to use it
• shortage of isolation facilities.
Contaminated patients
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In the case of a chemical attack, thefollowing aspects of decontamination
protocols are highly debatable:
• the use of chemical agentsto neutralise toxic substances
• whether to strip naked before treatment
• what decontamination techniqueshould be used if the toxic agenthas not been identified
• how many people can bedecontaminated per unit time.
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• restriction of physical activity(manual dexterity, hearing)
• communication problems
• dehydration
• heat-related illness
• psychological effect(e.g. claustrophobia).
Limitations on use of PPE:-
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• chronic injuries and diseasesdirectly caused by the toxic agent
• questions about adversereproductive outcomes
• psychological effects (persistent)
• increased levels of somatic symptoms.
Health concerns following a CBRN attack
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A study by Hantsch et al.* suggested thatone 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 informationand authoritative reassurance.
2004, Annals of Emergency Medicine
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Conclusions
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Conclusions
• a great many different scenariosand outcomes can be hypothesized
• the most significant, prolongedand costly impacts could well bethose associated with humanbehaviour and mental health.
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• emergency medical andpsychological assistance
• long-term healthcareand health surveillance
• extensive medical informationand risk assessment.
Medical personnel have the samevulnerabilities and preoccupations asthe general public: they may need...
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• 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...
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• "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:-
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"The onset of mild to moderate signs andsymptoms 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 forCBRN intervention...