Preparing NGOs for Operations in High Risk Environments

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Preparing NGOs for Operations in High Risk
Environments ________________________ Personal
Protection and Staff Health Issues
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• Mark Stinson,MD
• AAFP, AAEP
• Associate Clinical Professor, UC Davis
• Emergency Response Team Leader
• RELIEF INTERNATIONAL

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Snapshot Survey of Current NGO Preparedness

• RI contacted 14 International NGOs in November
  2002 to assess the current status of preparedness
  and planning for CBRN events. The selection of
  NGOs reflected a range of agencies, some less
  likely than others to be involved in critical
  phase emergency operations.
• Of the 14 agencies eight (57) indicated that
  they had no plans or preparations in place and an
  additional four (29) did not respond.
• Of the two (14) agencies who did respond
  positively one indicated preparedness activities
  were exclusively domestic focused and the other
  had developed a limited capacity to decontaminate
  people exposed to CBRN agents, although the
  variety of agents was not indicated.
• Data collected from January 2003 showed
  significant change in plans and attitude.

Agencies polled ADRA, MSF, CARE, ARC, Baptist
World Aid, Doctors of the World, IMC, Oxfam, CCF,
DRI, Health Volunteers Overseas, Project Hope,
UMCOR.
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Snapshot Survey of Current NGO Preparedness

• Conclusion
• Evident lack of capacity at present, across a
  spectrum of agencies.
• Some lack of willingness to share information
  between agencies.
• Absence of common vision of appropriate skills,
  equipment and level of acceptable risk for NGOs.
• Desire to improve capacity

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NGO CBRNE Preparedness

• Past
• Limited prior experience in CBRNE type response
  in humanitarian operations too much in military
  operations, except for naturally occurring
  infectious disease outbreaks, for example
  cholera/lassa fever.
• Evacuation only strategy
• Limited numbers of adequately trained staff,
  equipment, procedural knowledge.

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History

• CBRNE Agents have been used on unprotected civil
  populations on many occasions
• Some of the locations where the local population
  had no defense were
• Ethiopia
• Iraq
• Afghanistan
• Laos
• Japan

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NGO CBRNE Preparedness

• Present
• Intent to operate in hazardous environments/Iraqi
  theater in the event of a humanitarian crisis.
• Recognition of need to develop adequate CBRNE
  capacity to ensure staff safety as a minimum.
• Application of public health strategies to CBRNE
  response for protecting civilian populations.

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NGO CBRNE Preparedness

• Lack of clarity as to the focal points in
  government and military for assistance and
  technical support.
• Training curriculum, identification of material
  suppliers and related tasks now being developed
  for RI staff and as a service to other agencies,
  reflecting humanitarian priorities and modus
  operandi a lot of other agencies are now JUST
  BEGINNING to do this, but largely in silos.

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NGO CBRNE Preparedness

• Future
• Institutional capacity (material resources,
  knowledge, experienced staff cadre, training of
  new staff and procedures) developed for all
  relevant country programs as part of SECURITY
  PLAN.
• Agencies are confident in assessing their
  capacities to either protect own staff and
  civilian population and/or continue to implement
  emergency programs in contaminated environments.
• Mainstreaming CBRN preparedness in public health
  programming in all health related agencies to
  protect civilian population.
• Firm guidelines are established for all agencies
  entering potentially hazardous theaters.

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Concrete Actions

• Choices Facing NGOs
• Capability to to protect staff and to safely
  evacuate them.
• Capability to continue a level of service for
  those affected by the CBRNE event.
• Prevention capability to protect civilian
  populations from threats.

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Concrete Actions Threats / Difficulties

• Lack of quality training relevant to NGO
  personnel, role and operational orientation.
• Very rapid capacity development is required in
  relation to the Iraq theater.
• Adequate funding for relevant equipment and
  supplies, for example large stockpiles of
  appropriate for pre/post event prophylactic
  vaccinations or other treatments (as recommended
  by CDC,WHO).
• Inadequate information on the exact nature of
  CBRNE threats in a particular theater or early
  warning of attacks.
• Risk of over-estimating NGO capacity to provide
  humanitarian assistance in response to a large
  scale or prolonged CBRN event.

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Threats and Difficulties cont

• Expensive one use only personal protective
  equipment
• Staff concerns about risks of vaccination and
  pretreatment
• Potentially overly cautious military command
  preventing personnel from serving population in
  need
• Extremely remote locations with no sophisticated
  medical backup conflicting with Western medical
  paradigm

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Concrete Actions

• Prevention
• Humanitarian personnel must be pretreated against
  likely agents and antidotes for chemical agents
  must be readily available
• Military/NGO cooperation required for
  preplanning/preparation/assessment of likely
  threats maintaining neutrality at all cost
• Utilization of UN/ Mil/ OFDA DART teams to
  assist with risk assessment
• Impossible to provide mass prophylaxis of
  potential victims in the field prior to an event

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Training

• What do NGOs need to know?
• Range of threats in a particular theater,their
  treatments and all necessary protective measures
• Prophylactic immunization and pretreatment
  recommendations
• Mass casualty strategies
• Sources of technical assistance
• Supplies/knowledge of operation of all relevant
  material and equipment
• Fit testing all various types of PPE

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Training cont

• Improvisation knowledge for the unexpected
  exposure use of rainsuits,ponchos, etc.
• Construction of Safe Rooms/Shelter in Place
  techniques
• Civil - military liaison channels of
  communication

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Training - Present

• Military Personnel Only Training
• Center of Excellence
• USAF/CDC/USPHS training - TEIR 1 2
• CBDCOM Domestic Preparedness Program
• Government/NGO Internal Training
• Domestic Disaster Preparedness/CBRNE training
  courses available online. CBDCOM Disaster
  preparedness Program, ANSER, Mosby, NDMS, FEMA,
  etc.
• Excellent reference material available from
  numerous sources.
• Virtual Naval Hospital, ATSDR, US Mil, CDC,
  WHO, Chemtrac,USG,etc.

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Training- Future

• RI is currently developing training programs for
  its staff utilizing material from TIER II
  training
• OFDA/INTERACTION training programs geared for the
  NGO population soon to be implemented
• Private for-profit training programs
• Joint military/civilian training

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Preparation of Threatened Populations

• Population likely to be affected must be given
  information equipment supplies ahead of time
  regarding
• CBRNE Medical Diagnosis/Treatment protocols
• Practical personal protection strategies
• Decontamination techniques
• Evacuation strategies
• Quarantine requirements
• Long-term care provisions

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Diagnosis

• Diagnosis difficult given diseases have been seen
  by few living clinicians
• Abnormal presentations of classical diseases may
  be present due to super infection
• Diagnosis critical for epidemiological monitoring
• Accurate data required for potential future
  prosecution of war crimes
• Psychogenic overlay may cloud the diagnostic
  process

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Treatment

• Protocols/operational guidelines must be
  established which are available to all
  individuals and organizations involved in a given
  operation.
• Experts must be available to guide operations in
  a potentially rapidly changing environment.
• USG/ NGO specially trained decontamination teams
  should be utilized if available
• Information must be shared in a
• rapid and reliable fashion Civil/Military/UN

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Treatment cont

• Preparation be made for unexpected threats
  Moscow Theatre attack
• Stockpiles of medication and equipment must be
  repositioned in the area of operations
• NGOs must have prearranged authority to access
  stockpiles
• Oxygen, intubation and prolonged respiratory
  support may be required

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Mitigation- Post Event

• Well trained and disciplined NGO implementing
  teams and indigenous partners.
• Pre-positioned stockpiles of relevant material
  for post event response/treatment plus adequate
  training of indigenous health personnel.
• Effective interagency coordination and
  contingency planning for post event responses.
• Mental health professionals
  available for intervention/ counseling/training
  of local health officials.

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Mitigation Post event cont

• Aid must be provided for long-term consequence
  management
• Field staff will require long-term monitoring of
  health effects including psychological effects
• Aid groups must be prepared to deal with possible
  long-term disability issues with staff members

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WHO GuidanceCNBRE Agents of War

• Likely weaponized agents listed in upcoming WHO
  publication
• 17 Biological agents
• 16 Chemical agent
• Impossible to prepare for all inevitabilities but
  possible to prepare for likely events

Public heath response to biological and chemical
weapons WHO guidance, 2nd edition
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Health Issues Related to the CBRNE Environment

• Chemical agents
• Biological agents
• Radiologic agents
• Nuclear agents
• Explosives- High Yield

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Chemical Agents

• Lung irritants - Phosgene,
• Blood agents - Hydrogen Cyanide, ..
• Vesicants - Mustard Gas,
• Nerve agents - Sarin, VX,
• Disabling agents
• Incapacitatants-LSD, Agent BZ,
• Harassing Agents- Adamsite, Agent CN
  
• Public health response to biological and
  chemical weapons WHO guidance, 2nd edition

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Chemical AgentPrevention, Diagnosis and
Treatment

• Prevention - Avoidance/Personal Protective
  Equipment/Evacuation. Pretreatment with antidotes
  when possible
• Type of agent must be determined and its
  properties fully communicatedhow it was
  dispersed, its duration of action, how weather
  affects its properties, etc.
• Diagnosis - Basic knowledge of characteristics of
  various agents. Military intelligence. Specialty
  consultation

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Chemical agents Treatment

• Decontamination - Large quantities of water or
  whatever is available sand
• Large quantities of personal protective equipment
  required to conduct safety decontamination/treatme
  nt
• Treatment- Appropriate antidotes and supportive
  care
• Expensive treatment kits must be readily
  available cyanide,MARK1,CANA, etc.
• High-level medical care must be available after
  initial first-aid

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Biological Agents

• Bacteria - Anthrax,
• Fungi - Coccidioidmycosis,
• Viruses - Smallpox,
• Toxins - Ricin, Botulism,

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Biological AgentPrevention, Diagnosis, Treatment

• Prevention - Vaccination when appropriate.
  Pretreatment with antibiotics when appropriate
• Early detection difficult without complicated and
  expensive diagnostic equipment HRA, PCR, IR
• Diagnosis - Basic knowledge of disease patterns
  with ready access to specialty consultation.
  Super infection may complicate diagnosis

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Biological agents Treatment cont

• Decontamination/quarantine - as needed
• Treatment - appropriate amount and type of
  antibiotics post exposure vaccine, antitoxin,
  etc and supportive care
• Possibility of delayed infection/presentation
• Possibility of resistant strains

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Radiologic/Nuclear Agents

• Alpha, Beta, Gamma, Neutron radiation
• Depleted uranium from armor piercing shells
• Nuclear weapons
• Radioisotopes from dirty bombs/radiological
  dispersal device
• Radioisotopes from damage to nuclear power
  plants, medical equipment, industrial equipment

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Radiologic/NuclearPrevention/Diagnosis/Treatment

• Prevention - Intelligence regarding possibility
  of exposure to radiologic agents. Stockpiling of
  iodine other postexposure agents if exposure
  is likely
• Decontamination Strategies
• Diagnosis - Basic knowledge of radiation injury
  patterns
• Treatment - Ready access to specialists with
  knowledge of diagnosis and treatment of
  radiologic illness

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High Explosive Agents

• Landmines
• UXOs Unexploded Ordinance
• Booby-traps
• Mortars/RPGs rocket propelled grenades
• Rockets
• Suicide Bombers

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High ExplosivePrevention/Treatment

• Prevention - Landmine awareness training
  especially for local field staff
• Treatment - Adequate staff training on basic and
  advanced first-aid techniques
• Ready availability of medical expertise/equipment
  for patient evaluation/treatment
• Evacuation plans well established and
  tested