Getting Prepared for a Radiological Terrorist Event

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Getting Prepared for a Radiological Terrorist
Event

• David J. Brenner, Ph.D., D.Sc.,
• Center for Radiological Research
• Columbia University Medical Center
• djb3_at_columbia.edu
• You can view / download this lecture at
  www.columbia.edu/djb3

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Goiânia, Brazil, 1987Population 1.3 million
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Abandoned medical clinic in Goiânia contained
1,400 Curie radioactive cesium sources
The radioactive sources were stolen, broken open,
and dispersed
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Goiânia incident Equivalent to large-sized
dirty-bomb scenario in Manhattan

• 130,000 people (10) came to ER / temporary
  screening locations
• 250 (0.2) were contaminated
• 20 (0.01) required treatment

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Topics that we will cover

• What is ionizing radiation?How is it harmful?
• Radiation threat scenarios
• Appropriate medical responses
• Psychological aspects
• Resources

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Radioactivity

• The spontaneous emission of radiations alpha
  rays, beta rays, gamma rays
• from radioactive materials

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Radioactivity Alpha Rays
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Radioactivity Beta Rays
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Radioactivity Gamma Rays The Electromagnetic
Spectrum
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Interaction of alpha, beta, gamma rays with
matter Ionization
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Alpha, beta and gamma rays
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Radiation vs. Radioactive Material

• Radiation energy transported in the form of
  particles or waves (alpha, beta, gamma, neutrons)
• Radioactive Material material that contains
  atoms that emit radiation spontaneously

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Exposure vs. Contamination

• External Exposure irradiation of the body from
  external source
• Contamination radioactive material on patient
  (external) or within patient (internal)

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Radiation Dose

• Measured in milliGray (mGy) (1/1000 joule / kg)
• Equivalent dose is measured in milliSievert (mSv)
• For our purposes, 1 mGy 1 mSv
• Old units are the rad and the rem
• 10 mGy 1 rad 10 mSv 1 rem
• Average background radiation dose is 3 mSv /
  yearA mammogram produces about 0.01 mSv.A CT
  scan produces about 10 mSv.

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Radioactivity

• The activity (strength) of a radioactive source
  is measured inCuries (Ci) or Becquerels (Bq)
• 1 Bq 1 radioactive disintegrations / sec
• 1 Ci 37 GBq
• 37 thousand million disintegrations /
  sec

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The Principal Hazards ofIonizing Radiation

• Cancer risks
• Hereditary risks
• Effects on the developing embryo/fetus

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Radiation Risks
Teratogenic risks Order of magnitude larger than
Carcinogenic risks Order of magnitude larger
than Hereditary risks
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The Carcinogenic Effects of Ionizing Radiation
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Ionizing Radiation and Cancer
Most of our information comes from studies
ofA-bomb survivors
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Lifetime cancer mortality risk as a function of
age at exposure
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Individual Susceptibility to Radiation
Carcinogenesis

• There are likely to be subpopulations of
  individuals who are significantly more sensitive
  to ionizing radiation than the average
• Children
• ATM heterozygotes (Ataxia Telangiectasia, 1-2
  of the population)
• BRCA1
• BRCA2

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Radiation-induced hereditary effects

• Radiation does not produce new, unique mutations,
  but simply increases the incidence of the same
  mutations that occur spontaneously

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Teratogenic Risks(i.e., to the embryo/fetus, if
relevant)

• Moderate doses of radiation can produce
  catastrophic effects on the developing embryo and
  fetus.

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The principle effects of radiation on the
developing embryo and fetus are

• Growth retardation
• Embryonic, neonatal, or fetal death
• Congenital malformations and functional
  impairment,such as mental retardation.

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Radiation Risks
Teratogenic risks order of magnitude larger than
Carcinogenic risks order of magnitude larger
than Hereditary risks
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Radiation Threat Scenarios

• Nuclear device
• Damage to nuclear power plant
• Dirty bombs

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Nuclear Device

• Risk
• Exposure to ? rays and neutrons
• Fallout of fission products (including
  short-lived iodine isotopes)
• Outcome
• Large number of acute deaths
• Long-term carcinogenesis
• Likelihood
• Remote

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Attack on a nuclear power plant

• Risk
• Attack on the reactor itself
• Attack on stored used fuel elements
• Release of fission products I-131, Cs-137, etc
• Outcome
• Unlikely to involve acute deaths
• Long-term carcinogenesis
• Likelihood
• Extremely unlikely

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Dirty Bombs (Radioactive dispersal devices, RDD)

• Risk
• Release of radioactive cesium, cobalt or
  americium
• Small number of contaminated people
• Large number of very slightly contaminated people
• Psychological chaos (many frightened people)
• Outcome
• Unlikely to result in acute deaths
• Risk of long-term carcinogenesis
• Likelihood
• Likely

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Radioactive Dispersal Device (RDD)
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Dirty Bombs

• How available are the radioactive materials?

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August 1994

• Three people arrested at Munich airport having
  flown on a Lufthansa flight from Moscow carrying
  363 grams of plutonium

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November 1995
Moscow, Russia -- A group of Chechen rebels
contacts a Russian TV station to claim that they
have buried a cache of radiological materials in
Moscow's Ismailovsky Park. There, the authorities
find a partially buried container of radioactive
cesium.
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December 1998
Argun, Chechnya A container filled with
radioactive materials found attached to an
explosive mine hidden near a railway line. It is
safely defused. The location is Argun, near the
Chechen capital of Grozny, where a Chechen group,
led by Shamil Basayev, operated an explosives
workshop.
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June 2002
Chicago, Illinois -- Jose Padilla, a US citizen
with links to Al Qaeda, is arrested in Chicago
airport on suspicion of planning to build and
detonate a dirty bomb. F.B.I agents suspect
Padilla had recently undergone training in
Pakistan, where he allegedly studied the
mechanics of dirty-bomb construction, including
how to wire explosive devices and how to optimize
bombs for radiological dispersion.
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January 2003
Herat, Afghanistan -- Based on evidence uncovered
in Herat, including detailed diagrams and
computer files, British intelligence agents
conclude that Al Qaeda has succeeded in
constructing a small dirty bomb, though the
device has not been found.
A collage of dirty bomb plans journalists
recently discovered in Afghanistan
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March 1998
Greensboro, North Carolina -- Nineteen small
tubes of cesium are taken from a locked safe in
Moses Cone Hospital. The total activity was 22
Gbq (0.6 Ci). Each tube was three-quarters of an
inch long by one-eighth of an inch wide and were
used in the treatment of cervical cancer. The
cesium is never recovered.
Cesium tubes similar to the ones missing from
Greensboro
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March 2002Nucor Steel Mill, Hertford, NC

• 2 Ci cesium industrial gauge found on scrap metal
  conveyer belt
• Traced back to a batch of four belonging to a
  bankrupt Baltimore chemical company. Three have
  been located....

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Moisture Density Gauges, contain small quantities
of americium-241 and cesium-237About 22,000 in
use in the US. About 50 per year reported as
missing
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August 2004

• London Islamic terrorist cell, led by Dhiren
  Barot, raided. Large cache of household smoke
  detectors found, each containing small quantities
  of americium-241

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Small and large dirty bombs (RDD Radioactive
dispersal device)

• Small RDDHigh explosives dispersing 0.1 to 10
  Curies
• Intermediate RDDHigh explosives dispersing 10 to
  1,000 Ci
• Large RDDHigh explosive dispersing 1,000 to
  10,000 Ci

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Small Dirty Bomb (RDD) 2 Ci cesium source 10
lb TNT

• Inner Ring One cancer death per 100 people due
  to remaining radiation(typical dose 25 cGy)
• Middle Ring One cancer death per 1,000 people
  due to remaining radiation(typical dose 2 cGy)
• Outer Ring One cancer death per 10,000 people
  due to remaining radiation(typical dose 0.2
  cGy)EPA suggests decontamination

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Intermediate RDD 2,000 Ci of cesium chloride,
from a seed irradiator, and 10 lb of Semtex
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Large RDD 10,000 Ci cobalt source (food
irradiator rod)

• Inner Ring One cancer death per 100 people due
  to residual contamination (typical dose 25 cGy)
• Middle Ring One cancer death per 1,000 people
  due to residual contamination (typical dose 2
  cGy)
• Outer Ring One cancer death per 10,000 people
  due to residual contamination (typical dose 0.2
  cGy)

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Large RDD 10,000 Ci cobalt source (food
irradiator rod)

• Inner Ring Same radiation level as permanently
  closed zone around Chernobyl
• Middle Ring Same radiation level as permanently
  controlled zone around Chernobyl
• Outer Ring Same radiation level as periodically
  controlled zone around Chernobyl

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You need to be part of a radiation casualty
Immediate Medical Management Issues
team

• Health providers
• Physicists
• Social workers / administrators

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Immediate Medical Management Issues

• Triage
• Decontamination
• Initial stabilization and treatment of
  life-threatening injury
• Health care provider health and safety
• Surge capacity availability of staff (quantity
  and specialists), supplies, space

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Almost all the individual presenting at ER /
clinic will not have a measurable radiation
exposure

• Goiânia
• 99.8 of individuals at ER/clinic not
  contaminated
• 8 had psychosomatic reactions which mimicked
  radiation exposure
• Israel, attacked by Scud missiles during 1991
  Gulf war
• 51 of individuals at ER were stress casualties

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The job of the radiation physicists

• Determining / documenting radioactivity levels,
  and radiation dose levels
• Collecting samples to document contamination
• Assisting in decontamination procedures
• Disposing of radioactive waste

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Staff radiation protection

• Fundamental Principles
• - Time
• - Distance
• - Shielding
• Personnel Protective Equipment
• Contamination Control

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Contamination Control
Separate Entrance
CONTAMINATED AREA
Trauma Room
HOT LINE
BUFFER ZONE
CLEAN AREA
Clean Gloves, Masks, Gowns, Booties
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Protecting Staff from Contamination

• Use standard precautions (N95 mask if available)
• Survey hands and clothing frequently
• Replace contaminated gloves or clothing
• Keep the work area free of contamination

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Pregnant Staff

• Pregnant staff should be reassigned

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We need to be prepared for a radiological
incident

• Facilities should plan in advance and include
  procedures in their Disaster Plan

? Everyone needs training!
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If there is a plan in place and staff are well
trained, radiation exposure to staff should be
very low
When workers at Chernobyl who were in the
reactor area at the time of the nuclear accident
were decontaminated, the medical personal at the
site received less than 10 mGy of radiation.
Mettler Voelz,New England Journal of Medicine,
346 1554 (2002)
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Patient Management - Priorities

• Standard medical triage is the highest priority
  dont delay givingcritical care because a
  patient is contaminated
• Radiation exposure and contamination
  aresecondary considerations

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External Contamination

• Radioactive material (usually in the form of dust
  particles) on the body surface and / or clothing
• Radiation dose rate from contamination is usually
  low, but while it remains on the patient it will
  continue to expose the patient and staff

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Patient Decontamination

• Remove and bag patients clothing and personal
  belongings
• (typically removes 80 - 90 of contamination)
• Handle foreign objects with care until proven
  non-radioactive with survey meter
• Survey patient and collect samples

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Decontamination Priorities

• Wounds
• Intact skin
• Change outer gloves frequently to minimize spread
  of contamination

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Decontamination of Wounds

• Contaminated wounds
• Irrigate, gently scrub with surgical sponge
• Debride surgically only as needed
• Contaminated thermal burns
• Gently rinse
• Change dressings to remove additional
  contamination
• Avoid overly aggressive decontamination
• Change dressings frequently

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Decontamination of Skin

• Use multiple gentle efforts
• Use soap water
• Cut hair if necessary (do not shave)
• Use survey meter

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Cease Patient Decontamination

• When decontamination efforts produce no
  significant reduction in contamination
• When the level of radiation of the contaminated
  area is less than about twice background

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Removing internal contamination is more
problematic
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Internal contamination countermeasures?

• Potassium iodide blocks radioactive iodine from
  being absorbed in the thyroid.
• Very limited utility

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Internal contamination countermeasures?

• Potassium iodide blocks radioactive iodine from
  being absorbed in the thyroid.
• Totally useless

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Internal contamination countermeasures?
Traps cesium in the intestine, so that it can be
passed out of the body in the stool rather than
bere-absorbed Recently approved by FDA Only
useful if the radioactive material is cesium
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High-dose radiation syndromes
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Self Renewing Tissuese.g. lining of the G.I.
tract
Stem-cell compartment Differentiating
compartment Mature functioning cells
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Prodromal Effects

• Symptoms to be expected at about 50 lethal dose
• Neuromuscular Easy fatigability
• Gastrointestinal Anorexia, vomiting
• Additional symptoms to be expectedafter a
  supra-lethal dose
• Neuromuscular Fever hypotension
• Gastrointestinal Immediate diarrhea

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• Gastrointestinal Syndrome
• Results from whole-body exposure to gt8 Gy.
• Due to crypt cell depletion and sloughing off of
  intestinal villi
• Symptoms include nausea, vomiting,
  prolonged diarrhea, loss of appetite, lethargy,
  dehydration, emaciation, exhaustion
• Symptoms start a few hours after exposure but,
  depending upon the dose, there is often
  a latent period around day 2-6, at which time
  severe symptoms return
• Death occurs in around 5-15 days.

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• Hematopoietic Syndrome
• Results from whole-body exposure to 3 - 8 Gy.
• Due to depletion of blood stem cells
• Symptoms include all of GI syndrome nausea,
  vomiting, diarrhea, with similar latent period
• 3 weeks after exposure, chills, fatigue, skin
  hemorrhages, mouth ulceration, anemia, epilation
• Death within 60 days due to infections and fever
  (lymphocyte and granulocyte depression), or
  hemorrhage (platelet depletion)
• Some individuals may be saved by antibiotics,
  platelet infusions, bone marrow transplants, or
  growth factors.

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Treatment of Large Radiation Exposures

• Treat patients symptomatically
• Prevent and manage infections
• Reverse isolation
• Assess for infection and thrombocytopenia
• Antibiotics
• Electrolytes
• Hematopoietic growth factors,
• e.g., GM-CSF, G-CSF (Neupogen)
• Continued assessment and supportive care

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Bottom Line

• Medical centers in major cities need to be able
  to quickly assemble a competent team to cope with
  a radiation incident
• Physicists
• Emergency room specialists
• Radiation oncologist / radiologist
• Psychologists

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Selected Further Information
CDC and OSHA have good starting
websites www.bt.cdc.gov/radiation/index.asp www.o
sha.gov/SLTC/emergencypreparedness/rdd_tech.html
Documents American College of RadiologyDisaster
Preparedness for Radiology Professionals
Download at www.acr.org/departments/educ/disaster
_prep/dp_primer.html National Council on
Radiation Protection and Measurement Report No.
138, 2001Management of Terrorist Events
Involving Radioactive Material
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The real bottom line

• The threat of radiological terror is real
• Most scenarios will present primarily
  organizational challenges

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The real bottom line

• The threat of radiological terror is real
• Most scenarios will present primarily
  organizational challenges
• The answer