CBRN Terrorism andEmergency Preparedness

David AlexanderUniversity College London

The problem

Principal objectives of terrorism

• obtain political concessionsby negotiation

OR

• injure or kill many peopleor create great destructionor chaos (reprisals).

• 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

• unanticipated, unfamiliar threat to health

• lack of sensory cues

• prolonged or recurrent aftermath

• potentially highly contagious

• produces observable casualties.

A CBRN incident:-

• 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

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)

Industrialaccident

Medicalaccident

Nuclearaccident

Epiphytotic(food chain)

Epizootic(food chain)

People(victims)

CBRNattack

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

The instruments of attack

Some possible means of attack:-

• viral or bacterial pathogens

• chemical toxins

• radioactive substances

• nuclear weapons.

Possible means of dispersion ofa chemical or biological agent

• aerial dispersion or launch

• bomb

• missile

• dispersion by hand.

Possible events

• delivery of a weaponizedbiological or chemical agent

• use of a common pathogen

• contaminated missile or bomb

• hoaxes or false alarms.

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.

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).

Possible impact of a biological attackon the food chain - epizootics

• bovine spongiform encephalopathy

• foot and mouth disease

• mass poisoning.

• Karnal Bunt fungus

• Puccinia graninis avenae pathogen

• fungal infections of rice or other grains.

Possible impact of a biological attackOn the food chain - epiphytotics

Examples ofincubation periods

• anthrax: 1-6 days• smallpox: 12 days• plague: 2-3 days.

Biologicalagent

Chemical agent

Origin natural anthropic

Production difficult,small scale

industrial scale

Volatile? no yes

Toxicity more less

Effectson skin

not active active

Biologicalagent

Chemical agent

Taste/smell none sensible

Toxic effects

many few

Immunogens often generated

rarely generated

Delivery by aerosol aerosol cloud or droplets

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

Botulism Nerve gas

Gastro-intestinal

reduced motility

increased motility, pain

Ocular eyelidsdroop

pupils contract

Saliva difficulty swallowing

watery

Responds to atropine?

no yes

The response

• injuries and illnessescaused by the toxic agent

• risks to reproductionand human fertility

• psychological and psychosomatic effectsmultiple idiopathic physical symptoms.

Consequences of an attack

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

Elements of emergency response to plan

• quarantine

• specialised equipment

• safety of emergency workers

• apportion roles and tasks.

• diagnose and decontaminatethe site and victims

Situation monitoring requirements

• nature of symptoms

• rapid diagnosis

• number of sick people

• anti-microbe or anti-toxin therapies.

• mass casualtymanagement procedures

Analysis of samples takenfrom site or from victims

• special transport is requiredfor dangerous samples.

• rapid and timely alarm-raisingand analysis is essential

• 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.

Role of scenariosin indicating

preparedness needs

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)

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")

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)

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.

First responders

• 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?

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.

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.

• 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

• 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

Decontaminate:

• people

• internal environments

• external environments.

'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

Very considerable uncertainty surroundsthe practice of decontamination,regarding protocols, practices

effects, efficiency and timespans.

• risks of secondary contaminationof responders and hospital staff

• shortage of personal protectionequipment & expertise on how to use it

• shortage of isolation facilities.

Contaminated patients

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.

• restriction of physical activity(manual dexterity, hearing)

• communication problems

• dehydration

• heat-related illness

• psychological effect(e.g. claustrophobia).

Limitations on use of PPE:-

• 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

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

Conclusions

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.

• 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...

• 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...

• "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:-

"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...