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Public Health Radiological/Nuclear Preparedness Webinar - August 2017

On August 24, 2017, CDC’s Division of State and Local Readiness in the Office of Public Health Preparedness and Response sponsored a webinar to discuss priority public health actions for state and local radiological/nuclear preparedness and response.  CDC resources for planning were described and participants had the opportunity to ask questions and offer comments.  Webinar materials include:


Moderator:  Christine Kosmos

August 24, 2017

6:00 pm EDT

Coordinator: Welcome and thank you all for standing by.  At this time all participants will be in a listen-only mode until the question and answer sessions during today’s conference.

Today’s conference is being recorded.  If you have any objections you may disconnect at this time.  I would now like to turn the call over to Chris Kosmos.  You may begin.

Christine Kosmos: Thank you operator and thanks everyone.  This is Christine Kosmos.  I’m the Director of the Division of State and Local Readiness here at CDC, and on behalf of our office and our colleagues in the Radiation Studies Branch within CDC’s National Center for Environmental Health we want to welcome you to the National Public Health Rad/Nuc Preparedness Webinar for state and local public health planners.

So I want to start this afternoon first of all for apologizing for some of the technical difficulties and hopefully we’ve got that all resolved.  But I wanted to give you a couple of minutes of background information on why we thought it was important to bring this Webinar to our state and local public health colleagues.

So I’m going to focus for a moment on three things.  So between our colleagues here at Radiation Study Branch and our division we’ve received a fair amount of requests from our state and local public health partners for assistance in developing and further developing their state and local rad/nuc plans for public health response.

So we’ve gotten requests for tools, guidance, pamphlets, anything that could help our state and local public health partners.  Secondly, for those of you in the PHEP program, the Public Health Emergency Preparedness program at the state and local public health, I think you well know that it’s a grant requirement for our state and locals to have a CBRNE plan so I know that you’ve been working hard on that.

And then thirdly, here at CDC we recently participated in a national level exercise that was sponsored by FEMA and it was a rad/nuc scenario.  And during CDC’s participating in that national level exercise we learned some things that we thought would be important to share with our public health partners, and we wanted to take an opportunity to share that today.

So our two visions have – our divisions have come together to partner and put together this Webinar as I said for state and local public health partners to walk through what we feel at CDC are some of the priority public health actions for state and local rad/nuc response, as well as some of the CDC’s resources that Radiation Studies Branch has developed over the years that can really assist with some of this public health planning.

Finally, I want to caveat this by saying that certainly public health is only one piece of the puzzle and that of course public health does not do this sort of a response alone, nor is public health considered the lead agency either here at the federal level or at the state and local level.

But we are a piece of the puzzle and public health works with their emergency management partners, Homeland Security partners, healthcare partners, law enforcement partners, rad control experts, the RACs, et cetera to design, develop and respond to any sort of a rad/nuc event.

And because of that we have invited these other response partners on the call as well today, just so that they have some visibility as to what CDC is telling state and local public health and they can share in that information.

So let me walk through a little bit about what you will hear today.  You’ll hear a little bit about our CDC and the FEMA exercise that CDC participated in that I referenced earlier, Gotham Shield.

You’ll hear a little bit about Rad/Nuc 101201 and the expected role of public health, some public health actions, some key information that public health would need to know as well as decisions for public health leaders.

We’ll also talk about and drill down into what some of the specific responsibilities of public health would be in terms of population monitoring, health surveillance, distribution of medical countermeasures, distribution and development of guidance on altered standards of care, managing scarce resources, risk communications, et cetera.

And then we’ll do a drill down into some of those tools that we think could help support you in further developing your plans.  Towards the end of the Webinar we’re going to do a short poll to ask what else you would need from CDC to improve your planning and your readiness for a rad/nuc response.

So on our call today we’ve invited some of our speakers and colleagues from Radiation Studies Branch as well as some of our sister agency here at OPHPR, our Division of State – Strategic National Stockpile and you will hear also from some subject matter experts around risk communication.

So I want to introduce our first speaker today, Dr. Bob Whitcomb, who is from the Radiation Studies Branch, and for the Gotham Shield exercise Dr. Whitcomb served as the Exercise Director as well as the Chief Science Officer.

He’s been at CDC since 1993 and he serves as the Chief of the Radiation Studies Branch.  You’ll also hear from Dr. Adela Salame-Alfie who is the Senior Service Fellow within the Radiation Studies Branch.

You’ll also hear from Greg Burel who’s from the Division of Strategic National Stockpile as well as Sue Gorman who is the Associate Director for Science for Strategic National Stockpile, and Vivi Siegel who’s going to talk about some of the risk communication tools that we think would be important for state and local public health.

So first I’m going to turn it over to Bob as our first speaker who is going to walk through some of the exercise and some of the lessons that we’ve learned.  Bob?

Robert Whitcomb: Thanks Chris.  Welcome everyone.  It – glad to be here with you.  Glad to share some important new information that we’ve learned as Chris has already indicated from our own standpoint, and I’m talking about an internal standpoint from a CDC perspective.

I’m going to talk about many firsts that have happened for us as far as a learning curve, but let’s go ahead and go jump into the next slide so I can give you an overview as to how those lessons were learned.

As was already indicated there was a national level exercise in the planning for about a year or so prior to execution on April of this year.  It was a 3-1/2 day exercise for CDC.

It was designed to educate and prepare the whole community for an act of terrorism and a catastrophic event.  As you know it is – definitely a primary window for our opportunity was April 24 to the 27th.

There was a recovery phase.  CDC as a public health agency wasn’t so much involved and engaged with the prevent/protect.  That’s more of a law enforcement situation but know it was a year in the making.

Next slide please.  This graph shows by quarter the activities that the – that were undertaken here at CDC.  It was a yearlong as I said effort.  The first – was planning.

Then we went into organizing, equipping, training, the exercise and then evaluation phase which we’re still going through now in the after action report.

When you think about this and you think about public health and you think about a radiation program, even within public health there’s a learning curve.  The terms are different.

What we talk about in the way of exercise, excuse me, exposure and contamination are somewhat different than our colleagues who deal with infectious diseases when they talk about exposure and contagions, so those are differences we had to overcome.

The challenge of the language is a communication tool and a challenge for us internally as externally, so you’ll hear more about those from the other speakers.

But you’ll see our goals there.  We wanted to become more proficient, more efficient and more ready as an agency so that we can assist and support you in your planning and preparedness and response, so we looked at this as a crawl in the beginning to a walk and a run.

We knew we couldn’t hit the ground running but we knew – took to get there.  Next slide please.  So in the next part I want to talk about the scenario.  It was based on National Planning Scenario Number 1, an improvised nuclear device detonation, some intelligence information about terrorists trying to bring a gun type nuclear device using highly enriched uranium smuggled into the U.S., assembled here, transported to a large city and then detonated.

And as you can see it was detonated near a large U.S. city.  Gotham Shield – as you might expect Gotham meaning New York, Shield meaning protection.  It happened near New York so both the states and locals within New York, New Jersey and New York City were engaged and involved as we were.

So you can look at the numbers there.  Obviously this is a catastrophic incident.  Next slide please.  So one of the first questions we had – and you can go ahead and click one more time please operator.

One of the first questions was how does this compare – in other words how does an improvised nuclear device scenario – compared with the Hiroshima/Nagasaki bombings that occurred back in 1945?

Well in Hiroshima, and pretty much the little boy Hiroshima, that weapon was in essence an improvised nuclear device.  It was a uranium device.  The one used on Nagasaki was a plutonium device.

What’s unique about both of these is they were both airbursts, and as you see in the first descriptor here an airburst is a nuclear detonation where the fireball created with the explosion does not touch ground.

What that means is you don’t create a lot of fallout.  Next – if you can click – more time please.  The ground bursts  – the difference in this scenario, the one we dealt with, with Gotham Shield – this is where some perpetrator brings it in on the ground, detonates it, thereby it – the blast damage is still severe but not as severe had it – would – been detonated at an altitude.

But there the difference is all the material that is vaporized and sucked up/carried up into what is called a mushroom cloud – that’s what’s important because downwind now you create some dangerous fallout patterns, and some other fallout patterns that can extend hundreds of miles from it.

And just for example when you look at – and the stem of the mushroom cloud, 80% of the radioactivity produced in that detonation is in the cap.  Only 20% is in the stem.

So that cap can rise about 20,000 feet in the air.  What – wind speed and direction at ground level doesn’t really matter much.  It’s what it is up at 20,000 feet.

Next slide please.  So the things that we dealt with and our radiation experts for this exercise – I want you to keep in mind when you look at this list these are the thematic areas:  worker safety and health, medical countermeasures, community reception center operations, state and local needs, data needs, cost of a registry when this thing – when the dust settles who do we follow?

How do we follow?  How much will it cost?  Huge effort so think about this when you hear about the other topics that the presenters after me – these are huge public health issues and they’ll be talking about those in more detail.

Next slide please – give you a flavor of the types of questions that were brought up during this exercise that came to some of the Technical and Joint Information Center staff within the response for CDC.

Is the large number of fatalities unusual?  How does this compare with the Japan earthquake, things you might hear from the media, things you might hear from the public?

How was CDC involved in this event?  How were medical countermeasures delivered and distributed?  How soon will they get there?  One important or two important issues and – highlighted in blue I just want to call to your attention why is potassium iodide not relevant for this type of scenario – a very important question.

There’s a lot – information about KI out there.  We wanted to make it clear potassium iodide for a nuclear weapon detonation is not relevant.  The same goes for other countermeasures you may hear about later on.

Prussian blue for example, which helps with cesium contamination – yes cesium but there’s 100 of other – hundreds of other radionuclides that cause more problems than just cesium, so again just to highlight a few.

So I’m going to stop there but let me summarize three or four very important points so you – there were many firsts for us at CDC being involved with the Gotham Shield exercise from a public health agency perspective.

It’s the first time every center, every institute, every office within CDC was at the table engaged and defining the role and the responsibility.  It was also a first time we developed an incident management system so if this were to happen, if any other radiological emergency happened we would be ready to staff an incident management system structure already defined.

Another first – we’re revising the CDC Nuc/Rad Incident Annex that we have to our all hazards plan.  It will further advance our preparedness here at CDC.  And another first – the senior leaders here at CDC were amazing.

I had said early on in the preparedness for this exercise that I didn’t need to make everyone a radiation expert but what I’d like to do is let – help every center, institute and office become what I call rad savvy.

I can tell you that was successful.  At the end of this exercise we are, CDC is and now is rad savvy.  What does that mean?  It means CDC is better prepared now than ever in my career.

You heard Chris say it.  I’ve been here 23, 24 years or more.  We are better prepared now to assist and support our state, local, tribal, territorial partners in a preparedness to what we hope is a never to happen event.

So with that I’d like to turn it over to Dr. Adela to go through the – more specifics about the thematic areas I’ve mentioned already.

Adela Salame-Alfie: Thank you Bob and thank you for this opportunity to talk to you all.  What I’m going to do in my short presentation is to give you a brief overview of the topics that are in that briefing book that was sent out for comment.

And we sent out that book — we prepared it a while ago — because we were thinking that it will be good to have a good resource that if something should happen somebody can read on the plane on – two hours get – go – get some important information as to what key things I need to be aware of as I’m flying somewhere to assist with the response.

So that’s the intent of the book.  It is not an – in depth clearly on any of the topics.  We have plenty of references.  Some will be highlighted at the end of the talks.

We have a lot of information also on our Web site but I’m just going to highlight some of the key things that we think are important as – for a public health response.

Next please.  Thank you.  Why?  Why did we do it?  Because during a radiation emergency state and local authorities will need to do a quick assessment of the hazards and issue appropriate protective actions.

You need to know what the hazards are but you need to know what are the correct protective actions.  If you can have the next one please.  We believe – all in this call are familiar with the CBRN concept:  chemical, biological, radiological and nuclear.

Both radiological and nuclear deal with radiation.  Why do we make the distinction?  Because they’re different.  A radiological incident does not involve a nuclear detonation like Bob mentioned.

A nuclear incident involves a nuclear detonation but both can happen in unforeseen locations and both of them apply to all states and jurisdictions, so there are differences but there are things that will apply no matter what.

Next please.  Showing here there’s a list of potential radiation events ranging from a transportation accident.  Some truck carrying radiopharmaceuticals can get in an accident on the highway and that’s a radiological event.

We can have a power plant, industrial, medical and including terrorism so it can be one of many categories.  They all involve radiation but they have similarities and they have differences.

Next please.  I’m going to focus just on a couple of – like I said there’s more information on our Web site.  A radiological dispersal device – that’s what’s being referred to as a dirty bomb as well.

This is a device that disperses radioactive materials like conventional explosive, like a dirty bomb or it could be a dust cropper – a crop duster.  I’m sorry.

It’s something that spreads contamination.  That creates a lot of panic.  If people think that their water is contaminated/their food supply is contaminated that can create a lot of panic, so it’s more contamination than exposure hazards.

Next please.  Nuclear emergencies as we said earlier involve explosion of a nuclear weapon or an improvised nuclear device.  The explosion will produce an intense pulse of hot – of heat, light, pressure and radiation and it produces fallout especially if we’re talking about a ground burst.

There will be a lot of fallout and that will be carried a long distance in the wind.  It can impact a lot of people.  Next please.  I’m going to talk about some of the key information needed by the public health response.

And I’m making a distinction between the nuclear incident and radiological incident.  For the nuclear incident we’ll want to know what type of device, the size, where is it heading and the amount of radioactive decay, how quickly the radiation levels are decreasing?

For a radiological incident we might want to know if it’s a dirty bomb, a transportation, nuclear power, what radionuclides are involved, what is the half-life, et cetera?

Is it liquid/solid/gas?  Are there medical countermeasures available?  So there are different things to consider depending on the type of event.  Next please.  But there are also a lot of information needs that will apply no matter what such as the impacted area.

How large is the contamination?  What are the radiation levels?  What’s impacted?  Any critical infrastructures?  What’s the affected populations?  How many people live in the area?

How many people are transient?  They go, you know, go to work and go back home and is not living in the area but spend a lot of time in the area.  Are there any special events, a NASCAR, a big football game that we need to worry about?

What are the primary radiation hazards?  Is it an exposure or contamination?  Are there other hazards?  Are there fires, gas lines, buildings collapse?  I mean, it’s – radiation is a big concern but it’s not going to be the only concern.

And what assets do we have available to address those hazards?  Do we have search and rescue?  Do I have medical and what kind of training do they have?

Next please.  What are the safety precautions considerations?  First responders, first receivers and the hospital – do we need to issue any specific guidance?

Are they going to be able to deal with this?  Are they going to feel comfortable transporting people that are potentially contaminated?  On the right side communications – if I had to highlight one of the key issues it would be communication.

What we say, how quickly we say is really going to drive how the response is going to follow, so the more we know about it, the more we engage with the technical experts and we have the right channels to communicate to people the better off we’re going to be in how the response is going to go.

And last but not least on this slide who do we need to contact not just for notification but for assistance?  I’m going to talk about a bunch of resources – of course not all of them.

I’m just highlighting a few but these – the resources that can come and assist but there are also agencies especially if you’re at the local level.  Who do you want to notify?

And this is no different than a hurricane or a tornado.  When you escalate from the local to the state to the feds it’s – there’s no difference.  It’s just more pieces to the puzzle.

Next please.  Now I don’t need to stress that how much information we have is how good our decision-making is going to be, so the more information we have the better off we’re going to be.

So we need to determine what’s the most appropriate initial protective action for people in the affected area.  I mentioned there’s a range of events that are radiological events.

If it evolves slowly like a nuclear power plant it may be possible to evacuate people from the area before the contamination gets there.  As a matter of fact the plant’s goal for evacuating people before the release, to prevent exposure.

But evacuating large populations present other hazards.  Many people may have a higher risk by evacuating if there’s no need to.  It is important to consider the potential risk of evacuating versus issuing a shelter in place order.

Next please.  For a fast-moving event like a terrorist event, like a dirty bomb or an IND the best course of action is to shelter in place until the radiation experts can assess the hazard and provide further instructions.

An RDD or dirty bomb is unlikely to distribute enough contamination to present a really serious exposure, but if people leave the safe structure to go somewhere else they might get internal contamination/external contamination so we’re trying to prevent contamination.

Shelter in place – it’s a very important action also after an IND because we know from the science that the radioactive fallout from IND presents a really serious exposure hazard and going outside is just going to make things worse.

The radioactive levels decay very fast so just staying inside 24 hours is going to cut down the amount of exposure one would get, and I know it’s hard to tell people stay in for 24 or 48 hours.

It’s counterintuitive but it’s going to save lives.  If we really want to save lives that’s the protective action recommendation that we want to get in our communication.

Next please.  I’m going to talk a little bit on the roles and responsibilities and I’m assuming most of you are familiar with the National Response Framework and the Nuc/Rad Incident Annex to the NRF.

That is what defines the roles and responsibilities.  It also discusses the authorities’ capabilities and assets that the federal government can bring to bear to these events, and it also discusses how the assets will organize and operate in conjunction with each other and with local and state partners.

So it’s very important if you’re not familiar with the NRIA or the National Response Framework that you become familiar, because that would give you the framework that we’re going to be operating under.

Next please.  Now there are many responsibilities laid out in the plans – way too many to – that would cover a whole Webinar and – too.  But there are some that are very specific to public health.

One would be to conduct population monitoring.  Another one would be to initiate health surveillance and an epidemiological investigation for workers and the public.

Another one would be coordination of the countermeasures and coordination and the distribution of medical countermeasures, and communicating guidance regarding use of other standards of care and managing scarce resources.

As you can imagine we’re going to be operating this hopefully never, but if we ever have to deal with this under very, very stressful conditions.  Next please.

So just a few words on population monitoring because it’s likely to be the most challenging responsibility for state and locals.  Population monitoring will begin soon after the incident is reported and it will continue until all potentially affected people have been monitored and evaluated for a lot of things, so need for medical treatment, process of contamination, intake of radioactive material, possible decontamination, long-term health effects.

And it might go for a long, long time and it will include people that were not even in the area that want to be monitored, so it’s going to take a toll on our public health resources.

Next please.  Again these assessments except for the evaluation of the long-term health effects should be done as soon as possible, but others can take up to decades.

We know some of the registries.  We see it with the World Trade Center Registry and other registries.  They go on for a long, long time.  We’re still tracking people from Japan on the life span study so – and that was what, 60 years ago so it’s a longtime effort.

Next please.  Just a couple more things.  There are some special considerations for population monitoring after an IND, and those are spelled out in the Planning Guide for Response to a Nuclear Detonation that was put out by the interagency.

You have to remain flexible.  You plans need to be flexible and scalable to reflect the prioritized needs of the individuals and your resources.  You may not be able to do as much if you have 100,000 people than if you have 1000 people so keep that in mind in your plans.  You have to be flexible.

The immediate priority is to identify people whose health is in immediate danger and require assistance and deal with them.  The primary purpose is to detect and remove external contamination during population monitoring.

We want to prevent acute health effects, and please remember, and remind the people you work with, radioactive contamination is not immediately life-threatening.

People aren’t afraid to deal with contaminated individuals if there’s evidence it’s not going to put their health at risk.  Next please.  Just a couple more things to cover.

During the early –what is the timeline for the phases of radiation emergency response?  And we usually talk about the early, the intermediate and the late phases and just in terms of what information – and what needs to take place early phase is characterized by lifesaving and immediate protection from radiation.

Often it’s based on limited information and projections.  We might have data from models.  We may not have boots on the ground measurements so we have to rely on models early on that get refined as we are able to collect some real data.

The intermediate phase involves protecting people from chronic exposures, cancer primarily, and protecting people from ingesting contaminated food, water and other contaminants.

The late phase will involve activities that are designed to return people to normalcy if that’s possible or the new normal yes.  Next please.  I’m just going to – I’m not going to list all of them but this is a list of some of the federal aid – assets from the Department of Energy.

I mentioned modeling.  That will be the NARAC, National Atmospheric Release Advisory Center.  They also have the Radiological Assistance Program.

They have a plane also that can conduct quick measurements from the air.  We also have the FRMAC, which is a multi-agency organization that coordinates radiological monitoring, sampling and assessment activities across multiple agencies and there’s some assistance for medical questions from the REAC/TS site.

Next please.  The Environmental Protection Agency also has some very valuable assets, and both the DOE assets and the EPA were used in the response to Fukushima.

They have the RadNet, which is a network of 130 radiation monitoring stations but they also have deployable stations.  They have another plane like the DOE that can measure levels in the air and they have radiological emergency response teams, and again there’s more information on all of these assets in the plans that we mentioned earlier.  Next please.

Another – important asset that you need to be aware of is the Advisory Team for Environment, Food and Health also known as the Advisory Team.  And this core team is – represent – has representatives from EPA, Department of Agriculture, Food and Drug Administration and CDC and we will bring in other agencies as needed depending on the event.

The A-Team will interpret information provided by the FRMAC that I just mentioned, by the modeling group from NARAC and other resources, and they provide recommendations to coordinating agency and they provide answers to state and locals when they’re – looking for recommendations.

They don’t make decisions.  They make recommendations looking at the best science and reaching out back to the agencies where they come from, so they provide a lot of really good advice.

Next please.  And just want to highlight a couple of quick things.  Because we mentioned population monitoring is a very important function of public health we’ve developed a lot of tools.

We have a community reception center drill toolkit and I’m not going to read it through but it has templates, it has victim cards if you want to conduct exercises and it’s HSEEP compliant, and I’m pretty sure most of you on the phone are familiar with the HSEEP requirements.

Next please.  And last but not least I want to tell you that in an event of a contamination like from a dirty bomb, the way to find out if people have internal contamination is by conducting urine bioassays.

The CDC Laboratory has some resources and has been developing some methods to measure some of the radionuclides that may be in the environment – in people’s body from the environment.

They do – the purpose of that is to identify and quantify the radionuclides in the people potentially contaminated, provide critical information so people can be managed – effectively medically managed, if there’s a countermeasure to be provided countermeasures but also to reassure people,– and that’s the last line – provide negative results for people.

What we mean is people know they’re not contaminated.  They don’t, you know, so they can be at ease and that’s probably going to be the majority of people that will not have internal contamination, but they want an answer and that’s where the Lab will become very, very important.

Next please.  And our Lab like I mentioned has been developing some methods.  In the old days we were collecting 24-hour urine.  That can be extremely difficult even under the best circumstances, so they developed a method using only 10 mls of urine and they have some rapid screening methods that are listed, and we have more information on our Web site.  Next please.  With that I’m going to turn over to…

Sue Gorman: Sue Gorman.

Adela Salame-Alfie: …Sue Gorman, Associate Director for Science from Division of Strategic National Stockpile.  Thank you.

Sue Gorman: Thank you and I’m going to talk for a moment about medical countermeasures.  Next slide please.  Some of these incidents we’ve been talking about may lend themselves to the use of radio-protective drugs and these drugs work in several different ways.

For example, they could block internal contamination from being absorbed in particular organs.  Potassium iodide would be an example of this.  That’s going to block your thyroid gland from taking up radioactive iodine, or they may bind internal contamination to speed up excretion from the body.

Examples of these would be Prussian blue and DTPA, which I’ll talk more about in a moment, or they can stimulate your bone marrow to produce white blood cells.

These kinds of medical countermeasures are called granulocyte colony-stimulating factors and examples would be filgrastim and pegfilgrastim.  As Bob mentioned earlier in this talk some of these drugs work on very specific radionuclides, and not all of these would be useful in a nuclear detonation.

And depending on the nature of the incident the distribution of these medical countermeasures could be widespread, for example, potassium iodide or they might be very selective, for example, DTPA.

The efficacy of these drugs depends largely on the timeliness of administration.  Next slide.  I want to talk for a moment about acute radiation syndrome, which is also known as radiation sickness or ARS.

This is a serious illness that develops when a person receives a high dose of radiation over a short period of time, and people that are exposed to radiation will get ARS only if the radiation dose was high and it was penetrating and able to reach internal organs, the person’s entire body or most of it received the radiation dose and the radiation was received in a short time, usually within minutes.

Symptoms of ARS are very nonspecific and include things like nausea, vomiting, diarrhea and headache and these symptoms and their severity can vary depending on the dose of radiation that was received.

Next slide.  The treatment of acute radiation syndrome focuses mainly on reducing and treating infections, maintaining hydration and treating any injuries and burns that the patients may have sustained, and some of these patients may benefit from treatments that help the bone marrow recover its function.

Those are the granulocyte colony-stimulating factors I mentioned earlier.  The lower the radiation dose the more likely the person will recover from ARS, and the cause of death in most cases is going to be the destruction of the person’s bone marrow and which results in infections and internal bleeding.

This recovery process is prolonged and can last from several weeks up to two years.  Next slide.  I’d like to speak specifically about the medical countermeasures that are available for internal contamination and radiation injury.

The first example is potassium iodide.  This is given orally on a daily basis and it’s specific for radioactive iodine.  What it does is saturates your thyroid gland with stable iodine and blocks your thyroid gland from taking up radioactive iodine.

It’s most effective if it’s given before an exposure even occurs or within four hours after an exposure.  Next we have Prussian blue.  This is an oral drug as well.

It’s given three times a day and it is specific for cesium and thallium.  What it does is bonds cesium and thallium and keeps them from being absorbed, and increases the rate of elimination of these radioisotopes from your body.

The contamination is then excreted in your feces.  This is most effective when given as soon as possible after internal contamination, most effectively within the first few days but it is still effective later and shouldn’t be withheld if it’s not given right away.

Next we have DTPA.  This is an IV medication that’s given daily and it is specific for plutonium, americium and curium.  This bonds plutonium, americium and curium and keeps those radioisotopes from being absorbed and increases their rate of elimination from the body, and the contamination is then excreted in your urine.

These are most effective as soon as – when given as soon as possible after internal contamination, most effectively within the first 24 hours but still can be effective later as well.

And then we have filgrastim and pegfilgrastim and there are others in this category as well.  These are the granulocyte colony-stimulating factors.  These are given subcutaneously, injection either daily or weekly depending on which countermeasure and they’re used to treat high dose radiation exposure.

They’re not specific for any particular radionuclide.  These work by stimulating your bone marrow to produce new white blood cells and help the patients fight off infections during their recovery.

These should be used as soon as possible preferably after a laboratory test confirms a drop in your white blood cell count.  I would now like to turn it over to Greg Burel, who’s the Director of the Strategic National Stockpile, for some additional information.

Greg Burel: Thanks Sue.  I think the major things that I would emphasize at this point are these.  You know, we’ve spent a lot of time trying to be prepared for the CRI type scenario, and you know that our plan in that case is to move countermeasures to your receive/stage/store site so that you can be prepared to distribute those further, and to whatever system is necessary to dispense or make use of those most appropriately.

So I would say in this case just as everything else we’re prepared to move material in a timeframe that’s clinically relevant.  We need you to think about making sure your RSS is ready to receive.

If you’ve not exercised those in some time this would be a good time to think about that, and to make sure that you have transportation capability to move this further into the particular modality that’s necessary to make use of it when we can give it to you.

I will add we do have some burn blast material available and we can move that to you rapidly as well.  But one of the things that we’re able to do in those kind of cases with commercial items is reach directly into the market and get things to move to you in normal market operations, which is sometimes the most rapid way to do it.  And with that I’m going to stop and go back to you Chris.

Christine Kosmos: All right.  And I’m going to turn it over to Vivi Siegel to talk about some of the communications in a nuclear emergency.  Vivi?

Vivi Siegel: Thank you Chris and thank you for all of you who are here with us today.  I’m going to talk briefly, give you kind of a brief outline of communications in a nuclear emergency.

I’m going to go over some of the research that CDC has done with audiences over the past decade in this field, and some of the lessons learned from the Fukushima response and from our Gotham Shield exercise and other exercises.

Next slide please.  So for your risk communicators on the line you know that communications is tricky during an emergency, and that’s especially so for a nuclear emergency.

Radiation comes with some very specific terminology and people also have a lot of ideas about what it is/what it isn’t.  They’ve seen the movies.  You know, they’ve seen the TV shows and so there’s a lot of people – a lot of – a little bit of baggage that people come to – come with for a radiation emergency.

And so it’s something that people really don’t understand well and that’s from the lay public even to professionals, and scientists in different fields don’t necessarily understand radiation.

So – and it causes a lot of fear.  People are really afraid.  So what can communications do?  Next slide.  Communication can save lives.  In an improvised nuclear device scenario, as I think some of the other speakers mentioned communicating to someone to shelter in place, to get inside, stay inside and stay tuned can mean the difference between life and death.

So whether or not they follow that recommendation has a lot to do with how quickly we’re getting the message out, what channels we’re using to get the message out and who we’re using to get these messages out.

Communication can also give people positive actions to take.  If they’re not directly in harm’s way they’re still going to be very worried and they’re going to be looking for things to do.

And sometimes in that instance when people are looking for actions they can take, they can end up taking negative actions if we don’t give them appropriate positive actions to take.

Communications can reduce rumors and misinformation, reduce stigma and minimize drains on resources.  If people know and understand that – for example that they do not need a medical countermeasure they won’t show up at the hospital, and the hospital is more likely to be able to treat the people who really do need help.

So if I want to just get across that communicators are vital to a nuclear and radiological response and preparedness, then they should be involved at every step of the way.

Next slide please.  So as I mentioned there’s some specific things that make radiation difficult.  There’s a lot of myths.  People think that a radiation disaster is not survivable and that’s not true.

In many cases there are ways to greatly increase your chance of survival, increase your chance of health afterwards.  People are confused.  Not only is the terminology confusing.

There’s confusing measurement and we actually use different types of measurement in the United States than we do internationally.  So when you’re looking at an international disaster like we had with Fukushima response, there is a need to translate not only the words we’re using but the numbers.

Countermeasures are a really tricky thing to talk about.  When do people need them?  When do they not need them?  How are they distributed?  How are they prioritized?

Why do some people get them before other people?  And so that’s something that requires some very careful communications along with, you know, during Gotham Shield we talked about answering of the question of what do you do when people ask for a urine bioassay and they don’t need it?

And what are the limitations on our capacity to be able to perform those, and how do you tell people if all they want is a quick medical test to make sure they’re okay then no they’re not going to get one?

And finally, and I don’t want to underemphasize this point, in this type of scenario it’s pretty likely that we’re going to lose some communications capacity.

During Gotham Shield we practiced for if this happened losing Internet of – in the affected area and losing cell capacity in the effective area – affected area.

So do you know how you would get information to people with no Internet and no phone?  Do you have a backup way to get information to people?  In some kinds of disasters like a hurricane, when the power’s out and cell towers might be out we might go deliver information door-to-door on fliers.

That’s not something you can necessarily do in this situation when people are sheltering in place and not supposed to be outside.  So it’s important to plan in advance and think about if you don’t have the communication capacity to get the information out, who would you partner with that does have that ability?

Next slide please.  So we’ll go through a little bit about what we’ve learned from audience research as we’ve talked with people in focus groups over the years.

Like with other disasters even in the lowest risk situation everyone’s thinking about, “How do I protect myself and my family?”  People do not like uncertainty.

Well this can be a problem because as you may know scientists love uncertainty.  And so with communications and scientists working together it’s about finding a balance between not saying things that we don’t know, telling people when we don’t know if something is certain or not but giving them tools that they can use.

But can you give them a range of information and tell them, “You know, we don’t know how this might affect you but here’s what you can do to stay as safe as possible?”

People overestimate the risks and they resist reassuring messages.  They think you’re trying to talk down to them.  They don’t believe that simple measures work.

For example, decontamination – if you get radioactive material on you, if you’re externally contaminated, one of the things that we tell you to do is take a shower.  Wipe it off.

And people just don’t believe that that works.  It seems too easy.  People are more likely to take protective actions if they understand why.  They may not want to go get inside, stay inside, stay tuned.

If you have family that’s across town, if your kids or your parents are across town it’s human nature to want to jump in your car after something like this happens and go be with your family and get as close as possible.

And so we’re asking people to act against their instincts and if they understand why we’re asking them to do that, that by staying inside and by having their kids stay inside where they are, if they could be – you could be saving your life and theirs, people are much more likely to follow these actions.

Next slide please.  So as I said the best thing we can do in this kind of situation is give people as clear, easy to follow instructions as possible and to really think about who our audiences are, both audiences split by geographic area, people who are in the most affected zone following by people who are further away, and thinking about who are the vulnerable populations and then also thinking about how do we phase messages over time?

Like Adela said there’s – in those three phases the messages and the protective actions that we’re giving to people may change.  And the more actions that we can give people who are not directly affected, things that we can tell them, how to educate themselves, how they can check on people who they care about – the more they can take these positive actions the less they’ll be taking negative actions.

Using comparisons is something that is a little tricky in the field of risk communication, and in some instances we say not to compare a risk – an unknown risk to something that people are more familiar with usually because it involves telling people that some risk of a disease is similar to, you know, a risk that they would take voluntarily like smoking a cigarette, getting in a car and people don’t like being told that a risk that they’re involuntarily exposed to is similar to one that they would choose for themselves.

But with radiation we find that people just really don’t have a lot of context for how dangerous something is and so we do find – and we continue to do audience research on this topic but we do find that comparisons can be helpful, and I’ll talk a little bit more about that in the next slide.

And again, you know, acknowledge uncertainty, understanding that you’re putting people in an uncomfortable position and that they are going to be looking for something to do to alleviate that feeling of uncertainty and powerlessness.

Next slide please.  The CDC has developed a few communications tools to help people provide context to the public when we are talking about risk of radiation.

On the left you’ll see CDC’s radiation hazard scale, and this is a tool that was developed to be used by communicators to give people a sense of how much risk they are exposed to and can – has a way to stratify it to provide a frame of reference.

And one way to use this would be to say, “You know, if you do not use any protective actions this would be your risk level.  However, if you shelter in place it might go down to green or white.”

So it’s a way of showing people that the thing – the actions that they take can make a difference in their risk level.  On the right you see a radiation thermometer tool that allows people to choose a dose of radiation, and then it provides an example of a comparative dose that you might get by doing things like taking a flight from New York to L.A. as you see in the picture, getting an x-ray or a CT scan.

On the next slide you can see an example of how the hazard scale might be used in a map to show that certain areas would be – put people at higher risk than other areas, but then again if they take protective actions they could lower their amount of risk.

And the next slide please.  Communicating with professional audiences.  I think it was brought up earlier that the public are not the only ones scared of radiation.

We’re all scared, even first responders, even medical providers, clinicians and there are a lot of misunderstandings and for example, medical providers may be afraid to treat people who are contaminated.

We need to let them know that they can protect themselves and face very little risk to their own health in treating people who are – have life-threatening injuries.

And CDC has information and resources for medical providers and clinicians on our Web site that can help teach these tools, and teach how they can use personal protective equipment and explain the low level of risk that they face.

Next slide please.  So how do we get all these messages together?  How do we coordinate?  Like with other types of emergency, communications consistency is extremely important because we don’t want one agency telling people to evacuate and another agency telling people to shelter in place.

So one thing that the federal government has done is get a workgroup together to put together messages for a nuclear power plant incident and an improvised nuclear device, and you can find these on the FEMA Web site.

They are publicly available and they contain some messages that all these agencies have agreed upon could be useful in this type of situation including key messages, statements and messaging that we could transform and use for social media or Web content or other way that we’re trying to get information out.

So I’ll just give an example in the next slide of one of the things that – next slide please.  We’ve talked about it as one of the more difficult things that we talk about.

So potassium iodide is one of those medical countermeasures that we’re not recommending as a course of action for people to take in a IND response, but because people have heard of potassium iodide we get a lot of questions about it.

And we know that some of you may be getting questions about potassium iodide, and so it’s important to let people know when it’s appropriate and when it’s not appropriate.

You can see a tweet that we used in – during the Fukushima response because people in California were starting to find and take potassium iodide because they were worried about radiation coming over from Japan.

They didn’t need it and in fact it was causing more danger to their health to take it than to not take it.  Potassium iodide – as the Strategic National Stockpile folks explained it only works if you take it – it only helps against one type of radiation, only protects the thyroid and only works if you take it immediately before or very soon after exposure, so in most cases it’s not something that’s going to be helpful for people.

So we have materials to explain this on our Web site, and it’s something that we continue to work with other agencies to refine and be prepared to answer these types of difficult questions that people have.

So next slide please.  I just want to leave you with this question.  If something were to happen tomorrow how quickly would you be able to get these messages out?

How quickly would you be able to tell people, “Get inside, stay inside, stay tuned?”  And if the answer is not immediately, what do you need to do to get to that place where you can get this message out as quickly as possible?

Finally, on the last slide I have some resources that CDC has.  We have some videos on risk communication in a radiation disaster.  We have some great videos on radiation basics, kind of the 101 for people who are not health physicists and we also have some of the tools that I talked about.

In addition, there is a radiation glossary and FAQ and infographics, and please visit to see these tools and more.  Thank you.

Christine Kosmos: Thanks Vivi.  So at this time (Justin) if you could put up the poll.  We’re going to do a question and answer period in just a couple of minutes, but as we talked about in the beginning of the call what we wanted to do was after you had heard the presentations, that we would ask you to give us some information about what you think you need to have in order to continue your preparedness planning.  So (Justin) can you put up the poll?

Raffi Standifer:  Yes she’s getting it up there.

Christine Kosmos: All right.  So it asked you to give us some information on critical topics so that we can continue some of our planning, everything from radiation basics to early decision-making for state and local public health, more information on the federal assets, more specific information on planning and guidance documents, toolkits, medical countermeasures, et cetera.

So we’ll give you just a couple of minutes to select your top choice.  All right, it looks like people have voted.  The votes are in.  Okay thank you very much.  All right, so can we capture that data Raffi?

Raffi Standifer:  Yes.

Christine Kosmos: Okay.  All right.  So now operator if we could, could we go into the Q&A section?

Coordinator: Thank you.  We would now like to open the lines for any questions.  If anyone does have a question, please unmute your phone and record your name when prompted.

Again it’s star 1, unmute your phone and record your name when prompted.  One moment to see if we have questions.  We do have our first question from Mr. (Smith).  Your line’s open.

Mr. Smith: Yes.  Now that we have this agreement in place how long would it take if a state called in to get like Prussian blue?  Would it be a lot of red tape or would that be cut through so it – we could get it immediately?

Christine Kosmos: Greg do you want to take that?

Greg Burel: Sure.  So the way that we look at releasing countermeasures is if there is a requirement for that product we will work with you to get it to you as rapidly as possible.

So if there has been an event we’re going to be aware that there’s an event.  We’re going to be probably looking already at talking with you about sending you the most appropriate countermeasures for the event that’s occurred.

If it’s something where you’re wanting to contact us to look at maybe pre-deployment or something like that, we really have to look at that hard because the quantities of these in stock are not so great that we can release for pre-deployment typically.

I hope I’m answering your question.  I’m afraid I’m not quite in the ballpark that you want me to be but please tell me if I’m where you need me to be.

Christine Kosmos: Sir did that help?

Mr. Smith:Yes.

Christine Kosmos: All right, thank you.

Coordinator: Thank you.  Next we have Mr. (Green).  Your line’s open.

Mr. Green:Yes I had a couple of questions on the risk communication part.  During the exercise did you all use a Joint Information Center to coordinate your messaging?

Vivi Siegel: We did.  CDC has a Joint Information Center and during the exercise we brought together communicators from the Radiation Studies Branch, communicators from our Emergency Risk Communications Branch here in the Office of Public Health Preparedness Response and a few others from around the agency, Web, social media, media and used the JIC approach to creating, reviewing, querying communications.

We also worked closely with the National JIC, which is run out of the Department of Homeland Security, and they bring together representatives from each of the participating agencies all in communications and have a regular conference call.

Mr. Green:Okay and my other question was regarding your risk hazard scale, which I think could be very useful.  But has that been introduced to other radiation programs like the NRCs or DOEs or FEMA’s REP Program to where it might be used across the board, where everybody’s familiar with it and would know how to react to it?

Robert Whitcomb: Yes sir.  This is Bob Whitcomb.  I can answer your question.  That risk hazard scale, the radiation hazard scale, has been shared with our federal partners, both the Department of Energy, the folks that do the modeling as Dr. Adela had talked about so they can incorporate those color schemes in the risk scale into the modeling efforts so that the colors you see in the scale are reflected in the maps that are produced.

In addition, there’s a standing committee.  It’s called the Federal Radiological Preparedness Coordinating Committee and it’s run out of DHS FEMA, and that’s where all agency representatives that have anything to do with rad/nuc preparedness get together as a way to coordinate federal radiation protection programs and processes.

We took our scale to them to introduce it to them, to explain what the purpose was, how we are using the scale, both how it was developed – and by the way it was years in development.

It was since Fukushima back in 2011 that we’ve been working on this because of the difficulty we had with explaining risks.  So that was the impetus for the development, six years in the making including not just what we think it should be but we took what we wanted to communicate, and then focus group tested it with audiences across the nation, both professionals and lay audiences in a variety of formats.

So yes our federal partners are aware of it.  Some of them are using them in the modeling efforts so what you see in the chart shows up in the modeling, and it’s not widespread but it…

Dr. Adela Salame-Alfie: But it’s on the Web.

Robert Whitcomb: …it’s on the Web and in the use.

Mr. Green:Okay thank you.

Coordinator: Thank you.  Next we have Dave Allard.  Your line is open.

David Allard: Oh hi.  Yes thanks.  A very good job tonight folks.  Just a quick question either Bob or Adela.  As you folks know after the Three Mile Island my predecessors in the NRC (Shindilly) brought in houses of nuclear for whole body counting.

I think they counted some 200 – or 720 people.  What sort of assets do we have now or where are we headed to with the say whole body counting systems and/or bioassay laboratory?

I think that the big concern is also laboratory capacity for bioassay.  If you could just talk a little bit about that.

Robert Whitcomb: Okay Dave, good to hear your voice and…

David Allard: Thanks.

Robert Whitcomb: …thank you for joining us.  Yes there is a huge effort primarily run out of HHS, Health and Human Services, BARDA — that’s the Biomedical Advanced Research Development Authority — in developing not only new countermeasures but new diagnostic tools for the nation to prepare for radiological and nuclear emergencies.

One of those tools is a biodosimetry kit.  In fact it’s a couple of kits that are under development that are rapid assessments for what Dr. Sue Gorman mentioned as the acute radiation syndrome, in other words the very high exposures, very short-term.

Biodosimetry test would help – that would require the colony-stimulating factors that you discussed earlier, so again that’s a lifesaving measure for a very acute dose.

The other things you talked about Dave were whole body counting.  There are whole body counters available at REAC/TS for individual one or twos.  Because whole body counters are very heavy and not very mobile we do…

David Allard: Right.

Robert Whitcomb: …know there are some mobile services that can be brought from one area to the other like they do it at nuclear power plant outages across the country.  But in the meantime on our Web site, and we can go into this in a deeper dive in some other talks down the road, we’ve developed some quick assays where you can actually use external radiation measurements on a person if they’ve been deconned first.

In other words you get all the external contamination off of them and they’re still registering something, which…

David Allard: Right.

Robert Whitcomb: …means it might be in them.  You could use those external instruments to qualify whether a person was internally contaminated or not.  So again I hope that’s helpful Dave.


David Allard: It is.  And the – and so Bob the blood tests – so that would be sort of like a – sort of a – chromosome aberrations or something to screen people for acute radiation?

Robert Whitcomb: Yes we can provide some more information Dave.

David Allard: Sure.

Robert Whitcomb: I think it’s more a precursor to the actual cell changes.

David Allard: Okay.

Robert Whitcomb: It’s actually looking at protein development for the repair mechanisms that actually gives you a 24-hour window to do a quick assay…

David Allard: Right.

Robert Whitcomb: …to determine the radiation dose.

David Allard: Excellent.  Good.  Thanks Bob.

Coordinator: Thank you.  Next we have Helen Watkins.  Your line is open.

Helen Watkins: Thank you very much and I really appreciate the Webinar.  We in Texas recently had a nuclear plant drill and the question came up from FEMA, “How soon would we be able to get radio-protective drugs or – and conventional drugs from CDC?”

And my question really revolves around are there distribution centers located regionally, and can you give us some sense of the amount of time that it might take?

Greg Burel: So we can’t disclose Strategic National Stockpile locations.  They are protected by statute so I can’t tell you that.  What I can tell you is we’ve just run timelines and did an exercise with Public Health and Emergency Management in both the Dallas and Houston areas around a biologic scenario.

Our timelines for deployment of these countermeasures would be similar and we looked at the beginning of arrival of material between Hour 5 and 6, and completion of the full complement of support for a bio event I believe at about Hour 8 or so.

I can’t remember in each of those cities.  So it’s a very rapid process for these countermeasures as well.  It would run about the same timelines.

Christine Kosmos: And Greg can you talk about who you deliver to and…

Greg Burel: Sure.  So we deliver to the states’ receive/stage/store site that’s already preprogrammed with us, but they can always ask us to go to an alternative site.

And we’re discussing with Texas, Dallas and Houston particularly right now about whether we want to look at alternative RSS sites for them.

Christine Kosmos: And those are within state and local public health.

Greg Burel: Correct.  Control.

Helen Watkins: All right, thank you.

Coordinator: Thank you.  Next we have James Sold.  Your line is open.

James Sold: Thank you very much.  My question was similar to Mr. (Green)’s and you answered that quite efficiently.  My second question is where might we get a copy of the presentation today?  It was a very good presentation and you all did a great job.  Thank you.

Christine Kosmos: Thank you.  Our plan is to push it out.

Greg Burel: Yes.

Jim Crockett: We’ll copy this, get it cleared, have it posted online within ten days to two weeks.  We will ensure this same audience is forwarded that link to that site.  If we get it done sooner we’ll also send that notice out to you.

James Sold: Thank you very much sir.

Jim Crockett: All of the information came from the manual that was shipped with your invite that came out, so I would use that as a primary working reference for right now.

Christine Kosmos: Right.  And one other thing that we’re planning to do is package some of this material and send it out to our state preparedness directors as well.

James Sold: Great.

Robert Whitcomb: Crazy.

Adela Salame-Alfie: And furthermore if you go into the CDC Web site on the Radiations tab, emergency slash radiation, a lot of these resources are covered in way more detail that we didn’t do justice today.

There’s a lot more information on our Web site and a lot of training material as well.

Robert Whitcomb: I think what we can do is that final slide we had with all the references and the links to that – we can send that out early to this audience and get that out, so we’ll have it out by tomorrow.  Enjoy.  That’ll be a good start.  Is that helpful?

Christine Kosmos: Thanks (James).

Jim Crockett: Yes sir.

Coordinator: Thank you.  Next we have Kenneth.  Your line is open.

Kenneth: Thank you very much but my question has been answered.

Coordinator: Thank you.  Next we have
Warren: .  Your line is open.

Warren: Hi.  Thank you very much.  Actually my question is pretty much similar from Texas.  But the thing that our director kind of echoed as well during our teleconferences with our project officer was is there a way that CDC or we could request CDC to have the (SNS) assets to be pre-positioned just for, you know, the sake of being prepared rather than to wait for the incident to happen before any deployment of assets happened?

Greg Burel: So…

Warren: And my next question is that is CDC – will be – going to be providing fundings for these type of activities or protect on the – for the public health department’s standpoint?  Thank you.

Greg Burel: Thanks for your – for the question about pre-deployment.  We don’t typically pre-deploy medical countermeasures for this type of a scenario.  There are very few scenarios actually where we pre-deploy.

The reason for that is we’ve located countermeasures around the country so that we can move them to any point that we need them in a clinically relevant timeframe.

So what we would tell you is we’ll get them there in the timeframe that they’re needed with plenty of time for you to be able to dispense or make use of those in your systems.

Christine Kosmos: And your second question about funding for rad/nuc preparedness and response – this is already a covered activity through the Public Health Emergency Preparedness Cooperative Agreement.

So state and local public health planners are already working on these sorts of plans if – primarily if it’s part of their jurisdictional risk assessment, but this is a covered activity.

Warren: Thank you.  Thank you.

Christine Kosmos: You’re welcome.

Coordinator: Thank you.  Again if there are any questions, please hit star 1 and record your name when prompted.  Again it’s star 1 to ask a question.  One moment to see if we have more questions.

And we do have some queueing up.  One moment.  Next we have (Alice Bush).  Your line is open.

Alice Bush: Hi there.  Yes my question relates to the fears that are being expressed by our communities at this point in time, and my hesitancy to put out information about radiological hazards for fear of making the hazards seem more significant at this time than it is.

Is there any guidance or direction about whether or not we should be talking about it in the context of today’s political environment?

Christine Kosmos: It’s a great question.  Vivi you want to tackle that?

Vivi Siegel: (Alice) this is Vivi.  I can try.  It’s certainly a question that we’re thinking about here.  It’s not an easy one to answer.  I would say that, you know, think about who your audiences are/who is asking.

You know, one thing that we want to be able to do is get information to people at the state and local level so that they would have it ready and already be understanding these things, so that if something were to happen you’d be able to respond very quickly and there wouldn’t be that information gap.

But as far as getting information out to the public right now our strategy has been to do it kind of in a more passive way at the moment.  You know, if there were a decision made that we wanted to try to do more active education that’s certainly not off the table.

But right now what we’re trying to do at CDC is take the approach of making sure that everyone who would need to be, you know, the ones sharing this information when the time comes has it, that they’re familiar with it, that they know it, that they understand it and that people who are interested have a way to find out the information really easily.

So we have a lot of information that’s public-facing on our Web site.  We share information for preparedness month and we share information, you know, which is September and we’ll have – we have information for the media when they ask for it.

So right now we’re doing more passive education but active education is definitely a consideration.

Alice Bush: Yes.  So I’m a – I’m an emergency management agency and it was my public health department that told me people were concerned and asked if we were going to get information out.

Robert Whitcomb: Yes and this is Bob Whitcomb.  To further delve into your question one of the things that Vivi just mentioned, which we were hoping to – as an – as a – to use as an opportunity is the public health preparedness month coming up in September.

Again nothing relative to what’s going on in the world but because of public health preparedness month we always talk about, you know, get a plan, make a plan, get ready, be prepared.

So, you know, those type of things you can do with the messages we have.  Go in, stay in, stay tuned are good for a lot of emergencies.  So again relevance to September just around the corner might be a good time for you to think about that.

Vivi Siegel: Yes I think that’s a great thing that Bob said.  Any way that you can wrap this into existing preparedness education is a less scary way to get the information out.

Alice Bush: Right.  Because we’re having the same thing with the, “Should I buy those medications and take them?”  And so – okay thanks.

Coordinator: Thank you.  Again if there are questions please hit star 1 and record your name.  And we do have Mr. (Miller).  Your line is open.

Mr. Miller: Yes I was concerned with the Radiological Operations Support Specialist program.  I understand that they used them in Gotham Shield and did a real good job and that CDC is going to sponsor it.

Vivi Siegel: What did hey say?

Robert Whitcomb: I think we lost him.

Adela Salame-Alfie: Did we lose the speaker?  We are having a class in Atlanta, Georgia September 18 through the 22nd.  It’s coordinated through the FEMA ROSS and that’s – for those of you who are not familiar Radiation Operations Support Specialist is a position that is being typed by FEMA, somebody to train in radiological emergency response that can come and assist state and locals, answer some of the questions that are going to come up, help them in, you know, translate some of the technical terms to be able to make decisions.

It will be like an extension of a Radiation Control program.  Knowing fully well that there aren’t many around in the country this is a position that’s being created.

The class in Georgia is still a pilot class.  It’s expected that starting next year that’s going to be in the FEMA catalog.  It’s going to be provided by the counterterrorism – CTOS.

I forgot what the other two letters stand for but that’s a FEMA outfit and that will be available free of charge to state and locals that want to take the class.

Coordinator: Thank you.  One moment.  Okay Mr. (Miller) your line is back in.

Mr. Miller: Oh thank you.  That’s all I had.

Coordinator: Okay no problem.  If you did not record your name your line is open.


Coordinator: I have a participant from Guam.  Your line is open.

Dean: Yes this is (Dean).  A question is dealing with the responders – the initial response to nuc/rad.  A lot of them probably won’t know that they – they’ve been exposed until later in the – as the incident progresses.

So going back to that potassium iodine, at what point do once we know that we’re dealing with a nuc/rad type of a incident should CDC or public health start notifying the FR to start rotating any responders in the hot zone to come out and start beginning treatment?

Adela Salame-Alfie: Well this is Adela.  Potassium iodide would not be recommended in this case.  That’s the first thing.  The second thing is we recognize that early on responders may deploy to respond without knowing that they’re dealing with a radiation incident.

There is some information on the planning guide to respond to an improvised – talks about other things that they will see in terms of the level of destruction, the amount of rubble, the windows broken.

As they approach the scene they can anticipate that things are getting progressively worse, and the magnitude of the event will point to that they need to stand back and probably not go any further.

They – we recognize that they’d probably be operating without dosimetry early on and they’re in their mission saving lives.  And this is not CDC but the National Council on Radiation Protection and Measurements will be issuing a document for dosimetry for emergency workers and have some guidance as to what to do in instances when there’s not enough dosimetry available, how you can track their dose, how you can do group dosimetry, how can you rotate your folks.

There is some guidance.  Unfortunately, you know, out to the team.  Unless they have an instrument they will not know that they’re in a radiation environment, and we provide some guidance in that document.


Adela Salame-Alfie: And that will be issued probably within the next month or two.

Dean: Great.  Thank you.  I think that will be a big concern for us especially with managing resources/personnel.  Once they’ve – hitting a certain exposure limit pulling them out and starting any type of treatment if they need it – I know it’s not a rush initially.

But our biggest concern again is that trying to get these responders at least treated internally or whatever, to determine and then get them back at least to assist the incident is what I’m getting at, so I guess we’ll be waiting for that to come out.  Thank you.

Adela Salame-Alfie: Thank you.  And I just want to add that some of the planning considerations for population monitoring will be to take care of your responders, and those will be priority for a bioassay/biodosimetry because especially those that responded first and foremost – they will be the most likely to have potential for health effects.

So they will be a priority as well as some of the vulnerable population like pregnant women/children, but certainly the first responders will be a priority.

Dean: Absolutely.  Thank you.  And as far as for the local fire department very limited especially when it comes to weaponized and neutron radiation so that’s something that we’re addressing.

I know our military assets have that capability but again their mission statement or their responsibility is always within the gates, so getting our support team – civil support team activated, spun up and to come out again takes time.

So just looking at where we’re at with the responders and I guess we’ll be waiting for that draft or that communiqué to come out.

Adela Salame-Alfie: Thanks.

Coordinator: Thank you.  Next we have (Melanie Thompson).  Your line is open.

Melanie Thompson: Thank you.  My question kind of spins off of the last question, but we’re talking about clinically relevant countermeasures and getting them there in the right time.

If we’re asking people to shelter in place for 24 to 48 hours but we need these countermeasures immediately, what kind of issues am I going to be having when we ask our public health employees and the volunteers to show up at work or show up at the pods to give this medication out?

And, you know, we’re talking about the health effects of the first responders.  I mean, that does come into play here I realize.

Adela Salame-Alfie: If I might say something the protective action that is recommended to shelter in place – that’s for everybody.  We don’t expect people to go and set up a community reception center in the middle of the hot zone.

We want people to shelter in place because the radiation levels would drop dramatically within the first few hours.  There’s – there are some physics rules of thumb that we use and it’s going to drop a – tenfold within, you know, a certain time and it’s a hundredfold in another period of time.

So – key people and we’re not talking sheltering in place for two weeks, but even just staying one or two days shelter in place is going to reduce the amount of radiation dramatically, thus allowing some of these things to be set up.

And then if people shelter in place they’re unlikely to need countermeasures so it – countermeasure is not the one solution for everything.  Shelter in place is by far the most protective action that we can recommend.

Melanie Thompson: Thank you.  That’s exactly what I was looking for.

Adela Salame-Alfie: Thank you.

Coordinator: Thank you.  Again if there are questions please hit star 1.  Next we have (John Turner).  Your line is open.

John Kerner: Hi.  This is (John Kerner) and I just wanted to share a little bit of information with my colleague from Guam regards the worker safety health protection guidance.

If you go to the Web site and in the right – upper right hand corner – and REMM is the Radiation Emergency Medical Management Web site, a combined effort from ASPR and the National Library of Medicine.

If you go to the upper right for worker safety you will see the intergovernment document that was produced in – it was published in January 2017.

That will give you some good guidance on dose estimation and turn back times as well as some of the other hazards that are associated with a nuclear detonation, because recall that particularly for a nuclear detonation, you know, there was the detonation component as well.

On that same – and on a similar note as we’re looking towards the medical response to a nuclear detonation, we need to recall that managing the trauma from the blast/from the burns is a priority before we have to deal with the onset of salvageable radiation injuries so that the – those first responders do understand that as part of this problem set it’s very, very important to understand that maintaining the airway, controlling the bleeding and maintaining circulation are still the priorities because those will be the things that lead to mortality early in the incident.

And as was stated before – or by my esteemed colleagues at the CDC that the radiation injury can be managed at a later time, maintaining those vitals and taking care of the trauma is the priority.

There’s other assets I think that – and resources that everybody can benefit from if you go over to that REMM – to the REMM Web site to include some summaries of initial actions for EMS and ED staff, as well as treatment guidance with respect to the cytokines and so much more.

So thank you to our colleagues at CDC.  This has been an extra – and I thank you for doing this.

Christine Kosmos: Thank you very much.  So we are at our allotted time.  I want to thank all of the – our colleagues from Radiation Studies Branch and SNS for their input and for putting on a great Webinar.

I want to also reinforce that we’re going to be pushing out some materials, but also if there are questions that you didn’t get answered or need some specific additional information you can always email us at

It should be up on your screen right now.  And with that we will say thank you very much for attending this Webinar and we hope to speak to you again soon.  Thanks much everyone.  Good night.