The Impact of CBRN Incidents on First Responders,

Volunteers and Hospital Staff

David Alexander Global Risk Forum - Davos (CH)

What exactly is the problem?

• modern society changes so fast that historical analysis may not be useful for scenario building

• past events are too few and far between to help much with planning scenarios

• there is an infinity of possible attack scenarios - will 'orthodox' thinking help in the face of a terrorist's creativity?

• palliative and analytical capabilities are expensive but not necessarily effective.

The CBRN problem

Laboratory error with

CBR emissions

Sabotage with poisonous agent

Nuclear emission (NR)

Disease epidemic or pandemic (B)

Terrorist attack with C, B, R or N contaminants

Industrial or military accident with CNR emissions

Chemical, biological

or nuclear warfare (CBN)

• unanticipated, unfamiliar threat to health

• lack of sensory cues

• prolonged or recurrent & long aftermath

• potentially highly contagious

• produces observable casualties.

A CBRN attack:-

• possible contamination of responders and medical staff

• physical and mental state of 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 of protective equipment

• lack of training and exercising (to know what to do)

• lack of familiarity with equipment and procedures.

Organisation • procedures • event scenarios • emergency plans

Intelligence • collection • interpretation • warning

Training • plan dissemination • exercises

Stockpiling • equipment • supplies

Surveillance • automatic (CCTV) • manual (personnel)

Analysis • laboratory • forensic

Counter-terrorism activity

Involvement of civil protection

Organisation • procedures • event scenarios • emergency plans

Intelligence • collection • interpretation • warning

Training • plan dissemination • exercises

Stockpiling • equipment • supplies

Surveillance • manual (personnel) • automatic (CCTV)

Analysis • laboratory • forensic

Counter-bioterrorism activity

Involvement of health services

The role of scenarios in indicating needs for preparedness

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: 12 Critically injured: 17 Seriously ill: 37 Moderately ill: 984 Slightly ill: 332

• 110 hospital staff and 10% of first responders intoxicated

• "Worried well": 4,112 (85% of patients).

Aum Shinrikyo attack (1995)

• a small, concentrated attack with a highly toxic substance: 210Po

• 30 localities contaminated

• tests on hundreds of people

• a strain on many different agencies

• problems of determining who was responsible for costs of clean-up.

The case of Alexander Litvinenko

In the London Underground tunnels on 7 July 2005 rescue operations by London Fire Brigade were delayed by 15-20 minutes by the need to ascertain whether CBRN contaminants had been used in the attacks. Meanwhile, victims died of their injuries.

• ascertaining level of contamination takes specialised equipment & training.

• can slow down rescue in critical incidents

• risk aversion may lead to failure to 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 incidents lead to heavy criticism by the public

Operational problems for staff and responders

• requires specialised procedures

• must avoid contamination of staff

• requires ionising radiation dosimeter

• biological symptoms may be delayed by 3 minutes - 3 weeks.

Triage problems:- Level 1 - on-site triage Level 2 - medical triage Level 3 - evacuation triage

Mettag CB-100

• risks of secondary contamination of responders and hospital staff

• shortage of personal protection equipment & expertise on how to use it

• shortage of isolation facilities.

Contaminated patients

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

Very considerable uncertainty surrounds the practice of decontamination, regarding protocols, practices

effects, efficiency and timespans.

'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

Medical staff and

first responders

PPE level C

PPE=personal protection equipment

In the case of a chemical attack, the following aspects of decontamination

protocols are highly debatable:

• the use of chemical agents to neutralise toxic substances

• whether to strip naked before treatment

• what decontamination technique should be used if the toxic agent has not been identified

• how many people can be decontaminated 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 diseases directly caused by the toxic agent

• questions about adverse reproductive outcomes

• psychological effects (persistent)

• increased levels of somatic symptoms.

Health concerns following a CBRN attack

Mythmongering: "Problems with crowd control, rioting, and other opportunistic crime could

be anticipated" (Staten 1997)

The assumption of panic and the hiatus between sociological and

psychological views of the phenomenon.

A study by Hantsch et al.* suggested that one 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 information and authoritative reassurance.

2004, Annals of Emergency Medicine

Conclusions

• emergency medical and psychological assistance

• long-term healthcare and health surveillance

• extensive medical information and risk assessment.

Medical personnel have the same vulnerabilities and preoccupations as the 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:-

John Singer Sargent, Gassed, 1918

Thank you for your attention! David.Alexander@grforum.org

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