cbrn overview daniel kollek, md, ccfp(em) public health cbrn course

CBRN overviewCBRN overview

Daniel Kollek, MD, CCFP(EM)

Public Health CBRN course

Goals of sessionGoals of session

• To provide an overview of the categories and actions of CBRN agents and the roles of Public Health in responding to them

Outline of sessionOutline of session

• Definitions

• Chemical overview

• Biological overview

• Radiological overview

• Nuclear overview

• Roles of public health

DefinitionsChemical Biological Radiological Nuclear Public Health role


DisasterDisaster

• The Merriam-Webster dictionary definition of disaster is "a sudden or great misfortune."

• The Medical definition if a disaster is "when the destructive effects of an event overwhelm the ability of a given area or community to meet the demand for health care."

(1) Definitions

Mass Casualty IncidentMass Casualty Incident

A disaster that is typified by a large number of patients that outstrip resources on the basis of numbers of individuals requiring care.

(1) Definitions

CBRNCBRN

Disasters contaminated by an agent that can be Chemical Biological Radioactive or Nuclear. Each one of these has specific response needs .

Also known as NBC or ABC

(1) Definitions

TerrorismTerrorism

A terror attack is defined as an attack targeted at civilian non-combatants for the purpose of affecting the government that represents them. A successful terror event involves large number of casualties, may involve CBRN contaminants, causes infrastructure damage and has a psychological impact

(1) Definitions

• What is a hazardous material?

• How do we classify chemical agents?

• What are the chemical agents we worry about (and why)?

• What type of incidents might we face?

(2) Chemical

Chemical AgentsChemical Agents

Hazardous MaterialHazardous MaterialA substance is

considered

hazardous when,

because of its quantity,

concentration, or

physical

characteristics, it

poses a real hazard

to human health or the environment Mississauga train derailment 1979

(2) Chemical

Chemical Agent ClassificationChemical Agent Classification

Nerve agent

– organophosphate based, insecticides Blister agent

– Vesicants

Pulmonary agent

– Choking (ie Phosgene, Chlorine)Blood agent

- CyanideOther agents

Pepper spray, Tear gas, CS, OC

(2) Chemical

“TICs and TIMs”“TICs and TIMs”Toxic Industrial Chemicals

• Irritants (chlorine, phosgene, hydrogen chloride, ammonia, isocyanates)

• Pharmacologic-like agents (cyanide)• Hydrocarbons• Alcohol-based solvents • Corrosives (acids & bases)

• Pesticides (organophosphates and others)• Smoke • Riot Control (Tear Gas & Pepper Spray)

(2) Chemical

Incident TypesIncident Types

• Small, localized HazMat Incident– 84% of incidents occur at fixed sites– 70% involve 1 or 2 victims– 90% are ambulatory– Liquid contamination more common– Greater need for showering

• Chemical MCI– Most commonly gas or vapor exposure– Most exposures are mild with few significant toxic

effects– Beware of incidents in enclosed spaces– Clothing removal is the focus of decontamination

(2) Chemical

Response to chemical agentsResponse to chemical agents

• Decontamination

• Antidotal therapy

– 2PAM,

– Atropine,

– Benzodiazepines

(2) Chemical

DefinitionsChemical Biological RadiologicalNuclear Public Health role

DefinitionsChemical Biological RadiologicalNuclear Public Health role

(3) Biological

Types of Bio-agentsTypes of Bio-agents

• Bacterial

• Viral

• Toxins

(3) Biological

Characteristics of Bio-agents Characteristics of Bio-agents

• Low visibility

• High potency

• Latency

• Easy accessibility

• Simple delivery

• Good sustainability and propagation

• Does Not Affect Structures

(3) Biological

Entry ModesEntry Modes

• Inhalation

• Ingestion

• Injection

• Absorption

(3) Biological

Bioterrorism agentsBioterrorism agentsCategory A Diseases/Agents

Organisms that pose a risk to national security because they:

• can be easily disseminated or transmitted from person to person;

• result in high mortality rates and have the potential for major public health impact;

• might cause public panic and social disruption; and • require special action for public health preparedness.

(3) Biological

A level bioterrorism agentsA level bioterrorism agents

• Anthrax (Bacillus anthracis)• Botulism (Clostridium botulinum toxin) • Plague (Yersinia pestis) • Smallpox (variola major) • Tularemia (Francisella tularensis) • Viral hemorrhagic fevers (filoviruses

[e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo])

(3) Biological

Bioterrorism agentsBioterrorism agents

Category B Diseases/Agents

Second highest priority agents include those that:

• are moderately easy to disseminate; • result in moderate morbidity rates and low

mortality rates; and • require specific enhancements of laboratory

diagnostic capacity and enhanced disease surveillance.

(3) Biological

B level bioterrorism agentsB level bioterrorism agents

• Brucellosis (Brucella species) • Epsilon toxin of Clostridium perfringens• Food safety threats (e.g., Salmonella species, Escherichia coli

O157:H7, Shigella)• Glanders (Burkholderia mallei)• Melioidosis (Burkholderia pseudomallei)• Psittacosis (Chlamydia psittaci) • Q fever (Coxiella burnetii) • Ricin toxin from Ricinus communis (castor beans)• Staphylococcal enterotoxin B• Typhus fever (Rickettsia prowazekii)• Viral encephalitis (alphaviruses [e.g., Venezuelan equine

encephalitis, eastern equine encephalitis, western equine encephalitis])

• Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)

(3) Biological

Bioterrorism agentsBioterrorism agents

Category C Diseases/Agents

Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of:

• availability; • ease of production and dissemination; and • potential for high morbidity and mortality rates

and major health impact.

(3) Biological

C level bioterrorism agentsC level bioterrorism agents

• Emerging infectious diseases such as Nipah virus and hantavirus

(3) Biological



(4) Radiological

What Is Radiation?What Is Radiation?

Nuclear

Radio/TV

Sun

Light

Heat

Microwave

(4) Radiological

Electromagnetic SpectrumElectromagnetic SpectrumIncreasing Energy and Increasing Energy and FrequencyFrequency

Electrical Electrical PowerPower

Radio/Radio/TVTV

MicrowavMicrowavee LightLight

NON-IONIZING NON-IONIZING RADIATIONRADIATION

X-X-rayray

GammGammaa

IONIZING IONIZING RADIATIONRADIATION

Increasing HarmIncreasing Harm

UVUV

(4) Radiological

Health Effects of Radiation ExposureHealth Effects of Radiation Exposure

• Lethal at high doses

• Mutagenic

• Carcinogenic

• Other biological effects, especially at high doses

(4) Radiological

Time: DecreaseDecrease time spent near the time spent near the

radioactive sourceradioactive source

Distance: IncreaseIncrease distance between distance between you and the sourceyou and the source

Shielding: Increase Increase the physical the physical shielding between you and the sourceshielding between you and the source

(4) Radiological

Decrease Radiation EffectsDecrease Radiation Effects

Common SheltersCommon SheltersStructure Dose Reduction

Factors

Wood Frame (1st floor) 10%

Wood Frame (Basement) 40%

Masonry 40%

Large building 80%

From the Environmental Protection Agency’s Manual of Protective Action Guides and Protective Actions for Nuclear Incidents, Appendix C

(4) Radiological

Potential Terrorist ScenariosPotential Terrorist Scenarios

• Radiological– Radiological dispersion device;

e.g., “dirty bomb”

– Malicious use of radioactive substances

• Nuclear – Attack on nuclear facility– Nuclear weapon– Improvised nuclear device (IND)

(4) Radiological

Mass Radiological CasualtiesMass Radiological Casualties

“For an improvised nuclear device >100,000 patients could require evaluation and treatment.”

Department of Homeland Security Working Group on Radiological Dispersal Device (RDD) Preparedness, Medical Preparedness and Response Sub-Group Report (May, 2003)

(4) Radiological

Radioactive SourcesRadioactive Sources

• 157,000 licensed users in U.S.

• 2,000,000 devices containing radioactive sources

• Approximately 400 sources lost or stolen in U.S. every year

(4) Radiological

Sources used in mobile cesium Sources used in mobile cesium irradiators in the former Soviet irradiators in the former Soviet

UnionUnionPhotos courtesy of the International

Atomic Energy Agency (IAEA)

Recovered Recovered transport transport containercontainer

Sources Around the Sources Around the WorldWorld

(4) Radiological

Goiânia Radiological ReleaseGoiânia Radiological Release

Obsolete Obsolete radiotheraradiothera

py py machinemachine

Abandoned cancer clinicAbandoned cancer clinic

Photos courtesy of the International Atomic Energy Agency (IAEA)

(4) Radiological

Goiânia MorbidityGoiânia Morbidity

• 249 exposed; 54 hospitalized

• Eight with radiation sickness

• Four people died

• 112,000 people monitored (>10% of total population)

Photos courtesy of the International Atomic Energy Agency (IAEA)

(4) Radiological

How do you categorize exposures?

How do you categorize exposures?

(4) Radiological

Categorization

• External contamination– Patient is radioactive!– Remove all clothes is most

important part of decontamination• Irradiation - local or whole body

– Patient is not radioactive and poses no risk to others!

• Ingestion– Body fluids may be radioactive

• Combination of above

(4) Radiological

Remember!Remember!

Categorisation determines risk to others and can identify specific therapeutic steps to be taken

Dose determines severity, treatment plan and prognosis

(4) Radiological



(5) Nuclear

Key Issues in Nuclear EventKey Issues in Nuclear Event

• Same concerns as radiation event

• Added concerns of mass trauma and major system disruption

(5) Nuclear

So what have we learned so far?So what have we learned so far?

CBRN comparisonCBRN comparisonBiologic Nuclear/ Radn Chemical

Onset Slow Rapid Rapid

Transmission/ infectivity

Slow, Agent dependant

Particulate only, Fast

Fast, Agent dependant

Detection Difficult Easier Easier

Resource consumption

Gradual, long term

Rapid, short and long term

Rapid, short term

Some long term

Public Health involvement

Short & long term

Short & long term

Short term

Bed use Mixed Hospital Hospital

Decon. requirements

Agent dependant

Critical for particulate

Critical for all

Antidote Agent dependant

None Class dependant



(5) Public Health

Public Health Role Public Health Role

• Early Detection

• Mass Patient Care

• Mass Immunization/Prophylaxis

• Epidemiologic investigation

• Communication

• Command and Control

(5) Public Health

Public Health Role (2) Public Health Role (2)

• Mass Fatality Management

• Evacuations/sheltering (humans and animals)

• Environmental Surety

• Community Recovery (rapid health risk assessment, mental health etc)

(5) Public Health

Questions ???Questions ???

cbrn overview daniel kollek, md, ccfp(em) public health cbrn course

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