CBRN Disaster Management Dr. Rakesh Kumar Sharma Additional Director, Institute of Nuclear Medicine and Allied Sciences, Delhi @Training Programme on Chemical

CBRN Disaster Management

Dr. Rakesh Kumar SharmaAdditional Director, Institute of Nuclear Medicine and Allied Sciences, Delhi

@Training Programme on Chemical (Industrial) Disaster Risk Management, 27-28 August 2010

All-HazardsAll-HazardsHuman-made Fires Explosive devices Firearms Structural collapse Transportation event

Air, Rail, Roadway, Water HAZCHEM / HAZMAT WMD CBRN events etc…

NaturalEarthquakeLandslidesFloodsFires etc…

Radiological: trafficking in radio-isotopes but no incidents

Nuclear: trafficking in plutonium and highly enriched uranium – but no incidents with improvised, stolen or sold nuclear device

Chemical: Sarin attack in Tokyo’s subway system in April 1005: 12 killed, dozens wounded

Biological: Anthrax attack in USA 2001: 5 killed, 22 infected

CBRN Terrorism Threat: Fact or Fiction?CBRN Terrorism Threat: Fact or Fiction?

•Attempts to acquire Weapons of Mass Destruction•Religious Fanaticism•Catastrophic Terrorism•Border Porosity•Global Communication•Diaspora Bridgeheads (Portable conflicts)•Kamikaze Suicide Terrorism•Expansion of Range of Targets (Tourists, ICRC,

UN)•Links with Organized Crime•New Sources of Financing•Failed and weak states as de facto safe havens•New types of weapons (e.g. MANPADs)

‘‘New’ Elements in ‘ New Terrorism’New’ Elements in ‘ New Terrorism’

Emergency Vs. Disaster

A SUDDEN HAPPENING

WHICH REQUIRES PROMPT ACTIONS

A SUDDEN & MASSIVE& MASSIVE HAPPENING

WHICH REQUIRES

PROMPT AND HUGEHUGE ACTIONS

Phase 1: (2001-2003): “The Awakening”: awake the Islamic nation from its state of hibernation by causing United States to "act chaotically”.

Phase 2: (20032006): “Eye-Opening”: turn Iraq into a recruiting ground for young men eager to attack America; conduct “electronic jihad”

Phase 3 (2007-2010): “Arising and Standing Up” Al Qaeda focus of struggle on Syria and Turkey, also begin of confrontation with Israel

Phase 4 (2011-2013): Al Qaeda to bring about demise of Arab governments, continued attacks on oil industry, electronic attacks to undermine U.S. economy, bringing about the collapse of the dollar by promoting gold as exchange medium

Phase 5 (2014-2016): “declaration of Islamic caliphate” leading to change of int. balance of power by seeking new economic allies such as China

Phase 6 (2017-2020): “total confrontation”: the now established caliphate’s Islamic Army will achieve “definitive victory”.

Source: Lawrence Wright. The Master Plan. For the new theorists of jihad, Al Qaeda is just the beginning. The New Yorker , September 11, 2006, pp.7-8; at: http://www.newyorker.com/archive/2007/09/11/060911fa_fact3?cur..., as of 08/10/2008.

Al Qaeda’s Twenty-Years’ Grand PlanAl Qaeda’s Twenty-Years’ Grand Plan

http://www.newyorker.com/archive/2007/09/11/060911fa_fact3?cur

Stay alive and active and show that jihad against Crusaders and Zionists is a feasible strategy

Transform Al Qaeda from a militant group into a political movement Portray the GWOT as a war on Islam Trap the United States in “bleeding wars” Overthrow the government of Pakistan Crusaders and Zionist armies to leave Muslim lands defeated

after the collapse of their economies. Attack with weapon of mass destruction to make USA

isolationist. Provoke war between USA and Iran and Israel and Saudi

Arabia Overthrow of all apostate rulers in Muslim countries Recover “every stolen Islamic land from Palestine to al-

Andalus and other Islamic lands that were lost” Reunite the Ummah and establishment of a Caliphate Introduction of Salafism and Sharia law everywhere.Source: Various,;incl. Bruce Reidel. The Search for Al Qaeda. Its Leadership, Ideology, and Future. Washington, D.C. Brookings Institution Press, 2008, pp.34, 53,113, 121, 124.

Al Qaeda on the Path to a CaliphateAl Qaeda on the Path to a Caliphate

Disaster- dis·as·ter n. An occurrence causing widespread

destruction and distress; a catastrophe.

A grave misfortune. Informal- A total failure

‘‘Disaster’ DefinitionDisaster’ Definition

• A disaster is present when need exceeds resources!

Disaster = Need > Resources

• ‘Response need’ > ‘Response available’!

D: Detection

I: Incident Command

S: Safety & Security

A: Assess Hazards

S: Support

T: Triage & Treatment

E: Evacuation

R: Recovery

The DISASTER Paradigm

What is CBRN?

• CBRN is an acronym referring to – Chemical, – Biological, – Radiological, and – Nuclear threats

• It is in common use worldwide, generally to refer to PROTECTIVE MEASURESPROTECTIVE MEASURES taken against CBRN weapons or hazards.

CBRN Technologies…..Today….. Twenty years ago

• Access to Technology in hands of terrorists

• Force Multipliers :– Connections (good networking amongst

themselves as well as with rogue nations)– Terrorist organizations are Faster and

Flexible

• Requires Force Multiplication for Antiterrorism, Reaction and Response Technologies

• Requires New Ways/Paradigms of – Thinking– Technologies– Approach

• Great Technology in the hands of NATIONS

• Conventions in place

• Mainly in Military domain

• Military Intelligence input and War Gaming

• Defence Preparedness

• Prediction technologies

% of all events % of all casualties

Bombs 53.4 70.1Guns 19.9 23.0

Arson 9.8 2.7Remote control bombs 1.9 4.7Knives & other blades 1.3 2.1Chemical 0.2 0.59Biological 0.08 0.02Other 13.3 8.1

Total 100.0 100.0

Source: p.49.Kenneth T. Bogen and Edwin D. Jones. Risks of Mortality and Morbidity from Worldwide Terrorism: 1968-2004. Risk Analysis Vol. 26, No.1, 2006. – Data utilized are from RAND-MIPT. Incidents until 1997 include only international terrorism.

Terrorist Tactics, based on 25,303 terrorist Terrorist Tactics, based on 25,303 terrorist events, 1968-2004events, 1968-2004

List of probable agents for terrorist Attack(in descending order of likelihood)

Use of a conventional explosiveRelease of an industrial chemicalRelease of a military chemical agentUse of a ‘dirty’ bombRelease of a biological agentDetonation of a nuclear device

Sharp et al. Ann Em Med;32(2):214 (1998)CDC Science & Technology Center

…. don’t happen to places ….. happen to people ……can happen to us!

…. don’t happen to places ….. happen to people ……can happen to us!

CBRN Emergencies are HappeningWe are as much a target as any other …………

CBRN Emergencies are HappeningWe are as much a target as any other …………

Disruption

Terrorist Groups and Unconventional Weapons

CR CRB

RIRAETA MILFAUCIMUN17ROSLASGKach

Al Qaeda

Chechen Rebels

C CRBN

AUM

FARC (?)HAMAS (?)DHKP/C (?)PKK (?)BKI

LTTEHizbollah

GSPCGIA

High

HighLow

Da n

ger

Sophistication of Unconventional Weapons

PIJ

1. Nuclear Detonation Can vary widely2. Biological Attack 13,000 fatalities & injuries3. Biological Disease Outbreak (Pandemic Flu) 87,0000 fatalities, 300,000

hospitalized4. Biological Attack – Plague 2,500 fatalities;7,000 injuries5. Chemical Attack – Blister Agent 150 fatalities; 70,000

hospitalized6. Chemical Attack –Toxic Indust. Chemicals 350 fatalities;1,000

hospitalizations7. Chemical Attack – Nerve Agent 6,000 fatalities; 350 injuries8. Chem. Attack –Chlorine Tank Explosion 17,500 fatalities;

10,000 injuries9. Radiological Attach – RDD 180 fatalities;20,000

contaminations10. Explosive Attack IED Bombing 100 fatalities; 450

hospitalizations11. Biological attack – Food Contamination 300 fatalities; 400

hospitalizations

Table 29 : Homeland Security Planning Scenarios 2004Table 29 : Homeland Security Planning Scenarios 2004

The Impact

• Leaves a long trail of sufferings Leaves a long trail of sufferings

• Profound sufferings – beyond the range of normal Profound sufferings – beyond the range of normal human experiencehuman experience

• Impact is multi pronged Impact is multi pronged

Physical,Physical,

Psychological,Psychological,

Economical, andEconomical, and

SocialSocial

The Resultant

Psychological vulnerability and Neuropsychological Sequelae

Fear of unknown Fleeing of affected community Exponential spread of disaster victims Overwhelming of hospitals by people believing

themselves to be affected Hoardings Decreased efficiency of system Collapse of civil disorder and essential services …feeling of Powerlessness, …., ….., …..

Worst case scenario is much more threatening

• CHAOS at the Incident Site – are inevitable

– can not be PREVENTED

• TRY to Reduce chaos ASAP

• Organise the CHAOS

The Expectations

• ………………………….knee jerk reactions.knee jerk reactions

The Expectations


• Overall Preparedness and Risk Reduction at all levels

The Expectations



• Contingency Planning Abilities

The Expectations




• Capacity development InfrastructureTrained Human Resources

The Expectations




• Capacity development InfrastructureTrained Human Resources

• Attitudinal Changes

The Expectations

• ………………………….knee jerk reactions.knee jerk reactions• Overall Preparedness and Risk Reduction at all

levels• Contingency Planning Abilities • Capacity development

InfrastructureTrained Human Resources

• Attitudinal Changes• Coordination Issues

‘When a disaster strikes, the Community (general population) expects

branches of local, state, and Central government and

NGOs to rapidly mobilize to help the impacted

community.’

Disturbing Trends of DisasterDisturbing Trends of Disaster

The Sarin gas attack on the Tokyo subway, usually referred to in the Japanese media as the subway sarin incident was an act of domestic terrorism perpetrated by members of Aum Shinrikyo on March 20, 1995.

Disturbing Trends of DisastersDisturbing Trends of Disasters

30

120

Genie out of

the bottle

VE

RT

EX

OF

EV

IL

TOI dated 21st February 2007 Chemicals are toxic manmade Chemicals are toxic manmade

compounds including those designed compounds including those designed for warfare use or industrial usefor warfare use or industrial use

Disturbing Trends of DisastersDisturbing Trends of Disasters

• Chlorine bombings in Iraq began in January 2007, when insurgents in Al Anbar province started using chlorine gas in conjunction with conventional vehicle-borne explosive devices.

• Low level exposure results in burning sensations to the eyes, nose & throat, usually accompanied by dizziness, nausea and vomiting. Higher levels of exposure can cause fatal lung damage; but because the gas is heavier than air it will not dissipate well after an explosion, and so it is generally considered ineffective as an improvised chemical weapon.

Disturbing Trends of DisastersDisturbing Trends of Disasters January 28: A suicide bomber drove a dump truck packed with explosives and a chlorine tank into an

mergency response unit compound in Ramadi. 16 people were killed in the blast. February 19: A suicide bombing in Ramadi involving chlorine killed two Iraqi security forces and wounded 16

other people. February 20: A bomb blew up a tanker carrying chlorine north of Baghdad, killing nine and emitting fumes

that made 148 others ill, including 42 women and 52 children. February 21: A pickup truck carrying chlorine gas cylinders exploded in Baghdad, killing at least five people

and hospitalising over 50. March 16: Three separate suicide attacks on this day used chlorine. The first attack occurred at a checkpoint

northeast of Ramadi, when a truck bomb wounded one US service member and one Iraqi civilian. A second truck bomb detonated in Falluja, killing two policemen and leaving a hundred Iraqis showing signs of chlorine exposure. Forty minutes later, yet another chlorine-laden truck bomb exploded at the entrance to a housing estate south of Falluja, this time injuring 250 and according to some reports killing six.

March 28: Suicide bombers detonated a pair of truck bombs, one containing chlorine, as part of a sustained attack aimed at the Fallujah Government Center. The initial bombings along with a subsequent gun battle left 14 American forces and 57 Iraqi forces wounded.

April 6: A chlorine-laden suicide truck bomb detonated at a police checkpoint in Ramadi, leaving 27 dead. Thirty people were hospitalized with wounds from the explosion, while many more suffered breathing difficulties attributed to the chlorine gas.

April 25: A chlorine truck bomb detonated at a military checkpoint on the western outskirts of Baghdad, killing one Iraqi and wounding two others.

April 30: A tanker laden with chlorine exploded near a restaurant west of Ramadi, killing six people and wounding 10.

May 16: A chlorine bomb exploded in an open-air market in the village of Aby Sayda in Diyala province, killing thirty-two people and injuring fifty.

NDMG CDNDMG CD

CHEMICAL TERRORISMCHEMICAL TERRORISM When evil minds combine,

Good minds have to work together and combat.

We have to be lucky all the time.

They have to be lucky only once!!!

When planning, think

more than a terrorist!When implementing, think

as a ‘poor’ victim!

Chemical Use by a Non-State Group or Individual

• A non-state group or individual pursuing a chemical weapons capability is more likely to choose Industrial Chemicals; such agents are generally easier to handle and produce and require less specialized production equipment than do Chemical warfare agents.

What is the goal of the Terrorist?

• If the goal is to kill a single person or small group, there are chemical agents that can accomplish a murder on a small scale.

• For example, Ricin, produced from castor beans kills by epidermal contact.

A Terrorist’s Goal may be Mass Murder

• This objective is the most suitable for dissemination of a Toxic Industrial Chemical or a Chemical Weapon

• Chlorine is readily available. Disseminated in a closed, positive air pressure environment, it could get into the lungs of most people in the environment. In other settings, however, the difficulties of spreading chlorine outdoors and the unlikelihood of it spreading from one victim to another render it a poor open-air, urban-devastating weapon.

• CW agents carry the most potential to spread quickly and cause more casualties and panic

If the Terrorist’s Goal is a WMD• OP compounds has requisite attribute of lethality

• However, these are available, if at all, only from secured laboratories

• To obtain and transport it would entail and organized conspiracy and more a kind to an act of war than an act of terrorism

• Sophisticated CW agents, are similarly effective but require technical assistance in order to be obtained/manufactured

Scale for Grading of Chemical Disasters

Multiple life threatening injuries and / or fatality Uncontained release with potential for major environment

effects

4

Severe injuries or potential for a fatality Uncontained release with potential for moderate

environment effects

3

Injuries requiring a physician’s care Uncontained release with potential for minor environment

effects Chances of fire and explosion

2

Injuries requiring first-aid only Contained release with local environmental effect and

pollution problem

1

Qualitative Severity/ Consequence CriteriaGrades

• Occurrence of chemical accidents and possibility of these manifesting in a chemical disaster remains a cause of concern

• Unanticipated events can lead to uncontrollable releases with devastating effects

• Unprecedented scale of disaster potential of a hazchem incident in terms of loss of life, health injury and evacuation needed

• The need for an effective Disaster Management approach to lessen disaster impact is increasingly being felt

• Post-BHOPAL - a new era of restructuring and inducting new hazchem control systems and procedures has emerged

• Chemical Disaster Management revisited

Lessons Learnt…Lessons Learnt…

GapsGaps …… ……RecognitionRecognition

BETWEEN THE CAPACITIES OF THE VARIOUS AUTHORITIES,

LEGISLATION AND ACTUAL

REQUIREMENT DURING A DISASTER

While considerable progress has While considerable progress has

been made in the last two been made in the last two

decades in the development and decades in the development and

implementation of regulations implementation of regulations

and programmes for the and programmes for the

management of chemical management of chemical

disasters, salient gaps still exists disasters, salient gaps still exists

in certain areasin certain areas …….

NDMA• Mandated to laying down policies, plans and guidelines

for the Nation, State, Ministries and departments (Under Section 6 of the Disaster Management (DM) Act, 2005

• State, Ministries and departments shall prepare plan for preparedness and response

• The National and State Disaster Management Plans will finally be approved by NDMA and respective SDMA as specified in Section 11 and Section 23- subsection 3 of DM Act, 2005 respectively

• NDMA to coordinate and ensure implementation of the guidelines and plans (Section 35 seeks to enjoin upon the Central Government, as it deems necessary or expedient, for the purpose of disaster management)

The role of NDMA and Govt.The role of NDMA and Govt.

The main goal of NDMA and ministries in the Central Government will be to to promote the cooperationpromote the cooperation between the different sections of the government, stakeholders and the society for the promotion of Chemical Disaster-Resilient Society and the implementation of CDM action plan

• Mainstreaming Disaster Mitigation into all Developmental Programmes; Mitigation Projects

• Rs. 10000 Crores earmarked for medical preparedness• Techno-legal and techno-financial regime to promote

chemical safety and risk reduction• NIDM has been tasked to developed various training modules

related to chemical (industrial) disaster management • Liaison with DRDO and other research organisations for

development of advanced equipment / logistics for CDM• Chemical Security has been identified as core issue related to

chemical terrorism –addressed as separate guidelines

Proactive Activities and Initiatives Undertaken by NDMA

National Disaster Management Guidelines-Management of Chemical (Terrorism) Disasters

National Disaster Management National Disaster Management Guidelines: Chemical DisasterGuidelines: Chemical Disaster

Core Group for Chemical Disaster Management

Lt Gen (Dr) JR Bhardwaj, Member, NDMA …… Chairman

Mr. KC Gupta, NSC ………………………………. Member

Dr. Indrani Chandrashekharan, MoE&F…..….….... Member

Dr. KP Mishra, BARC ………………..…..…... ….. Member

Maj Gen JK Bansal, DRDO…..…………………… Member

Mr. S. Kumar, FICCI…..……. ……………………. Member

Dr. Rakesh Dubey, DMI…..………………………. Member

Dr. Rakesh Kumar Sharma, DRDO …………….... Member & Co-ordinator

Core Group for CIDM

• It is extremely important that the professional or specialised inputs are not confined only to policy-making, but are also used for its dissemination, implementation and monitoring

• The availability of professional expertise will be a crucial factor for the successful and sustainable implementation of the Chemical disaster management action plan

• Shall promote the cooperation between the different sections of the government, stakeholders and the community for promoting activities aiming towards Chemical Disaster Resilience and the implementation of CDM action plan.

The road map towards developing Chemical Risk Reduction and Safety

The National Disaster Management Guidelines – Chemical Disaster recognizes the following Pillars of Strength:

• A Rational Chemical Disaster Management Framework • Emphasis on risk reduction, mitigation & awareness, while

strengthening response• Awareness program to sensitise and help preparedness of

all stakeholders• Capacity development• Training, mock drills of emergency plans • Compliance of MAH units to regulatory requirements• Techno-legal and techno-financial regime to promote

chemical safety and risk reduction

Regulations Capacity Development

Coordination Implementation

Focus areas requiring attention

RegulationsRegulations

MultiplicityMultiplicityLand Use PolicyLand Use PolicyCodes of Practices and ProceduresCodes of Practices and ProceduresSafety Audits and InspectionsSafety Audits and InspectionsInstitutional frameworkInstitutional frameworkTesting -On-Site and Off-Site PlanTesting -On-Site and Off-Site PlanCommissioning and Commissioning and DecommissioningDecommissioningTraining Training

Capacity Development –Infrastructure & Trained Manpower

Poison CentersDatabase management of HazchemControl Rooms- EOCsEmergency functionaries–Hazmat Vehicles; Medical PreparednessHazchem Transport- Highway DMPResearch and Development AspectsInstitutions – for conducting training and knowledge management

CoordinationCoordination ImplementationImplementation




Capacity Development –Infrastructure Capacity Development –Infrastructure & Trained Manpower& Trained Manpower

Poison CentersPoison CentersDatabase management of HazchemDatabase management of HazchemControl Rooms- EOCsControl Rooms- EOCsEmergency functionaries–Hazmat Vehicles; Emergency functionaries–Hazmat Vehicles;

Medical PreparednessMedical PreparednessHazchem Transport- Highway DMPHazchem Transport- Highway DMPResearch and Development AspectsResearch and Development AspectsInstitutions – for conducting training and Institutions – for conducting training and knowledge managementknowledge management

Coordination

Within MAH unitsWith other MAH unitsWith all Emergency FunctionariesResponse mechanisms and linkages between various levelsNational level

ImplementationImplementation







CoordinationCoordination

Within MAH unitsWithin MAH unitsWith other MAH unitsWith other MAH unitsWith all Emergency FunctionariesWith all Emergency FunctionariesResponse mechanisms and Response mechanisms and linkages between various levelslinkages between various levelsNational level National level

Implementation

Compliance Commensurate infrastructure and trained manpowerFinancial ArrangementsTime bound implementation models







CoordinationCoordination

Within MAH unitsWithin MAH unitsWith other MAH unitsWith other MAH unitsWith all Emergency FunctionariesWith all Emergency FunctionariesResponse mechanisms and Response mechanisms and linkages between various levelslinkages between various levelsNational level National level

Implementation

Compliance Commensurate infrastructure and trained manpowerFinancial ArrangementsTime bound implementation models


NDMG CDNDMG CD

Guidelines for Chemical Disaster Management

focus on all aspects of disaster management cycle lay stress on preparedness including prevention/

mitigation of Chemical Industrial Disasters while strengthening their emergency response.

pertain to industrial installations, storage and transportation of hazardous chemicals.

highlight the salient gaps evaluated based upon the critical review of the present status.

have also included the latest international best practices and recent developments within the country

The Guideline

Regulatory framework Code of Practices, Procedures and StandardsStatutory Inspection, Safety Auditing and Testing of Emergency PlansTechnical and technological information PreparednessEducation and Training Creation of InfrastructureCapacity Development Awareness GenerationInstitutional Framework Networking and Information Medical PreparednessResearch and Development Response, Relief and Rehabilitation

GUIDELINES for CDM–GUIDELINES for CDM– Major subheadsMajor subheads

• CDM at State and District levels

• Preparation of On-Site and Off-Site Emergency Plans

• Industrial (Chemical) Installations and Storages

• Management of Transport Accidents

Separate focus on…Separate focus on…

• Besides updation and strengthening of the existing CDM system, some value additions have been proposed………..

The Guidelines……….

Value Additions

• Issues related to multiplicity of regulations • National regulation on Occupational Safety and Health• National regulation on medical emergency

management• Regulations on storage and transportation of

cryogenics • Regulatory framework on safety measures for pipelines

and area en-route.• Establishment of a National Risk Management

Framework Criterion for chemical assessment• Empowerment of Factory Inspectorates to take legal

actions for non-compliance of MSIHC Rules• National Register on Potentially Toxic chemicals and

establishment of poison centers• Promotion of development and standardization of

personal protective equipment

Value Additions

• Information exchange on banned/severely restricted chemicals in International trade

• Legislation on buffer zone (or to be referred as ‘no man’ zone) around MAH units

• Rules for units holding quantity marginally lower than those specified limits for MAH units including small and medium entrepreneurs (SMEs)

• Standardization of safety audits, inspection system and planning aspects- identification and selection of professionals organizations these of for accreditation

• Issues related to commissioning and decommissioning of chemical industries

• Promotion of International Chemicals Safety Cards (ICSCs)• Critical Analysis and Documentation of major chemical

accidents • Third party evaluation of CDM plans

Value Additions

• Promotion of chemical safety studies by the professional bodies identified with in the network of academia, institutions and industry

• Specialized training and retraining concepts, standardized training modules for all stakeholders

• Identification, budgeting and time bound provision of infrastructural facilities in installations and at district level for emergency functionaries

• Inventory of resources and equipment (including PPE, Hazmat etc.) at all levels and networking under a National vision- utilization of IDRN network

• Resources pertaining to DM and its mobilization shall be in accordance with risks being assessed

• Augmenting point-to-point ambulance services on Highways• ERCs to also cater transport emergencies involving Hazchem• Strengthening of National Disaster Response Force, Fire

Services, Medical First Responders, paramedics and other emergency responders

• Revamping of Home Guards and Civil defence for CDM

Value Additions

• Capacity development of medical preparedness– Creation of trained Medical First Responders (MFRs)– Initiation of training of paramedics for CDM management– Creation of detection, decontamination and decorporation

facilities– Uniform Causality Profile and Classification of Casualties– Risk Inventory and Resources Inventory– Proper Chemical Casualty Treatment Kits– Crisis Management Plan at Hospitals– Mobile Hospitals/ Mobile Teams – Medical Response to Long Term Effects– Psychosocial Care for management of community behavior

and response – Issues related to public health response and medical

rehabilitation and harmful effects on the environment

Value Additions

• Promotion of National Initiative of GIS based emergency planning and response by using multi-stakeholder approach

• Promotion of Community Awareness through:– Introduction of mechanisms of surveillance, – concepts of emergency action advice,– dedicated DM channels and – involvement of Community Information Representatives

• Establishment of Information Networking System by development of an exclusive CDM website for Knowledge management and two-way flow of information with standardized reporting mechanism

• Establish a register of relevant National and International Institutes and information exchange programme

Value Additions

• Research & Development Activities –– Develop safer and cost effective alternative technologies

for operations– Development of need-based technologies for detection,

protection (including for improving personal protective equipment so as to make suitable for Indian tropical conditions)

– Development of biosensors and newer biomarkers for detection of exposures, effect and susceptibility

– Research on risk management criterion for chemical safety management system

– Pilot Projects of data generation on newly emerging toxicants and its byproducts

– Mock drills –simulation model development

Value Additions

• Research & Development Activities –– Develop safer and cost effective alternative technologies

for operations– Development of need-based technologies for detection,

protection (including for improving personal protective equipment so as to make suitable for Indian tropical conditions)

– Development of biosensors and newer biomarkers for detection of exposures, effect and susceptibility

– Research on risk management criterion for chemical safety management system

– Pilot Projects of data generation on newly emerging toxicants and its byproducts

– Mock drills –simulation model development

Value Additions

• Indicators for declaration of different levels of disasters based upon the magnitude of chemical accidents

• Establishment of post-disaster documentation procedures, epidemiological surveys and minimum criterion for relief and rehabilitation

• Compensation to the non-governmental people including the community, if they are injured during any humanitarian activity

• Detailed guidelines for development of State, District DM plans including Off-Site and On-Site planning aspects

• Roles and responsibilities of different stakeholders – specifically for the districts with MAH units located at the boundary or the overlapping boundaries

• Mock drills to test these Off-Site and On-Site plans to standardize the response time for different responders

• Specialized focus on the technical improvements and preventive actions needs to be taken at Installations level

• Inclusion of isolated storages and storages at installations into the chemical safety management system

• Promotion of transportation emergency management (development of highway disaster management plans) and pipeline management system)

National Vision for Management of Chemical Disasters

1. To prevent Chemical Disasters


1. To prevent Chemical Disasters


2. In the event of occurrence of CD, various stakeholder shall under take certain pre-planned and established Structural and Non-structural measures so as to minimize risks to health, life and environment

Something may go wrong in spite of best system.History repeats itself as we don't learn from it.

Many big mishaps have apparently small causes behind, which are likely to be overlooked.

Table 29: Possible Scale of Terrorist Attacks Table 29: Possible Scale of Terrorist Attacks (1993 Estimates)(1993 Estimates)

Type of Attack Possible Fatalities

Estimated Likelihood

Efficient biological attack 1,000,000 Very low

Atomic bomb detonated in major US city 100,000 Very low

Successful attack on nuclear or toxic chemical plant

10,000 Very low

Simple, relatively inefficient biological or chemical attack in one skyscraper or stadium

1,000 Low

Conventional attack on a single train or airplane

250 Low

Suicide attack with explosives or firearms in a mall or crowded street

50-100 Modest

Source: Office of Technology Assessment. Proliferation of Weapons of Mass Destruction: Assessing the Risks. U.S. Congress, 1993; cit. Michael E. O’ Hanlon et al. Protecting the American Homeland. A Preliminary Analysis. Washington, D.C., Brookings Institution Press, 2002, p.6.

Thanks

CBRN Disaster Management

Dr. Rakesh Kumar SharmaAdditional Director, Institute of Nuclear Medicine and Allied Sciences, Delhi

@Training Programme on Chemical (Industrial) Disaster Risk Management, 27-28 August 2010

• Chemical Burns (strong acids, strong bases)• Heat Burns (flammable materials)• Poisoning (many chemicals are damaging or

fatal if taken internally, whether by swallowing, injection, or leaching through skin)

• Chronic illness (long-term exposure to even low doses of certain chemical agents can lead to chronic health conditions)

• Etc.

Modes of Chemical Injury

General Signs and Symptoms

Cough

Chest pain

Lacrimation

Eyelid oedema and

Unconsciousness

Leads toAcute lung injury

Cardiac arrest

DEATH

CorrosivenessErythemasIrritations

Corneal OpacityRetinal Damage

SensitizationPneumoconiosisFibrosisAdenomasAsphyxiation

MiscarriageNeonatal deathFetal abnormalities

Behavior ChangesPeripheral neuro degenerationLocomotion rigidityNarcosis or DepressionRespiratory Paralysis

MFO inductionCholeostasisCarcinogenesisNecrotic/Cirrhotic liverDefense system loss

Aminoacid ureaUremiaRenal failure

Bone marrow depressionAnaemiaCancerMet hemoglobinemia

OsteoporosisArthritisImmuno

Suppression

TARGET ORGANS AND EFFECTS INDUCED BY CHEMICALS

Gather information regarding: place, time and type of emergency also type of chemical,

chemical toxicity, route of exposure

Mobilization of Resources

o Manpower: Disaster Management Team medical , nursing and other Personnel

o Material and supply eg: antidotes o Transportation means

Transport to the critical patients for medical care / hospitals

Decontamination done at decontamination area in the hospital

Triage

Documentation done at reception

Treatment to the patient (Emergency Dept.)

OT

IPD / ICU

OPD

Discharge

Getting initial alert from:

Police, casualty and telephone

On site treatment / operations

o Mass decontaminationo Transported in a safe placeo Provide necessary treatment , first aid and antidote administration to chemical contaminated patients

Notify to Key Personnel

Initiate preparationo All the dept & designated staff get into

readiness to attend casualtieso Crisis expansion of hospital beds.o Preparation for decontamination area

o Diagnostic Services o Other support services

Chemical Disaster Action Plan

Management of Chemical accident

• Pre-hospital

• Hospital

• Post-hospital

• Preventive

CBRN Disasters

Are we Prepared?

Predictable Surprises and System challenges

• Improbable scenarios emerges every time• Planning mostly fails with every new disasters

– We don’t have proper Plans (rudimentary!)– Capacity Development not matching (un-/under

Preparedness)– Vibrant institutional system are not in place (tendency

to maintain status quo)– Regular rehearsal of Plans to check efficiency?– Good Practices and Lessons Learnt not imbibed– Tunnel Vision

• Authorities at various levels yet to incorporate and come up with implementable plans with dedicated resources

Are We Prepared?

• Is the Healthcare System Prepared?• We appear to be… each Hospital, EMS

agency, Law enforcement agency, Fire & Emergency Services, and Community has…

… a disaster plan

… properly documented mock exercises

… annual training documented

• But...

Are We Prepared?

• Interagency communication failures!

• Why do we all treat a cardiac arrest the same?

• …because there is an agreed-upon approach.

Are We Prepared?

• Critical to healthcare preparedness

– uniform

– coordinated approach

– mass casualty management from any cause

• NEED: A need based and standardized training program

Why are we not prepared?

• Traditional approach fails

• Need unique equipment and training

• Rupiya, Rs., ………

• Fear of the unknown

• It can’t happen here

Levels of Disasters

• The levels of disasters have already been categorised and disseminated as L0, L1, L2 and L3, based on the ability of various authorities to deal with them.

• Colour codes relating to the level of alerts.

‘L0’ Level

• denotes normal times which are expected to be utilised for close monitoring, documentation, prevention, mitigation and preparatory activities. This is the planning stage where plans at all

levels from community to the State shall be put in place.

Training on search and rescue, rehearsals, evaluation and inventory updation for response activities will be carried out during this time.

‘L1’, ‘L2’, & ‘L3’ Levels• L1 specifies disasters that can be managed at the district

level.• L2 specifies disaster situations that may require

assistance and active participation of the state, and the mobilisation of resources at the state level.

• L3 disaster situations arise from large scale disasters where districts and the state may not have the capacity to respond adequately and require assistance from the central government for reinstating the state and district machinery.

Even though there cannot be watertight compartmentalization of responsibilities between states and the centre, especially in the case of

man-made disasters, the participation by the Centre will normally be at the L3 level.

Even though there cannot be watertight compartmentalization of responsibilities between states and the centre, especially in the case of

man-made disasters, the participation by the Centre will normally be at the L3 level.

- Authorities, Media- 2nd level Triage

ZONING REFERENCE TERMINOLOGY TO HELP DEFINE A SCENE LAYOUTZONING REFERENCE TERMINOLOGY TO HELP DEFINE A SCENE LAYOUT

- Not Dangerous- Operational

- Potentially Dangerous- Operational

- Dangerous- Operational

- Dangerous- Not operational (not accessible)

- NOBODY closed area ( immediate danger)

- ICP- Fire with ordinary protect.- Medical Post- Support- 1st level Triage

- Not Dangerous - Not operational

- Decontamination- Fire CBRN protected- Medics CBRN prot.- Support / Backup

Permitted ENTRYPermitted ENTRY

- ONLY CBRN trained & fully protected TEAMS

WIN

D

Command Post

DECON

- Not Dangerous- Operational

- Potentially Dangerous- Operational

- Dangerous- Operational

- Dangerous- Not operational (not accessible)

- Not Dangerous - Not operational

- Authorities, Media- 2nd level Triage

- NOBODY closed area ( immediate danger)

- ICP - Fire with ordinary protect.- Medical Post..- Support- 1st level Triage

- Decontamination- Fire CBRN protected- Medics CBRN prot.- Support / Backup

- ONLY CBRN TEAMS fully protected

ZONING REFERENCE LAYOUTZONING REFERENCE LAYOUT

Scenario

Emergency SiteTriage Area

Retriage

Hospitals

Decontamination Areas, Basic First AidWarm

Hot

Cold

Cardoning off the Chemical Disaster areaWind direction

No incoming traffic except for disaster management

No incoming traffic

No incoming trafficNo incoming traffic

No incoming traffic

Site of DisasterSite of Disaster

Medical Aid PostMedical Aid Post

Control HQrsControl HQrs

POLICE POLICE CHECK POSTCHECK POST

Outer Cardon

Inner Cardon

Response by DDMA in a Post-Disaster Scenario

1. Instantaneous instruction for forthwith movement of rescue team with personal protective equipment (PPE)

2. Simultaneously, QRMT with PPE on will reach to Mishap site immediately along with Resuscitation, protection, detection and decontamination equipment and material. Resuscitation, triage and evacuation work must be done as per sops.

3. DDMA will immediately inform State and National Disaster Management Authorities appraising about situation and extent of damage so that SDMA & NDMA can plan to send relief teams

Response by DDMA in a Post-Disaster Scenario (contd)

4. Hospitals must be alerted to be ready to receive casualties

5. If there is a major chemical disaster and management is beyond the capacity of District resources. In that situation DC can request for help from adjacent district, state DMA and NDRF

6. Simultaneously, DDMA will instruct other agencies to plunge into action as per the responsibilities assigned to them

Standard Operating Procedures for Disaster Site

• Rescue & Quick Reaction Medical Team must put on full protective gear

• Cordon off the Disaster Site• Do not allow Entry within five kms of Disaster site• Find out the wind direction & Clear the down wind side

immediately

• Detect & Identify the Chemical Substance• Demarcate the area of Contamination• Do not crowd near the victim to avoid further contamination• Carryout Rescue, Resuscitation & Evacuation work properly

Augmentation of Incident Site Management Capabilities

• Detection/Protection Equipment (conditioned to be useful in Indian climatic conditions)

• Decontamination

MANAGEMENT OF MANAGEMENT OF CONTAMINATIONCONTAMINATIONPROTECTION DETECTION

DECONTAMINATION

On-Site Emergency Medical Care

• Health Care Centers ~ Two in perpendicular directions

• Inhabited with Qualified Medical Officer and male nurses ~ 24X 7 services

• Dedicated well equipped Ambulance with driver~ safe transportation of victim

• 10 bedded clinic • Equipments- Oxygen Cylinders, masks, Ambu

bags, First aid box, essential medicines, antidotes specific to particular hazard

• Minor O.T. and small laboratory to analyze routine blood samples

Legal RequirementsLegal Requirements

Off-Site Medical Preparedness

• Emergency Management at the incident Site:– Personal Protective Equipment will be made available – Temporary decontamination facility– On-Site Triage, Resuscitation and safe transportation

• Safe transportation of the chemical casualties in ambulances fitted with chemical filters

• Evacuation Plans from Plants and nearby affected communities

Off-Site Medical Preparedness

• Earmarking of health care facilities able to cater different types of chemical casualties like chemical burns, respiratory problems etc.

• Hospital disaster management plans to deal with mass casualty events caused due to chemical disasters

• Creation of Trained Medical First Responders• Uniform Casualty Profile & their classification• Risk and Resource Inventories

Off-Site Emergency Medical Care

• Proper Chemical Causality Treatment Kits including essential medicines and antidotes

• Dedicated Group of Specialists to manage multi- organ dysfunctions caused by chemical exposures

• Provisions for mobile hospitals and teams, if needed

• National and Regional Poison Information Centers for information about various antidotes and treatment profiles

• Preparedness for Public Health and Environmental Effect Response

• Mechanism to follow up the long term medical care to the numerous victims

Guidelines for public during chemical disaster

• Report about mishap to police or fire station• Stay upwind & uphill• Self protection by stopping breathing immediately

and closing eyes• Then put on the NBC protective mask • Avoid contact with chemical agents• Seek qualified medical advice for those persons who

have been harmed by chemicals• Do not eat, drink or smoke on contaminated terrain

POST TRAUMATIC STRESS DISORDER & ITS MANAGEMENT

• PTSD is a psychological response to the experience of intense trauma due to Disaster.PTSD is characterized by

• Intrusive symptoms include distressing memories or

images nightmares sweating, heart racing or muscle tension

• Avoidance symptoms of PTSD trying to avoid any reminders of the trauma, such as thoughts, feelings, conversations, activities, places and people.

• Arousal symptoms of PTSD include sleep disturbances, anger and irritability, concentration problems, constantly on the lookout for signs of danger

Post-disaster Public Health Response

1. Prime responsibility of medical authorities

2. They must ensure safe water supply, clean food availability

3. Maintenance of hygiene and sanitation by proper bio- waste disposal

4. Water testing and food inspection must be carried out

Post-disaster Epidemiological Study

1. It must include accurate estimation of chemical exposure of effected population, correlation of environment and human exposure data, relationship of chemical and dose to the observed effect,

2. Sub clinical effects, morbidity and mortality must also be analyzed

3. Epidemiological studies be conducted for assessment of psychosocial effect of disaster

4. Analysis to find out the success and failure of Disaster Management Plan and failure must be addressed

5. Epidemiological studies team should have Clinician, Epidemiologist, Toxicologist, Pathologist, Environmental scientists and reps from Industry

Medical Response to Long Term Effects

1. In post-disaster scenario some of the casualties will develop sequel due to chemical injuries

2. These cases may need regular follow-up, medical care, reconstructive surgery and rehabilitation

3. Close monitoring is required to see any long term health effects like blindness, interstitial lung fibrosis and neurological deficiencies etc., and need to be treated as well

Post Disaster Documentation and Analysis

1. Information will be prepared by a medical administrator

2. During response in hospital an information centre will provide information to public, to relatives of victims and media

3. Warning guidelines, “DOs and DON’Ts” and condition of patients in the hospital

4. dissemination of information to electronics and prints media will also be carried out by medical team

5. Documentation, follow up and research programs should be used as feedback for future improvement and lessons learnt

Rehabilitation

• It involves providing temporary shelters with minimal hygiene sanitation to the affected, restoring “normalcy” through ensuring resumption of family’s daily living patterns

• Psychological impact of chemical disaster manifested as post traumatic stress disorders (PTSD) in displaced people due lo disaster, needs care by a psychologist and psychiatrist

Recovery

• Decontamination of the area, equipment, vehicles and disposal of left over contaminants, removal of dead bodies from site has to be carried out in the Post-disaster Scenario.

• It also involves restoring life of victims to normalcy.

Post-Disaster Emergency Medical Response 1. Activate resuscitation, first aid and triage

system. 2. Provide immediate relief to seriously ill and

injured.3. Carry out resuscitation followed by

decontamination4. Collect biological samples of casualties and

sample from environment as well.5. Carry out proper diagnosis and proper antidote

administration.6. Carry out simultaneous documentation of the

patients.7. Provide accurate information to public health

authority and public.

Develop the Dreaded Disaster Develop the Dreaded Disaster Plan and Sleep WellPlan and Sleep Well

EM Plan Testing, Training & EM Plan Testing, Training & Mitigation- Mitigation- A Continuum

Failure to prepare is

preparing to failJohn Wooden

What Needs to be Done? Professionalizing disaster risk management Filling knowledge gaps through information sharing,

training and capacity building initiatives Networking and building partnerships among all

institutions Creating environment for disaster risk management

capacity Development Developing research and knowledge management

systems Professionalize training and capacity development Sustainability of Initiatives

• CBRN Emergency Scenarios

• Common Indicators of CBRN Emergencies

• Dos and Don’ts for incident Site Management

Eight Sections; 177 pages;

9 Figs; 42 Tables; 8

Annexure

• An Overview

• What to Expect?

• What to do in Initial

Phase?

• Managing Afterwards

• Future Perspectives

• Conclusions

• Suggested Readings

• Annexure

Thanks

Documents

CBRN Disaster Management Dr. Rakesh Kumar Sharma Additional Director, Institute of Nuclear Medicine and Allied Sciences, Delhi @Training Programme on Chemical