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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
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
DefinitionsChemical Biological Radiological Nuclear Public Health role
DefinitionsChemical Biological Radiological Nuclear Public Health role
• 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
DefinitionsChemical Biological Radiological Nuclear Public Health role
DefinitionsChemical Biological Radiological Nuclear Public Health role
(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
DefinitionsChemical Biological Radiological Nuclear Public Health role
DefinitionsChemical Biological Radiological Nuclear Public Health role
(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
DefinitionsChemical Biological Radiological Nuclear Public Health role
DefinitionsChemical Biological Radiological Nuclear Public Health role
(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 ???