Introduction to Large Scale Disasters & Weapons of Mass Destruction A course developed for School...
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Transcript of Introduction to Large Scale Disasters & Weapons of Mass Destruction A course developed for School...
Introduction toIntroduction toLarge Scale Disasters &Large Scale Disasters &
Weapons of Mass Weapons of Mass DestructionDestruction
A course developed
for
School Based Personnel/School Based Personnel/First RespondersFirst Responders
New Jersey Preparedness New Jersey Preparedness Training ConsortiumTraining Consortium
An association of public health agencies An association of public health agencies tasked by the federal government with tasked by the federal government with providing Weapons of Mass Destruction providing Weapons of Mass Destruction and Terrorism education to health care and Terrorism education to health care providersproviders
Traditional WMD education targets have Traditional WMD education targets have been physicians, nurses and EMS workersbeen physicians, nurses and EMS workers
New Jersey Preparedness New Jersey Preparedness Training ConsortiumTraining Consortium
Consortium MembersConsortium Members Saint Barnabas Health Care SystemSaint Barnabas Health Care System University of Medicine and Dentistry of New JUniversity of Medicine and Dentistry of New J
erseyersey Rutgers, the State UniversityRutgers, the State University New Jersey Primary Care AssociationNew Jersey Primary Care Association New Jersey Hospital AssociationNew Jersey Hospital Association Liberty HealthLiberty Health
““This program is funded by the U.S. Department This program is funded by the U.S. Department of Health and Human Services, Health Resources of Health and Human Services, Health Resources and Services Administration, Grant No. and Services Administration, Grant No. T01HP01407.”T01HP01407.”
The Center forThe Center forHealth Care PreparednessHealth Care Preparedness
Established as a Established as a center of excellencecenter of excellence, , furthering education and research in the furthering education and research in the
field of health care disaster readinessfield of health care disaster readiness
Why you need to be Why you need to be prepared:prepared:
Catastrophic Natural Catastrophic Natural DisastersDisasters
Emerging/Re-emergingEmerging/Re-emerging Infections Infections
Why you need to be Why you need to be prepared:prepared:
Technological DisastersTechnological Disasters Chernobyl, Bhopal, Three Chernobyl, Bhopal, Three
Mile IslandMile Island TerrorismTerrorism
ConventionalConventional explosives, incendiariesexplosives, incendiaries
Non-conventionalNon-conventional nuclear, biological, chemical nuclear, biological, chemical
attacksattacks
Role of RespondersRole of RespondersAwareness !!!!!!!!Awareness !!!!!!!!
maintain a high index of suspicion… be on the alertmaintain a high index of suspicion… be on the alert Case Examples – Filming Facilities, Residential Case Examples – Filming Facilities, Residential
Warehousing, Hospital Surveillance, Approach to Buy Warehousing, Hospital Surveillance, Approach to Buy Ambulance Equipment/UniformsAmbulance Equipment/Uniforms
ResponseResponse Personal protection and infection controlPersonal protection and infection control Meet patient’s emergency needsMeet patient’s emergency needs Implement facility response protocolImplement facility response protocol Notifications:Notifications:
Clinical / Psychosocial referralClinical / Psychosocial referral Law enforcementLaw enforcement Public healthPublic health
ParticipationParticipation Drills and exercisesDrills and exercises
Weapons of Weapons of Mass Mass
DestructionDestruction
WMD IntroductionWMD Introduction
Terrorism involving weapons of mass Terrorism involving weapons of mass destruction is an ever-present threat destruction is an ever-present threat in today’s worldin today’s world
As a provider, you may be called on to As a provider, you may be called on to deal with people / patients involved in deal with people / patients involved in an incident involving WMDsan incident involving WMDs
Weapons of Mass Destruction:Weapons of Mass Destruction: are chiefly designed to incite terror, are chiefly designed to incite terror,
not to killnot to kill consist of a variety of different agentsconsist of a variety of different agents can be delivered through a variety of can be delivered through a variety of
different meansdifferent means can be extremely difficult to controlcan be extremely difficult to control are designed to cause are designed to cause widespreadwidespread and and
indiscriminate indiscriminate death and destructiondeath and destruction
WMD IntroductionWMD Introduction
Categorization ofCategorization ofWeapons of Mass DestructionWeapons of Mass Destruction
Useful mnemonics to categorize Useful mnemonics to categorize WMDs:WMDs:
B NICEB NICE CBRNECBRNE
B B Biological Biological CC Chemical Chemical
NN Nuclear Nuclear B B Biological Biological
I I Incendiary Incendiary RR RadiologicalRadiological
CC Chemical Chemical NN Nuclear Nuclear
EE Explosive Explosive EE Explosive Explosive
ChemicalChemicalWeapons of Mass Weapons of Mass
DestructionDestruction
Why CW are attractive to Why CW are attractive to terrorists:terrorists:
They are inexpensive to manufacture to obtainThey are inexpensive to manufacture to obtain Simple technology is needed to produce themSimple technology is needed to produce them They are difficult to detectThey are difficult to detect They are highly efficient (little quantity is They are highly efficient (little quantity is
needed)needed)
Nerve Agent LethalityNerve Agent Lethality
An amount of VX equal in size to one An amount of VX equal in size to one column of the Lincoln Memorial on column of the Lincoln Memorial on
the back of a penny would be the back of a penny would be lethallethal to you to you
Sources of CW AgentsSources of CW Agents Foreign governmentsForeign governments Internet recipesInternet recipes ““Black Market” of the former Soviet UnionBlack Market” of the former Soviet Union U.S. chemical plants (Chlorine, Phosgene, etc.)U.S. chemical plants (Chlorine, Phosgene, etc.) U.S. Military StockpileU.S. Military Stockpile
30,600 tons of nerve agents and vesicants at 8 sites 30,600 tons of nerve agents and vesicants at 8 sites across U.S.across U.S.
1985 law directed DoD destroy stockpile by 20041985 law directed DoD destroy stockpile by 2004 Outdated and recovered CW are buried at 215 sites Outdated and recovered CW are buried at 215 sites
across U.S.across U.S.
Recent Chemical Terrorism Recent Chemical Terrorism EventsEvents
1995: Aum Shinrikyo cult releases 1995: Aum Shinrikyo cult releases Sarin vapor into Tokyo subwaySarin vapor into Tokyo subway 12 deaths and 5,500 casualties12 deaths and 5,500 casualties 4,000 w/o clinical manifestation of 4,000 w/o clinical manifestation of
injuryinjury
1993: World Trade Center 1993: World Trade Center BombingBombing Explosive contained sufficient Explosive contained sufficient
cyanide to contaminate entire cyanide to contaminate entire buildingbuilding
Cyanide destroyed in blastCyanide destroyed in blast
Classification of Chemical Classification of Chemical WeaponsWeapons
Chemical agents are classified by Chemical agents are classified by the toxic effects they have on the the toxic effects they have on the bodybody
Chief Categories of Agents:Chief Categories of Agents: Nerve AgentsNerve Agents Vesicants or Blistering AgentsVesicants or Blistering Agents Choking or Pulmonary AgentsChoking or Pulmonary Agents Blood AgentsBlood Agents Incapacitating or Riot-Control AgentsIncapacitating or Riot-Control Agents
S.L.U.D.G.E.S.L.U.D.G.E.
Muscarinic Effects of Nerve AgentsMuscarinic Effects of Nerve Agents
SSalivationalivation
LLacrimationacrimation
UUrinationrination
DDiaphoresisiaphoresis
GGI distress (diarrhea, I distress (diarrhea, vomiting)vomiting)
EEmesismesis
Nerve Agent Antidote: Nerve Agent Antidote: MARK I KitMARK I Kit Self-injectable needleSelf-injectable needle Pralidoxime Chloride Pralidoxime Chloride
(600 mg)(600 mg) Atropine (2 mg)Atropine (2 mg)
Case Study: RussiaCase Study: Russia October 26, 2002October 26, 2002 50 heavily armed Chechen insurgents 50 heavily armed Chechen insurgents
hold hundreds of civilians hostage in a hold hundreds of civilians hostage in a Moscow theaterMoscow theater
Russian Special Forces use fentanyl Russian Special Forces use fentanyl derivative to incapacitate the terroristsderivative to incapacitate the terrorists
Over 100 hostages die from the gasOver 100 hostages die from the gas
General Treatment General Treatment GuidelinesGuidelines
for all classes of Chemical for all classes of Chemical WeaponsWeapons
Move to fresh airMove to fresh air Supplemental oxygenSupplemental oxygen Remove clothingRemove clothing Decontaminate skinDecontaminate skin Restrict physical activityRestrict physical activity Hospitalization/medical attentionHospitalization/medical attention
BiologicalBiologicalWeapons of Mass Weapons of Mass
DestructionDestruction
What is What is Bioterrorism?Bioterrorism?““Intentional or threatened use of Intentional or threatened use of viruses, bacteria, fungi or toxins viruses, bacteria, fungi or toxins from living organisms to produce from living organisms to produce
death or disease in humans, animals death or disease in humans, animals or plants”or plants”
1918 2004
Why Biologics are attractive Why Biologics are attractive to terrorists:to terrorists:
Some can be obtained from Some can be obtained from naturenature
Potential dissemination over Potential dissemination over large geographic arealarge geographic area
Creates panic and chaosCreates panic and chaos Can overwhelm medical Can overwhelm medical
servicesservices Civilian populations may be Civilian populations may be
highly susceptiblehighly susceptible High morbidity and mortalityHigh morbidity and mortality Difficult to diagnose and/or Difficult to diagnose and/or
treattreat Some are transmitted person-Some are transmitted person-
to-person via aerosolto-person via aerosol
Characteristics of Characteristics of Biological AttacksBiological Attacks
Incident may not be recognized for Incident may not be recognized for weeksweeks
Responders and health workers are at Responders and health workers are at risk of becoming casualties themselvesrisk of becoming casualties themselves
Continuing effect with re-infectionContinuing effect with re-infection Require special training and equipment Require special training and equipment
to handleto handle Large numbers of “worried well” (30:1 Large numbers of “worried well” (30:1
ratio)ratio) Fear of the unknownFear of the unknown
History of SmallpoxHistory of Smallpox
Most deadly germ in all of human historyMost deadly germ in all of human history First recorded case of biowarfareFirst recorded case of biowarfare Last natural case in U.S.: 1947Last natural case in U.S.: 1947 U.S. phased out vaccination from 1968-U.S. phased out vaccination from 1968-
19721972 Last natural case in world: 1977 Last natural case in world: 1977 ““Eradicated” from the globe in 1980Eradicated” from the globe in 1980 Two live cultures kept for researchTwo live cultures kept for research Only 10% of Soviet stockpile accounted Only 10% of Soviet stockpile accounted
forfor
Variola majorVariola major (Smallpox) (Smallpox)
Highly contagious virus (Attack rate: Highly contagious virus (Attack rate: 90%)90%)
Person-to-person spread (by Person-to-person spread (by inhalation)inhalation)
Mortality rate: 35%Mortality rate: 35% Vaccine ~95% effective, can be Vaccine ~95% effective, can be
administered up to 4 days after administered up to 4 days after exposureexposure
No effective anti-viral agentsNo effective anti-viral agents
Smallpox VaccineSmallpox Vaccine
Made from live Made from live VacciniaVaccinia virusvirus
Intradermal inoculation Intradermal inoculation with bifurcated needlewith bifurcated needle
Scar (permanent) Scar (permanent) demonstrates successful demonstrates successful vaccinationvaccination
Immunity Immunity notnot life-long life-long Adequate vaccine for all of Adequate vaccine for all of
U.S. populationU.S. population
Anthrax: OverviewAnthrax: Overview
Forms highly stable spores Forms highly stable spores No person-to-person transmissionNo person-to-person transmission Easy to manufacture, difficult to Easy to manufacture, difficult to
aerosolizeaerosolize History:History:
1979:1979: Accidental release of spores from a Accidental release of spores from a USSR Bioweapons factory, at least 66 deadUSSR Bioweapons factory, at least 66 dead
2001:2001: Anthrax attacks in the United Anthrax attacks in the United States, 11 contract inhalational anthrax, 5 States, 11 contract inhalational anthrax, 5 dieddied
Anthrax: VaccineAnthrax: Vaccine Current U.S. vaccineCurrent U.S. vaccine
For persons 18 - 65 years of ageFor persons 18 - 65 years of age Protective against cutaneous anthrax and Protective against cutaneous anthrax and
possibly inhalational anthrax (animal data)possibly inhalational anthrax (animal data) 6 dose regimen over 18 months6 dose regimen over 18 months Limited availabilityLimited availability Not currently administered to the civilian Not currently administered to the civilian
populationpopulation
Radioactive and NuclearRadioactive and NuclearWeapons of Mass Weapons of Mass
DestructionDestruction
Penetration Abilities of Penetration Abilities of Different Types of Different Types of
RadiationRadiationAlpha ParticlesStopped by a sheet of paper
Beta ParticlesStopped by a layer of clothingor less than an inch of a substance (e.g. plastic)
Gamma RaysStopped by inches to feet of concreteor less than an inch of lead
RadiationSource
Methods of protectionMethods of protection
TimeTime
DistanceDistance
ShieldingShielding
Potassium Iodide (KI) Potassium Iodide (KI) TabletsTablets
Only helpful in certain casesOnly helpful in certain cases Only protects the thyroid from Only protects the thyroid from
radioactive iodineradioactive iodine KI saturates the thyroid gland with KI saturates the thyroid gland with
stable iodinestable iodine KI must used prior to exposure to KI must used prior to exposure to
radioactive iodineradioactive iodine
Radioactive/Nuclear Radioactive/Nuclear WMDs:WMDs:
Possible ScenariosPossible Scenarios Nuclear power plant Nuclear power plant
incidentincident Nuclear weaponNuclear weapon Improvised Nuclear Device Improvised Nuclear Device
(IND)(IND) ““Dirty bomb”Dirty bomb”
Nuclear Power Plant Nuclear Power Plant IncidentIncident
Attack by air fairly Attack by air fairly easy for terroristeasy for terrorist
Would result in little Would result in little release of radioactive release of radioactive material, if anymaterial, if any
Redundant safety Redundant safety systems make systems make catastrophic catastrophic radiation leak highly radiation leak highly unlikelyunlikely
Nuclear WeaponNuclear Weapon Manufacture requires extraordinary Manufacture requires extraordinary
degree of scientific expertisedegree of scientific expertise Requires constant maintenanceRequires constant maintenance Unlikely that a terrorist organization Unlikely that a terrorist organization
has the resources to effectively has the resources to effectively accomplish a NW attackaccomplish a NW attack
Improvised Nuclear Improvised Nuclear DeviceDevice
Weapons made from small devices Weapons made from small devices that trigger uncontrolled nuclear that trigger uncontrolled nuclear reactionsreactions
Difficult to manufactureDifficult to manufacture Require frequent maintenanceRequire frequent maintenance
Chairman Dan Burton Committee – Demonstration of example “suitcase nuke” made from US nuclear shell
““Dirty Bomb”Dirty Bomb” Radioactive/Nuclear weapon of Radioactive/Nuclear weapon of
greatest concerngreatest concern Relatively easy to manufactureRelatively easy to manufacture Consists of radioactive material Consists of radioactive material
coupled with a conventional coupled with a conventional explosiveexplosive
Immediate effect: Blast injuriesImmediate effect: Blast injuries Long term effect: chronic Long term effect: chronic
radiation exposureradiation exposure Would require massive decon Would require massive decon
effort (of people, buildings, effort (of people, buildings, environment)environment)
Explosive/IncendiaryExplosive/IncendiaryWeapons of Mass Weapons of Mass
DestructionDestruction
Conventional Weapons and Conventional Weapons and Incendiary DevicesIncendiary Devices
Conventional weapons: BombsConventional weapons: Bombs Incendiary devices: Fire-Causing DevicesIncendiary devices: Fire-Causing Devices The Most Widely Used WMDs!The Most Widely Used WMDs!
Conventional Weapons and Conventional Weapons and Incendiary DevicesIncendiary Devices
ExplosivesExplosives Ignite special fuels that burn Ignite special fuels that burn
extremely rapidlyextremely rapidly Cause a shock wave or a blastCause a shock wave or a blast Cause injury by:Cause injury by:
Pressure wave that damages air Pressure wave that damages air containing organs in the bodycontaining organs in the body
Throwing the body into the Throwing the body into the ground or other objectsground or other objects
Propelling debris that strikes a Propelling debris that strikes a patient causing a traumatic patient causing a traumatic injuryinjury
Causing building collapseCausing building collapse
Incendiary DevicesIncendiary Devices Designed to burn at Designed to burn at
extremely high extremely high temperaturestemperatures napalm, thermite, white napalm, thermite, white
phosphorousphosphorous
Cause thermal burnsCause thermal burns Patients exposed to an Patients exposed to an
incendiary device are incendiary device are treated as any other person treated as any other person suffering thermal burnssuffering thermal burns
Conventional Weapons and Conventional Weapons and Incendiary DevicesIncendiary Devices
Personal ProtectionPersonal Protection
Personal ProtectionPersonal Protection
Proper PPEProper PPE should be worn at all times should be worn at all times Disposable, non-sterile glovesDisposable, non-sterile gloves GownsGowns Eye shieldsEye shields N95 Respirator Face MasksN95 Respirator Face Masks
No eatingNo eating, , drinkingdrinking, applying , applying cosmeticscosmetics or handling or handling contact lensescontact lenses in in clinical areasclinical areas
Do not touch your Do not touch your eyeseyes, , nosenose or or mouthmouth
Infection Control: GlovesInfection Control: Gloves
Discard gloves in biohazard bags Discard gloves in biohazard bags after patient care is completed or after patient care is completed or when soiled or damagedwhen soiled or damaged
Wash hands immediately after Wash hands immediately after removal of glovesremoval of gloves
Patient Respiratory Patient Respiratory ProtectionProtection
Patient may wear a paper surgical Patient may wear a paper surgical mask to reduce droplet production, if mask to reduce droplet production, if toleratedtolerated
NRB masks offer some protection in NRB masks offer some protection in reducing droplet spreadreducing droplet spread
CPR should never be performed using CPR should never be performed using mouth-to-mouth or mouth-to-maskmouth-to-mouth or mouth-to-mask
The N95 The N95 RespiratorRespirator
Why a Respirator Is Why a Respirator Is NecessaryNecessary
You work in an environment You work in an environment where there is a high risk of where there is a high risk of disease transmission through disease transmission through infectious airborne infectious infectious airborne infectious particulatesparticulates
Respirators, such as the N-95, Respirators, such as the N-95, provide protection from provide protection from airborne infectious particulates airborne infectious particulates when properly fitted and wornwhen properly fitted and worn
The Strategic National StockpileThe Strategic National Stockpile
(SNS)(SNS)
MissionTo meet the nation’s pharmaceutical and medial supply needs in the event of a
chemical, biological, radiological, nuclear or explosive mass casualty event by delivering adequate medications and medical materiel to the site of a national emergency.
Strategic National Strategic National Stockpile:Stockpile:ContentsContents
Oral AntibioticsOral Antibiotics Intravenous SuppliesIntravenous Supplies Nerve Agent Antidotes and Nerve Agent Antidotes and
AntitoxinsAntitoxins Airway Maintenance SuppliesAirway Maintenance Supplies Medical/surgical itemsMedical/surgical items
Push Package being loaded on to an 18 wheel truck
Push Package configured to fit within a commercial aircraft
The clock is ticking…The clock is ticking… Governor and Commissioner of Health Governor and Commissioner of Health request therequest theSNS from the CDC (zero hour)SNS from the CDC (zero hour) Within 12 hours, SNS arrives in the Within 12 hours, SNS arrives in the statestate In 12-24 hours, SNS is distributed to In 12-24 hours, SNS is distributed to hospitals, counties, the military and hospitals, counties, the military and prisonsprisons In 24-36 hours, goal is to have “Pills in In 24-36 hours, goal is to have “Pills in People”People”
Thank You!Thank You!
Robert J. Bertollo, M.I.C.P., L.R.C.P., M.B.A.Robert J. Bertollo, M.I.C.P., L.R.C.P., M.B.A.
Associate Director, Associate Director,
Center for Health Care PreparednessCenter for Health Care Preparedness
95 Old Short Hills Road95 Old Short Hills Road
West Orange, NJ 07979West Orange, NJ 07979
973-322-4581973-322-4581
[email protected]@sbhcs.com