Transcript Slide 1

RITN Overview
®
Speaker Name
Speaker Organization
Speaker Telephone
Speaker Email
-Fortuna Favet Paratusest. 2006
As of March 13, 2013
Agenda
• What is RITN?
• What is RITN preparing for?
• How RITN fits into the response
• Victim profile
• Is RITN ready?
• Organization structure
• Initiatives
• Resources
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Who we are?
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Who are RITN centers?
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RITN centers are hospitals that work with the
National Marrow Donor Program to facilitate
unrelated marrow transplants
Preparing to receive casualties from a mass
casualty Marrow Toxic Incident
RITN centers may:
– Accept patient transfers to their institutions
– Provide intensive supportive care to victims
– Provide treatment expertise to practitioners caring for
victims at other locations
– Travel to other centers to provide medical expertise
– Provide data on victims treated at their centers
– Facilitate marrow transplant for those who require it
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Possible Incidents Involving RITN
• Focus of preparations: Any incident resulting in mass
casualties with a marrow toxic injury
• Marrow is damaged by exposure to low levels of radiation
• Possible incidents:
– Radiological - exposure to ionizing radiation
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Improvised Nuclear Device (IND)
Nuclear power plant accident
Radiological exposure device (RED) a.k.a. open source
Radiological Dispersal Device (RDD) a.k.a. dirty bomb
– Less likely to overwhelm existing response resources
• Industrial accident
• Military grade nuclear weapon
– Chemical: Mustard agent
– Unknown
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Prevailing opinion of experts is not if, but when…
“the possibility of a group making a weapon using highly enriched uranium
is very plausibly within capabilities of a sophisticated terrorist group.” Matthew
Bunn (Harvard Belfer Center) 3/22/2012
“Making a simple “gun-type” bomb, the easiest for terrorists to build,
requires at least 50 kilograms of HEU enriched to 90% U-235.” From
“Consolidation: Thwarting Nuclear Theft” Harvard Belfer Center, March 2012
“Between 1995-2011 the IAEA has confirmed 2164 incidents, 399 involved
unauthorized possession and related criminal activities. Incidents included in
this category involved illegal possession, movement or attempts to illegally
trade in, or use, nuclear material or radioactive sources. 16 incidents in this
category involved HEU or plutonium. There were 588 incidents reported that
involved the theft or loss of nuclear or other radioactive material and a total
of 1124 cases involving other Unauthorized activities, including the
unauthorized disposal of radioactive material or discovery of uncontrolled
sources.” IAEA “Nuclear Security Achievements 2002-2011 “
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IAEA Reported Incidents of Theft/Loss
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Goals
1. To develop treatment guidelines for managing
hematologic toxicity among victims of radiation
exposure
2. To educate health care professionals about
pertinent aspects of radiation exposure
management
3. To help coordinate the medical response to
radiation events
4. To provide comprehensive evaluation and
treatment for victims at participating centers
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It is not the Cold War….. It is not a futile effort!
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From: Wikipedia
Damage will not be as Catastrophic as a
Military Nuclear Device
From: Wikipedia
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Damage will not be as Catastrophic as a
Military Nuclear Device
Anticipated Damage Zones from a 10 kT IND
~3 Miles
Epicenter of detonation
~1 Mile
Damage Zones
Severe: complete devastation/buildings collapsed
Moderate: buildings damaged & roads impassible
Light: windows & doors blown out
~0.5 Mile
Radius
Adapted From: Planning Guidance for Response to a Nuclear Detonation, Second Edition, June 2010
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Fallout May Cause the Most Radiation Injuries
Dangerous Fallout Zone
•The dose in the Dangerous Fallout zone could cause marrow injury
•Sheltering-in-place is key to reducing dose, as the hazard dissipates
relatively quickly
Illustration from: Knebel AR, Coleman CN, Cliffer KD; et al. Allocation of scarce resources after
a nuclear detonation: setting the context. Disaster Med Public Health Prep. 2011;5 (Suppl 1):S20-S31
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How would RITN fit in?
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Office of Assistant Secretary
for Preparedness and Response
ASPR
Dr. Nicole Lurie
Immediate Office
of the ASPR
Office of Policy &
Strategic Planning
Biomedical
Advanced Research
&
Development
Authority
Office of Medicine,
Science
& Public Health
Office of
Preparedness &
Emergency
Operations
http://www.hhs.gov/aspr/
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Wikipedia, June 2011
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Reality will probably not be this orderly
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Conceptual Flow of Victims to a RITN Center
*** This model does not account for victims with trauma or no injuries.
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Survey & Decon
NDMS
Contracted
Transportation
Survey & Decon
Radiological Survey
&
Spot Decontamination
First
Responder
Medical Aid
Stations
Radiological Survey
&
Gross Decontamination
Ad hoc
First Aid
Sites
State/Local
Public Health
Casualty
Collection
Centers
NDMS
Contracted
FCC/NDMS Hospitals
Patient
Reception
Specialized
Area
Medical Care
Facilities (burn,
RITN, etc…)
Expected distribution of victims (in a nutshell)
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RITN Casualties Will Take ~7-10 Days
Alert and Notification
Early Symptoms – e.g., nausea and vomiting
Day 1
RITN Centers - review capabilities & prepare to receive casualties
Day 3
Earliest casualties arrive at RITN Centers near incident
Daily/Periodic CBCs
Day 7
Expected initial surge of casualties for RITN Centers
Day 30
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Discharge and return to home region
Only a small minority would benefit from
intensive care or a transplant
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Small Percent Will Require Transplant
Hick JL, Weinstock
DM et al. Disaster Med Health Prep 2011
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RITN
patient
candidate
*Radiation dose received by the whole body or a significant portion of the whole body.
**Institute of Medicine. Guidance for establishing crisis standards of care for use in disaster situations: A letter report.
Washington, DC: Institute of Medicine, National Academies of Science; 2009.
Coleman CN, Weinstock DM, Casagrande R; et al. Triage and treatment tools for use in a scarce resources-crisis standards of
care setting after a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1):S111-S121
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Combined Injury Significantly Worsens Outcomes
No longer
likely a
RITN
patient
candidate
Coleman CN, Weinstock DM, Casagrande R; et al. Triage and treatment tools for use in a scarce resources-crisis standards of
care setting after a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1):S111-S121
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RITN ARS Treatment Guidelines
• Follow standard approaches for patients with bone
marrow toxicity from chemotherapy
• Based on severity of cytopenias and presence of
complications (e.g. neutropenic fever)
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Irradiated, leukoreduced transfusions
Antibiotics
IV fluid and other support
G-CSF
Hospitalization when indicated
Opportunity to apply new mitigation approaches
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Biodosimetry of Casualties
• Daily CBCs at RITN centers to determine clinical
need for treatment
• Biodosimetry using online algorithms (REMM)
– Blood counts (before and after arrival at RITN centers)
– Geographic dosimetry
– Opportunity to apply new biodosimetry approaches
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Is RITN ready?
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Radiation Casualty Estimates for an Improvised Nuclear Device
ModeratelyHigh
Casualty
Estimate
(85th %tile)
High
Casualty
Estimate
(95 %tile)
Radiation Dose (Gy)
Care Requirement
Mid
Casualty
Estimate
(50th %tile)
Mild (0.75-1.5)
Outpatient monitoring
5,000
32,000
91,000
Moderate (1.5-5.3)
Supportive Care and possible inpatient
admission
7,000
29,000
51,000
Severe (5.3-8.3)
Intensive Supportive Care (most
possibly including HCT)
3,000
9,000
12,000
Expectant (>8.3)
Comfort Care
10,000
28,000
47,000
Combined Injury and Radiation
(>1.5)
Stabilization and monitoring, pending
resource availability
3,000
20,000
44,000
10,000
38,000
63,000
Total Possible Estimate of Victims for RITN
(Moderate + Severe categories)
***Radiation doses are estimates based on clinical presentation and laboratory values.***
Table adapted from: Knebel AR, Coleman CN, Cliffer KD; et al. Allocation of scarce resources after a nuclear detonation: setting the context.
Disaster Med Public Health Prep. 2011;5 (Suppl 1):S20-S31
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2011 Capacity Survey
Answer
Options
1-10
11-50
51-100
101-499
>500
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2011 Capacity Survey
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Still have more work to do…
Radiation-only
casualties requiring
monitoring, supportive
care and possible
transplant (~38,000)
Current
capacity of
RITN
(13,000)
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To treat that many it would get this bad
From: http://1918.pandemicflu.gov , accessed 31Oct2011
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Structure
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Organization Structure
Network Composition:
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67 total centers
54 Transplant centers
6 Donor centers
7 Cord blood banks
As of March 13, 2013
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Center Locations
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Initiatives
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Preparedness Efforts
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Standard Operating Procedures
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Standardized admission and treatment orders
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Standardized data collection protocol
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Training/education:
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Over 2,300 RITN staff completed Basic Radiation Training
since 2006
110 staff have attended REAC/TS training since 2008
Contracted HLA typing laboratories 6,000 – 10,000 per
week during an emergency
• Internet based unrelated donor and cord blood unit
searching
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Preparedness Efforts
• Readiness exercises/events
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Annual RITN directed tabletop exercise
Top Officials IV (TOPOFF) (2007) - DHS
Pinnacle 07 (2007) – DHHS-ASPR
ConvEX 2008 – IAEA
Democratic National Convention (2008)
Republican National Convention (2008)
National Level Exercise 2010 (NLE 2010)
• Emergency communications equipment
– Government Emergency Telecommunication Service (GETS)
calling cards
– Satellite telephones
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Ongoing Initiatives
• Funding to cover cost of treatment beyond 30 days
• Strengthen relationship with NDMS to facilitate transfer
of casualties with ARS
• Distribution to non –NDMS RITN centers
• Establish guidelines for management of pediatric
casualties with ARS
• Support planning of outpatient and inpatient capabilities
at non-RITN centers through referral guidance
• Education of non-physician hospital staff
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Resources
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Fantastic Resources at a Price You Can’t Beat
FREE
http://www.dmphp.org/content/vol5/Supplement_1/index.dtl
http://www.remm.nlm.gov/PlanningGuidanceNuclearDetonation.pdf
http://www.ritn.net/About/
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Treatment Guidelines & Crisis Assistance
www.RITN.net
www.REMM.NLM.gov
For decorporation help or crisis assistance call
REAC/TS: 865.576.1005 (24x7 - Ask for REAC/TS)
http://orise.orau.gov/reacts
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Partners
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American Society for Blood and Marrow Transplantation
Department of Defense - Office of Naval Research
Health Resources and Services Administration
Center for International Blood and Marrow Transplant Research
Radiation Emergency Assistance Center/Training Site
Dept. Health & Human Services - Asst. Secretary for Preparedness and Response
AABB Disasters Task Force
New England Center for Emergency Preparedness
World Health Organization – Radiation Emergency Medical Preparedness and
Assistance Network
• European Group for Blood and Marrow Transplantation-Nuclear Accident
Committee
• National Library of Medicine - Radiological Event Medical Management
www.remm.nlm.gov
• Leading hematopoietic stem cell transplantation physicians
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