Transcript EMS The Canadian Experience

Public Health CBRN course
CBRN overview
Daniel Kollek, MD, CCFP(EM)
Goals 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 session
•
•
•
•
•
•
Definitions
Chemical overview
Biological overview
Radiological overview
Nuclear overview
Roles of public health
Definitions
Chemical
Biological
Radiological
Nuclear
Public Health role
(1) Definitions
Disaster
• 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 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
CBRN
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
Terrorism
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
Definitions
Chemical
Biological
Radiological
Nuclear
Public Health role
(2) Chemical
Chemical Agents
• 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
Hazardous Material
A 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 Classification
Nerve agent
– organophosphate based, insecticides
Blister agent
– Vesicants
Pulmonary agent
– Choking (ie Phosgene, Chlorine)
Blood agent
- Cyanide
Other agents
Pepper spray, Tear gas, CS, OC
(2) Chemical
“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 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 agents
• Decontamination
• Antidotal therapy
– 2PAM,
– Atropine,
– Benzodiazepines
(3) Biological
Definitions
Chemical
Biological
Radiological
Nuclear
Public Health role
(3) Biological
Types of Bio-agents
• Bacterial
• Viral
• Toxins
(3) Biological
Characteristics of Bio-agents
•
•
•
•
•
•
•
Low visibility
High potency
Latency
Easy accessibility
Simple delivery
Good sustainability and propagation
Does Not Affect Structures
(3) Biological
Entry Modes
•
•
•
•
Inhalation
Ingestion
Injection
Absorption
(3) Biological
Bioterrorism agents
Category 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 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 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 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 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 agents
• Emerging infectious diseases such
as Nipah virus and hantavirus
(4) Radiological
Definitions
Chemical
Biological
Radiological
Nuclear
Public Health role
(4) Radiological
What Is Radiation?
Radio/TV
Sun
Nuclear
Heat
Light
Microwave
(4) Radiological
Electromagnetic Spectrum
Increasing Energy and Frequency
Radio/TV
Microwave
Electrical Power
X-ray
Light
UV
NON-IONIZING
RADIATION
Increasing Harm
Gamma
IONIZING
RADIATION
Health Effects of Radiation
Exposure
(4) Radiological
• Lethal at high doses
• Mutagenic
• Carcinogenic
• Other biological effects,
especially at high doses
(4) Radiological
Decrease Radiation Effects
Time: Decrease time spent near the
radioactive source
Distance: Increase distance between
you and the source
Shielding: Increase the physical
shielding between you and the source
(4) Radiological
Common Shelters
Structure
Wood Frame (1st floor)
Wood Frame (Basement)
Masonry
Large building
Dose Reduction
Factors
10%
40%
40%
80%
From the Environmental Protection Agency’s Manual of Protective Action Guides and
Protective Actions for Nuclear Incidents, Appendix C
(4) Radiological
Potential 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 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 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 Around the World
Recovered
transport container
Sources used in mobile cesium
irradiators in the former Soviet Union
Photos courtesy of the International
Atomic Energy Agency (IAEA)
(4) Radiological
Goiânia Radiological Release
Obsolete
radiotherapy
machine
Abandoned cancer clinic
Photos courtesy of the International
Atomic Energy Agency (IAEA)
(4) Radiological
Goiânia 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?
(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!
Categorisation determines risk to
others and can identify specific
therapeutic steps to be taken
Dose determines severity, treatment plan
and prognosis
(5) Nuclear
Definitions
Chemical
Biological
Radiological
Nuclear
Public Health role
(5) Nuclear
Key Issues in Nuclear Event
• Same concerns as radiation event
• Added concerns of mass trauma and
major system disruption
So what have we learned so far?
CBRN comparison
Biologic
Onset
Slow
Nuclear/ Radn
Chemical
Rapid
Rapid
Transmission Slow, Agent
/ infectivity
dependant
Particulate only,
Fast
Fast, Agent
dependant
Detection
Difficult
Easier
Easier
Resource
consumption
Gradual, long
term
Rapid, short and Rapid, short
long term
term
Some long term
Public Health Short & long
involvement
term
Short & long
term
Short term
Bed use
Mixed
Hospital
Hospital
Decon.
requirements
Agent
dependant
Critical for
particulate
Critical for all
Antidote
Agent
dependant
None
Class
dependant
(5) Public Health
Definitions
Chemical
Biological
Radiological
Nuclear
Public Health role
(5) Public Health
Public Health Role
• Early Detection
• Mass Patient Care
• Mass Immunization/Prophylaxis
• Epidemiologic investigation
• Communication
• Command and Control
(5) Public Health
Public Health Role (2)
• Mass Fatality Management
• Evacuations/sheltering (humans
and animals)
• Environmental Surety
• Community Recovery (rapid health
risk assessment, mental health etc)
Questions ???