Planning for Wide Area Radiological Emergency Response What

Planning for Wide Area Radiological Emergency Response What South Carolina Can Learn From Fukushima

Wide Area Radiological Preparedness Framework • Assumption: an event has contaminated a metropolitan center or a large (tens to hundreds of square miles) area with long-lived radioactive isotopes requiring the evacuation and displacement of a large population for months to years. • What are the public health consequences? • How can the medical/public health community respond?

Rad Resilient City: A Preparedness Checklist for Cities to Diminish Lives Lost from Radiation after a Nuclear Terrorist Attack

Topographic map of the surveyed area including Fukushima and its adjacent prefectures; contour maps of depositions for 131 I, 129 m. Te, and 134, 136, 137 Cs; and activity ratios for 129 m. Te/137 Cs, 131 I/137 Cs, and 129 m. Te/131 I. * As of April 1, 2012, 87, 000 residents still subject to evacuation orders; 47, 000 more residents voluntarily evacuated. Kinoshita N et al. PNAS 2011; 108: 19526 -19529 © 2011 by National Academy of Sciences

Oconee NS – three reactors Catawba NS – two reactors HB Robinson NS – one reactor VC Summer NS – one reactor Plant Vogtle – two reactors under construction – six more

Existing plans for response to releases from Fixed Nuclear Facilities (FNFs) • Evacuation of up to ten miles from plants, depending on wind and weather • Sheltering • Controls on food crops, dairy production out to fifty miles • Exposure limits • Distribution of potassium iodide

Potassium Iodide • What is KI? • Potassium iodide (also called KI) is a salt of stable (not radioactive) iodine. Stable iodine is an important element needed by the body to make thyroid hormones. Most of the stable iodine in our bodies comes from the food we eat. • http: //www. bt. cdc. gov/radiation/ki. asp

Potassium Iodide • What does KI do? • Following a radiological or nuclear event, radioactive iodine may be released into the air and then be breathed into the lungs. Radioactive iodine may also contaminate the local food supply and be ingested through food or through drink. • In the case of internal contamination with radioactive iodine, the thyroid gland quickly absorbs it. Radioactive iodine absorbed by the thyroid can then result in thyroid disfunction or cancer. Non-radioactive KI acts to block radioactive iodine from uptake into the thyroid gland, thus protecting the thyroid from injury.

Potassium Iodide • What KI cannot do: – KI cannot prevent radioactive iodine from entering the body. – KI cannot reverse the health effects caused by radioactive iodine once damage to the thyroid has occurred. – KI cannot protect the body from radioactive elements other than radioactive iodine—if radioactive iodine is not present, taking KI is not protective. – KI cannot protect other organ systems

Annex 6 to SCORERP • Prepositioned stocks of KI – In county health departments serving populations within 10 miles of nuclear plant – Stocks for institutionalized individuals and emergency workers – KI has been distributed by the utilities to households within the 10 mile Emergency Planning Zones

Oconee NS – three reactors Catawba NS – two reactors HB Robinson NS – one reactor VC Summer NS – one reactor Plant Vogtle – two reactors under construction – six more

• Types of radiation – Gamma • Similar to x-rays • Penetrates deeply – Beta (electrons) • Penetrates millimeters – dermal or epithelial exposure – Alpha • Least penetrating, but alpha emitters tend to concentrate in organs, bones • Not usually a factor in FNF exercises, but could have been a factor at Fukushima I-131 emits beta radiation.

• Radiation units – Curies or Becquerels: disintegrations per second – Roentgen: radiation absorbed in air, measured by ionization – rads or Grays: Radiation absorbed dose – rem (Roentgen Equivalent Man) or Sievert: Effective dose, Equivalent dose, Dose Equivalent Very roughly speaking: One rad, one rem, one centi. Gray, and 10 milli. Sieverts have the same physiological effect.

• Half life – Each radioactive isotope has a characteristic half life: the length of time it takes for half of the original amount to decay – Rule of thumb: after 10 half lives have passed, the amount remaining is one millionth of the original amount – I-131 has an eight day half life – The half life of the contamination is an issue primarily for recovery and reentry.

• Dose Response – Response to exposure to ionizing radiation depends on many factors including: • Energy deposition (alphas most strongly absorbed, followed (roughly) by neutron, beta, gamma) • Organ(s) absorbing the dose • Rate of deposition • Age at exposure

• Acute vs stochastic effects – High dose delivered quickly may cause observable effects: nausea, vomiting, hematologic changes, etc – Lower dose exceeding regulatory limits probably will not cause observable acute effects but may cause cancer – Radiogenic cancers are indistinguishable from other cancers

• Risk vs Dose Response – Difficult to extrapolate risk estimates derived from data on relatively high acute exposures in case of the Japanese atomic bomb survivors Life Span Study (LSS) cohort to low dose, or chronic exposure situations – there is inadequate statistical power to quantify risk below about 0. 1 Gy [10 rem]. This is about 100 times the annual whole-body, low. LET dose to an average individual from natural background. EPA Radiogenic Cancer Risk Models and Projections for the U. S. Population (EPA 402 -R 11 -001, April 2011), pp. 3 -4

• In a lifetime, approximately 42 of 100 people will be diagnosed with cancer from causes unrelated to radiation. The calculations in the BEIR VII report* suggest approximately one cancer in 100 people could result from a single exposure of 100 m. Sv [10 rem] of low linear energy transfer (low-LET) radiation. • Adapted from *Biological Effects of Ionizing Radiation VII: Health Risks from Exposure to Low Levels of Ionizing Radiation, (The National Academies, 2005)

• Medical Management of Individuals Exposed to Ionizing Radiation: A Layman’s Summary – Treat the physical injuries first – Slightly exposed individuals may need psychological support but any medical effects will be stochastic and years down the road – Highly exposed individuals are expectant but may benefit from palliative care – Patients in between may benefit from supportive treatment, chelating agents, treatment for neutropenia; highly resourceintensive

Wide Area Radiological Preparedness Framework • Assumption: Because major emergencies are infrequent, specific models or tools designed in advance will likely be out of date and inappropriate when needed; therefore, this Framework describes a general methodology to be applied for prioritization purposes. • “No plan of operations extends with any certainty beyond the first contact with the main hostile force. ” Von Moltke, “On Strategy”

Japanese Experience September 30, 2011 TOKYO — Despite continued fears over radiation levels, Japan lifted evacuation advisories for an area spanning five towns and cities around a tsunami-ravaged nuclear power plant on Friday, the first such move since multiple fuel meltdowns at the site led to a substantial radiation leak and forced more than 100, 000 surrounding residents to flee. … A 12 -mile exclusion zone will remain in place around the nuclear power plant, Fukushima Daiichi, which the government is working to bring under control. The worst contaminated areas close to the plant are likely to remain uninhabitable for decades, government officials have acknowledged. New York Times

Japanese Experience The Yomiuri Shimbun Since the start of the crisis at Tokyo Electric Power Co. 's fukushima No. 1 nuclear power plant, hundreds of doctors and nurses have resigned from nearby facilities, according to a survey by an association of Fukushima Prefecture hospitals. Their departures have resulted in some hospitals in the prefecture suspending nighttime emergency care and other treatment services, the association said. Daily Yomiuri Online, Oct 4, 2011 http: //www. yomiuri. co. jp/dy/national/T 111003004497. htm

Japanese Experience Via The Daily Yomiuri: Fleeing crisis takes deadly toll on elderly / 77 Fukushima evacuees died within 3 months. Excerpt: Nearly 80 elderly people who were evacuated from nursing homes near the Fukushima No. 1 nuclear power plant died within three months of the accidents at the plant that forced them to move, according to a Yomiuri Shimbun survey. The 77 deaths are more than triple the 25 recorded at the nursing homes during the corresponding period last year. Officials at the homes believe many of this year's deaths resulted from a decline in physical strength caused by moving far from the nursing homes and living in an unfamiliar environment. Many of the people who died had struggled to adapt to their new living conditions, the officials said. Daily Yomiuri Online, July 3, 2011

Japanese Experience The Yomiuri Shimbun FUKUSHIMA--More than 70 percent of households from Narahamachi, Fukushima Prefecture, say their health has deteriorated during their time as evacuees, according to a recent survey by the Narahamachi municipal government. … Asked why they did not go or had stopped going to a hospital, 40. 7 percent said their usual doctor did not practice near their current residences, followed by 21. 4 percent of households who had no hospitals or clinics near their current residences. Daily Yomiuri Online, October 2, 2011

Japanese Experience Fukushima City began its first decontamination of private properties on Tuesday, seven months after the worst atomic accident since Chernobyl spread radioactive materials over eastern Japan. The first such organised cleanup of peoples' homes by an affected municipality follows work by various communities in northeast Japan to decontaminate public areas such as schools, parks and daycare centres. … The government has sought to calm public fears and overcome mistrust of official radiation surveys, claiming that areas away from the immediate vicinities of the wrecked plant should be safe. But concerned citizens armed with their own measuring tools have been finding small localised 'hot spots' with high radiation levels. … The accident has discouraged consumers from buying farm produce from Fukushima and surrounding regions, following reported cases of contaminated water, beef, vegetables, tea and seafood. http: //wap. news. bigpond. com/articles/Travel/2011/10/19/Fukushima_city_beg ins_decontamination. html

Japanese Experience ONAMI, Japan — In the fall, as this valley’s rice paddies ripened into a carpet of gold, inspectors came to check for radioactive contamination. Onami sits just 35 miles northwest of the wrecked Fukushima Daiichi nuclear plant, which spewed radioactive cesium over much of this rural region last March. However, the government inspectors declared Onami’s rice safe for consumption after testing just two of its 154 rice farms. Then, a few days later, a skeptical farmer in Onami, who wanted to be sure his rice was safe for a visiting grandson, had his crop tested, only to find it contained levels of cesium that exceeded the government’s safety limit. In the weeks that followed, more than a dozen other farmers also found unsafe levels of cesium. An ensuing panic forced the Japanese government to intervene, with promises to test more than 25, 000 rice farms in eastern Fukushima Prefecture, where the plant is located. New York Times

Japanese Experience (continued) More than a dozen radiation-testing stations, mostly operated by volunteers, have appeared across Fukushima and as far south as Tokyo, 150 miles from the plant, aiming to offer radiation monitoring that is more stringent and transparent than that of the government. “No one trusts the national government’s safety standards, ” said Ichio Muto, 59, who farms organic mushrooms in Nihonmatsu, 25 miles northwest of the Fukushima Daiichi plant. “The only way to win back customers is to tell them everything, so they can decide for themselves what to buy. ” New York Times, Jan 22, 2012

Psychological impact “Although radiation escaping from a nuclear power plant catastrophe can increase the risk of many cancers and other health problems, stress, anxiety and fear ended up in many ways being much greater long-term threats to health and well-being after Chernobyl, Three Mile Island other nuclear accidents, experts said Monday. “ ’The psychological effects were the biggest health effects of all — by far, ’ said Fred Mettler, a University of New Mexico professor emeritus and one of the world’s leading authorities on radiation, who studied Chernobyl for the World Health Organization. ‘In the end, that’s really what affected the most people. ’ “ Washington Post, early March, 2011

Liberty Rad. Ex (LRE) demonstrated the importance of community recovery and mass care planning for RDD and for WMD generally. … Shortage of Radiological Expertise: LRE demonstrated that EPA does not have enough professional radiological staff for long‐term deployment for RDD and IND. Other agencies and exercises have identified a similar shortage across the Federal Government. EPA and other federal agencies will need to share and optimize use of radiological expertise in the event of a RDD or IND. Consideration should be given to whether industry, university, and state resources (in unaffected states) can be tapped.

Wide Area Radiological Preparedness Framework Assumptions • Response to a wide-area radiological emergency will require coordinated responses from all levels of government and the private sector. • Many activities during the course of response and recovery will have to be delegated or conducted on a volunteer, selfhelp basis

Wide Area Radiological Preparedness Framework • Assumption: Participation by volunteer organizations, non-governmental organizations, private enterprises, public and private educational institutions, and citizens will be required to arrive at consensus decisions on many issues: – – contamination limits; clean-up standards; disposal options for contaminated materials; recovery and reuse or replacement of contaminated facilities; – radiation protection standards for reentry and reoccupation of contaminated areas;

Wide Area Radiological Preparedness Framework • “Stakeholders and Radiological Protection: Lessons from Chernobyl 20 Years After, ” Committee on Radiation Protection and Public Health, Nuclear Energy Agency, Organisation for Economic Co-operation and Development

Wide Area Radiological Preparedness Framework Assumptions • Sampling and radiological surveys will be required for the duration of the recovery and restoration phase. Epidemiological surveillance of the impacted population will be required for years. • Response, reentry, recovery, and restoration will take months to years. Response activities will transition from an initial crisis reaction to mid- and long-term activities.

Wide Area Radiological Preparedness Plan • No Victims: An incident the size of an Improvised Nuclear Device detonation does not allow for the luxury of narrowly defined responders who rescue victims. Rather, everyone alive is a survivor who must support other survivors and the nation in response. The public, private sector, and even the injured can play important roles in reducing the burden on traditional response organizations by using actionable information to guide behavior while supporting a whole community response. Key Planning Factors: Response to an IND in the National Capitol Region

Wide Area Radiological Preparedness Framework • Organization And Responsibilities – Local, State, and Federal Agencies – Volunteer, Nongovernmental, Private Sector, and Citizen Groups • Pre-event Planning • Post-event Planning and Operation

Wide Area Radiological Preparedness Framework • Concept of Operations – Short-term (hours to days) • • • Discovery of Radiological Event First Response: Tasks and Goals Initial Identification of Contaminated Zone Protective Action Recommendations Radiological Survey of Exposed Population – – Use of Volunteers Post-evacuation Radiological Surveys • Decontamination of Persons and Vehicles (Initial) – SCORERP Guidance – Exception to SCORERP

Wide Area Radiological Preparedness Framework • Concept of Operations – Short-term (hours to days) (continued) • Triage and Medical Treatment – – Triage Health Care Delivery • Sheltering – – – Shelter In Place Pre-designated Shelters Expanded Shelter Network • Risk and Health Hazard Communication – – – Preplanned Communication Networks Ad hoc Communication Networks Information and Protective Action messages

Wide Area Radiological Preparedness Framework • Concept of Operations – Intermediate Period (days to weeks) • Lessons Learned from Fukushima – Need for transparency, best available information – Need for practical just-in-time training – Radiological screening and surveys are long-term – Regulatory limits may be impractical – Regulatory limits and official approval may be ignored • Health Care Facilities – Limited Resources – Need for Training – Medical staff: Use of Volunteers; Displaced staff

Wide Area Radiological Preparedness Framework • Concept of Operations – Recovery Period (weeks to years) • Convening community-based groups to agree on restoration goals and criteria • Identifying and prioritizing critical infrastructure for restoration or replacement • Risk-Based Remediation Decisions • Contamination Surveys • Risk Estimates • Risk Communication • Environmental Clearance Committee • Environmental Clearance Sampling Strategies • Environmental Clearance: Pre-Incident Planning • Health Care: Long Term Medical Monitoring • Repopulate through Public Reassurance and Incentives • Health Care: Insurance and Medical Records • Health Care: Accommodating Displaced Medical Professionals

Wide Area Radiological Preparedness Framework • Some of the questions to be addressed include: • If decontamination capabilities are overwhelmed, what standards will we use and who will determine them? • How do we set priorities for decontaminating and recovering critical facilities?

Wide Area Radiological Preparedness Framework • If facilities begin receiving contaminated individuals before radiological controls have been established, what procedures should be in place? Existing plans assume evacuees will be monitored and decontaminated before proceeding to reception centers and treatment facilities; if this is not possible, how do we respond? • What training should we provide staff for dealing with possibly contaminated patients and for working in contaminated areas?

Wide Area Radiological Preparedness Framework • How can we compensate for the loss of use of health care facilities? • How can we accommodate displaced medical professionals at other facilities? • How can we incorporate volunteers into the response organization?

Wide Area Radiological Preparedness Framework • Draft Annex 5 to the Mass Casualty Plan • Plan for the first 72 hours, recognizing that complete response will require months/years

Planning for Wide Area Radiological Emergency Response: What South Carolina Can Learn From Fukushima • Questions? Sam Finklea finklesl@dhec. sc. gov (803)898 -3734