Introduction 

The purpose of this playbook is to provide guidance for executive decision makers within the Department of Health and Human Services (HHS) in the event of an actual radiological terrorist attack in a U.S. city. Specifically, it outlines key measures and options to aid the Secretary in making essential decisions and directing the HHS response to a radiological attack.

The playbook functions as a resource document to the Assistant Secretary for Preparedness and Response (ASPR) to assist in coordinating the Department’s Emergency Support Function (ESF #8) with other Federal and local emergency support agencies. It is not intended to serve as an instruction manual for implementing the ESF #8 missions at the operational or tactical level; rather, it illustrates the capabilities required to meet probable mission requirements.

This playbook is a living document that must be updated periodically to reflect evolving processes and policy decisions including changes resulting from interagency plans or policies. ASPR is responsible for managing this process of bringing the playbooks up to date.

Radiological Dispersal Device Playbook Overview

The playbook is based on the chronology of events outlined in the Radiological Attack scenario of the National Planning Scenarios (Scenario #11). The following phases drive the actions outlined in this playbook:

• Phase 0: – Pre-Incident (Situational Awareness, Credible Intelligence). Steady state operations and advance preparations are initiated for a large-scale response to a radiological attack, based upon credible intelligence of a plan to detonate a Radiological Dispersal Device (RDD) or a Radiological Explosive Device (RED) in a U.S. City. The primary strategy is to closely monitor events and begin advance preparations for an effective and timely response.
• Phase I: – Early Phase (0 – 24 Hours Post Detonation). The primary U.S. strategy is to assess the events and deploy assets to maximize survivors, treat injured victims, and aggressively administer an effective post-exposure prophylaxis program
• Phase II: – Intermediate Phase (24 – 72 Hours Post Detonation). The strategy is to provide surge capacity and rapidly deploy ESF #8 assets to provide assistance to State, Territorial, Tribal, or local officials in saving lives, minimizing adverse health effects, stabilizing public health, medical and human services infrastructure.
• Phase III: – Late Phase (72 Hours – 2 Weeks Post Detonation). The goal of this phase is to effect a smooth and transparent transition to long-term recovery while continuing to provide technical expertise to regional, state and local authorities as they rebuild their public health and medical infrastructure.

This Radiological Attack Playbook is prepared in accordance with the National Response Framework (NRF) and associated Federal regulating documents. There are six major sections to this Playbook including (A) introduction, (B) scenario; (C) concept of operations (CONOPs); (D) actions/issues; (E) pre-scripted mission assignments, and (F) essential elements of information (EEIs). These sections are briefly discussed below.  At the end of the playbook, a list of acronyms used and their definitions is provided

• Introduction: The introduction briefly addresses the purpose of the playbook and how it is structured. This section also provides an overview of radiological dispersal devices and radiological explosive devices providing relevant information for preparedness and response operations. In addition, it covers some technical discussions which may be of interest primarily to subject matter experts.
• Scenario: The Homeland Security Staff Council (HSC) (now National Security Staff-(NSS)) –in concert with the Department of Homeland Security (DHS) the federal interagency, and State and local homeland security agencies– has developed fifteen all-hazards planning scenarios for use in National. Federal, State and local homeland security preparedness activities. These scenarios are designed to be the foundational structure for the development of coordinated national preparedness standards from which homeland security capabilities can be measured or assessed, The Radiological Attack scenario is an account or synopsis of a projected event. This scenario is used in policy planning within the Department of Health and Human Services (HHS) in an effort to set the conditions for conventional thought on how the department would approach, plan for, and possibly test strategies against uncertain future developments. The radiological attack scenario alerts us to different ways that future events could unfold. This scenario should not be used to forecast future events, but rather, it offers a plausible story line to account for possible future events leading toward a radiological attack as depicted in National Planning Scenario #11. The decision to use the HSC scenarios in the development of the playbooks provides a common set of conditions that provide interoperability with Federal, State and local emergency responders. It also allows HHS to work closely with our interagency partners through the National Response Framework (NRF) and the National Incident Management System (NIMS) to ensure efficiency and interoperability in responding to radiological incidents.
• Concept of Operations (CONOPs): This CONOPs evolves from a vision of actions and events and is a description of how a set of capabilities may be employed to achieve desired objectives or a particular end state for the radiological attack scenario. CONOPs take into account the steps and procedures that may be found in State, local, and Federal response plans to a radiological attack. The approaches incorporate the synchronized activities and capabilities under consideration and add the resource management details of whom, and where resources may be applied to achieve desired mitigating outcomes. The CONOPs do not describe how to conduct preparedness activities but merely serve as a discussion point for Federal, State, local, tribal, regional and territorial, planners to use as a baseline for a coordinated preparedness effort.
• Actions/Issues: This section refers to the steps associated with each phase of the event, further segmented by functional activity, including:
  • Planning and Coordination
  • Healthcare, Emergency Response and Human Services
  • Surveillance, Investigation, and Protective Health Measures
  • Pharmaceuticals, Medical Supplies and Equipment
  • Patient Evacuations, and
  • Communications and Outreach
• The actions/issues are the heart of this document and outline the steps necessary to achieve interagency coordination effects for the Radiological Dispersal Device Playbook. They also assign lead and supporting government agency responsibilities.
• Pre-Scripted Mission Assignments (PSMA) for ESF #8: PSMAs are defined as coordinated critical tasks that must be performed with or by other departments and/or agencies in the federal government. Representative departments and agencies are supporting entities within ESF #8. Federal supporting agencies include: the Departments of Agriculture, Energy, Homeland Security, Interior, Justice, Labor, State, Transportation, Veterans Affairs, and other agencies including Environmental Protection Agency, General Services Administration, and U.S. Agency for International Development, U.S. Postal Service, and the American Red Cross.
• Essential Elements of Information (EEIs): EEIs are those critical items of information needed to respond appropriately to circumstances surrounding the event. EEIs provide decision makers at all levels insight into how and where resources should be applied to achieve maximum benefit for the general population in easing suffering or protecting infrastructure. In this playbook, information requirements are derived as they relate to the preparedness and response activities for a radiological dispersal device attack.

Overview of Radiological Attack Devices

This playbook is based on the chronology of events in the National Planning Scenarios (Scenario #11) Radiological Attack - Radiological Dispersal Device. Since the emergency response has generic (triage, beds, medicines, transportation) and specific components (radionuclide specific response) some of the supporting details are useful but not essential for general operations personnel. They are more practical for Subject Matter Experts and other educational purposes.

Information in a gray box contains non-essential supporting information and may be bypassed when using the playbook.

Essential Facts

The widespread availability of radioactive material for industrial and medical use provides a broad range of scenarios for the abuse and subsequent exposure of civilian populations to radioactive material in potential terrorist events. The types of event can be:

• RDD- Radiological Dispersal Device can be of two general types. In both, radioactive material is dispersed into the environment.
  • Dispersal of radioactive material via explosive detonation, i.e., a combination of an Improvised Explosive Device (IED) and radioactive material
  • Dispersal of radioactive material via non-explosive means, e.g., in food, water, soil, or air, etc.
• RED- Radiological Exposure Device refers to a sealed radioactive source that is placed in a public place and causes exposure but not contamination to those in proximity. (Note: if an RED were to break open, it would then be similar to an RDD)

Exposure versus Contamination:

Matter that contains radiation-emitting atoms is radioactive material. Radiation is the energy released from radioactive material. It is critical to understand the difference between (a) exposure to radiation and (b) contamination with radiation. The medical effects and countermeasures differ significantly.

• Radiation exposure (or irradiation) occurs when radiation penetrates tissue, for example, when a patient undergoes a diagnostic X-ray. A person can be irradiated without physically contacting radioactive material. Exposure results from radiation external to the victim, and the victim is NOT radioactive. This radiation can be in the air or on the ground (groundshine). Internalized radiation can cause exposure.
• Radioactive contamination is radioactive material located in unintended places. Note: An exposed person is not necessarily contaminated because exposure does not require contact with radioactive material. However, as long as a person remains contaminated they will continue to be exposed to the radiation being emitted by the radioactive material with which they are contaminated. Contamination can be external (outside of the body) or internal (inside of the body) or both.
  • External contamination is radioactive material on a person’s clothes, hair, or skin.
  • Internal contamination is radioactive material that has entered the body by inhalation, ingestion, or absorption through the skin or wounds.

Decontamination

• External decontamination: This is often readily accomplished by removing the person's clothing and shoes and washing the skin and hair with soap and water.
• Internal decontamination: Normal body-cleansing mechanisms (e.g., digestion and excretion) can often partially remove internal contamination. When medically indicated, decorporation agents, such as laxatives or chelating compounds, are administered to speed up excretion of internal contamination. Similarly, blocking agents can be used to inhibit uptake of some radioactive materials. Knowledge of the chemical nature of the contaminant is essential in making initial treatment decisions.

Matter that contains radiation-emitting atoms is radioactive material. Radiation is the energy released from radioactive material.

Properties of the radiation

Two properties of atoms are considered when determining how radiation affects people:

• Element itself (e.g. Cobalt, Cesium, Iridium, Iodine, Strontium) determines the chemical properties and biological distribution in the body.
• The isotope of an element determines the amount and type of radiation emitted. (Radionuclide and radioisotope, used interchangeably and refer to an unstable form of an element that decays resulting in the emission of radiation).

The selection of a medical countermeasure (e.g. decorporation, blocking agent, diuresis) is based on the element and its properties (e.g., Iodine vs. Cesium), the type and amount of radiation exposure received by an individual (alpha, beta, gamma, neutron), and the specific isotope (e.g., Iodine-131 vs. Iodine-125) and how much was encountered.

Clinical presentation and injury:

• Explosive RDD. Depending of the size of the explosion, an RDD detonation could generate a modest number of patients with physical trauma, thermal burns, contamination, and (in rare cases) radiation injury. These combined injuries (radiation injury plus trauma) range from mild to severe/fatal. In this instance, the incident will be detected by physical detection devices.
• Non-explosive RDD. A non-explosive RDD (e.g. contamination of food or water, aerial dispersal, dispersal in a ventilation system), can potentially expose a modest number of people to moderate doses of radiation and many people to low doses of radiation. The event may be obvious in real time or may be subtle becoming recognized over time. In this instance, the incident can be detected by physical detection devices or by an astute clinician who recognizes the syndromes related to radiation injury. For low exposure (less than ~100 centiGrays (cGy) whole body dose) particularly with protracted exposure, there may be few telltale symptoms to suggest radiation injury.
• RED. An RED incident may be realized by direct discovery of an RED or by clinical recognition of an incident due to a number of people presenting at an Emergency Department, (not discovering the device per se), developing symptoms, and signs of radiation injury. As long as the radiation source remains closed and sealed, there will NOT be any contamination.

Psychological consequences:

• For both a non-explosive RDD and an RED, many people may present for medical care out of fear of possible exposure, far greater than those actually affected. Both the psychological impact of these events and the economic factors related to a contaminated environment can be substantial and long lasting. Those who are neither exposed nor contaminated may require reassurance. Responders, too, can have profound psychological effects from participating in the response to an incident and will need assistance.

Radiation Event Medical Management (REMM):

• Radiation Event Medical Management (REMM) is a web portal developed to assist health care providers to respond to mass casualty radiation events. It is collaboration between HHS/ASPR and the National Library of Medicine and contains just-in-time response algorithms, detailed event management information, and large amounts of supporting information explaining radiation and response, training and planning issues. A zip file with almost all the REMM files can be downloaded to a PC or to a PDA. Users are encouraged to join the REMM ListServ to be notified when updates are released. It can be used either online of offline. A ZIP file with almost all the REMM files can be downloaded to a personal computer or to a PDA device. Users are encouraged to join the REMM ListServ to be notified when new versions of REMM are released

Table A1. Overview of Radiation Events
RDD - Explosive IED, etc.	RDD Non-Explosive: Air, Food, Water, Soil	RED - Exposure
Immediately recognizable as "an explosive event". Radiation might not be detected immediately. Health physicists must map radiation levels in contaminated area to assess safety and determine allowable response time in various zones due to radiation. Casualties from explosion are immediate. No immediate deaths expected from radiation, but victim decontamination is essential.	Time for initial release may not be known. Can produce mass casualties by inhalation of contamination in ventilation or ingestion of food/water or products from soil. Radiation dose can cause death in some scenarios. Health physics measurements are critical in environment and probably in people. May require broad interdiction of food, water until details sorted out.	Time of initial exposure may not be known. There can be exposure but no contamination (unless the source is broken). Risk of mass casualty low. Likely only partial body dose, so radiation-related death would be low. Maybe difficult or impossible to sort out who was exposed to low doses.
Long term monitoring maybe required for victims and responders

Assessing an RDD Attack

As a weapon, an RDD or RED (AKA “Dirty Bomb”) is considered as follows:

• Not a nuclear weapon
• Not a weapon of mass destruction
• A weapon of mass disruption, economic weapon, psychological weapon
• Impact depends on type of explosive, amount and type of radioactive material, and weather conditions
  Source: The Armed Forces Radiobiology Research Institute

Initial Steps: Determining the Type of Incident

• Is this a radiological event? It takes health physicists (includes other radiation protection specialists) to detect radionuclide, interpret data from radiation monitors, determine exposure rate, initially and over time, and help manage safety issues of the response to the event on site.
• Is there exposure? Is there radioactive contamination? Is radioactive material free in the environment from the explosion or dispersal?
  • If there is environmental contamination, highly contaminated areas will have to be cordoned. If there has been population contamination, decontamination of victims will be required for their safety and to prevent contamination of transportation, medical facilities, individuals or the environment. Life-threatening injury must be treated before decontamination. Removal of outer garments, showering and superficial decontamination removes about 90% of the external contamination.
• Is there internal contamination? If patients have ingested or inhaled radioactive material, or taken that material into their body through a wound or other means, they could be internally contaminated.
  • Special medications (e.g. decorporation and blocking agents) may be needed for those who have internalized radionuclide in sufficient quantity.
  • Subject matter experts will provide recommendations for which medications will be needed based on the identified radionuclides. Some of these medications are available in the Strategic National Stockpile, some are in state/local stockpiles, and others would need to be obtained through commercial sources.
  • Both exposure and contamination will likely happen to those very near the center of an explosive RDD. Further away, victims will likely have less intense contamination and consequently a lower exposure rate.

What Is The Size Of The Event?

• Number of Casualties. The number of casualties is very scenario dependent (nature of explosive, amount and type of radioactive material dispersed, location of the event, number of individuals affected, weather, etc.).
  • Serious injuries are likely to be in the hundreds; victims requiring decontamination and medical care may be in the thousands.
  • Victims requiring treatment for acute radiation syndrome (ARS) are likely in the hundreds at most. Most RDD events will have few severe ARS victims.
  • Individuals in need of counseling or consultation may be in tens of thousands, including responders.

Radiation doses

Unlike an IND event, an explosive RDD event produces no nuclear explosion or huge burst of radiation.

• Radiation dose is cumulative. The radiation dose from an explosive RDD can accumulate over time and the radiation injury depends on the duration and amount of exposure or contamination. The dose from an RED depends on the radionuclide used and how long any individual was near the radionuclide. “Committed dose” (term used to evaluate effects of the radiation) is a calculation of the dose an individual will receive over their lifetime from internal contamination. It is calculated from the knowledge of the radionuclide and from the amount a person has within them.
• Acute Radiation Syndrome (ARS) with nausea and vomiting can occur with doses above 0.75 Gray (Gy). However, clinically significant ARS requiring medical countermeasures for the hematological syndrome is unlikely unless victims absorb a cumulative whole body dose above 2 or 3 Gy (200 – 300 rem or higher).  (rem is a radiation unit of measure and stands for "Roentgen Equivalent Man". While not precise, Roengten/hr and rem/hr are often used interchangeably.)
  
  • Permitted dose for responders is determined by the lifetime potential risk of radiation-induced cancer. Doses above 5 rem (5,000 mrem), but especially above 25 rem (25,000 mrem) would be of concern. At a dose rate of 1,000 mrem/hr, it would take a responder 5 hours to reach 5,000 mrem (or 5 rem).
• Concentric radiation “response zones”: will be created at the scene based on the dose rates measured at the scene. The dose rates measured will define the time people can spend in a particular location. Over time the dose rates will diminish and the perimeters of the zones will change. Weather conditions and ground topography also affect the shape and location of the zones.

Radiation Response Zones

Radiation “response zones” Determination

• Radiation “response zones” will be determined based on both data modeling and measured data by health physicists or other radiation protection experts (Military/Civil Support Teams, Interagency Advisory Team for Environment, Food and Health (A-Team) and possibly Radiation Emergency Assistance Center & Training Site (REAC/TS, in Oak Ridge, TN), and the Armed Forces Radiobiology Research Institute (AFRRI, at USUHS in Bethesda, MD)
• The "HOT" zone: perimeter at 5 rem or greater per 5 hrs (or 25 rem cumulative)
• The boundary line for the “no entry zone” will likely be about 100 meters for a small to intermediate sized device and up to 600 meters for a very large device (Harper 2007). Evacuation is recommended around 150 m and 1-15 km from the epicenter of detonation for these devices respectively.
• In the absence of real time measured radiation data, a zone of approximately 500 meters is a reasonable first estimate but this will be rapidly refined as measurements are obtained.
• Zone perimeters will change over time as the plume and footprint evolve. For most RDDs, the plume passage will last 20-30 minutes. Continuing on-scene measurements will be essential.
• The National Council on Radiation Protection (NCRP, Commentary 19) has made recommendations similar to those in Figure A1:
• The Inner Perimeter is 10 R/hr (similar to 10 rem/hr or 10,000 mrem/hr). (Note: “R/hr” means Roetgens/hour.)
• The Outer Perimeter is 10 mR/hr (similar to 10 mrem/hr)
• Boundaries of exclusion and short term activity are determined by local authorities, often with Federal advice. Boundaries will be refined as data are received and conditions evolve.
• Interagency Modeling and Atmospheric Assessment Center (IMAAC) models which account for event type and wind and weather data will be useful in creating response zones, but dose rate cannot be fully predicted because wind current and patterns are very complex, especially with the urban canyon effects. On ground measurements will be more accurate than modeling data.
• Illustration of prototypical “response zones” are in Figure A1 and described in Table A2 below.

Figure A1. Example of “boundary zones" (Conference of Radiation Control Program Directors)
Figure A1 shows typical radiation zones (outlined in Table A2) and illustrates how boundaries could be established and how the allowed “work time in a zone” can be estimated. Concentric radiation “response zones” will be based on the dose rates measured at the scene. (The shape and location of the zones is a result of weather conditions and ground topography). The dose rates measured will define the time people can spend in a particular location. Permitted dose for responders is 5 rem. Doses above 5 rem (especially above 25 rem) are cause for concern. The Extreme Caution Boundary is the innermost perimeter which measures 10 rem/hr; the 5 rem limit is reached after 0.5 hours (and 25 rems within 2.5 hours) It is considered a “no entry zone”, restricted to very short-term life saving activities only. The figure shows the successive radiation zoning from High Radiation Boundary (the “Inner Zone” at 1 rem to Medium Radiation Boundary (the “Buffer Zone”) measuring 0.1 rem to Low Radiation Boundary (the “Outer Zone”) at 0.01 rem where initial decontamination may take place. The Incident Command Center (marked ê) is located outside the radiation zone. .Note that over time the dose rates measured will diminish and the perimeters will change.

Table A2 How Radiation Zones could be determined - One Example (Conference of Radiation Control Program Directors)
Extreme Caution Radiation Zone	Extreme Caution Radiation Boundary	≥10,000 mR/hr (10 R/hr)	Activities restricted to saving lives Total accumulated stay time for first 12 hours: minutes to hours.
High Radiation Zone	High Radiation Boundary	1000 mR/hr	Access restricted to authorized personnel performing critical tasks: Firefighting Medical Assistance Rescue Extrication Other time-sensitive activities
Medium Radiation Zone	Medium Radiation Boundary	100 mR/hr	Access restricted to authorized personnel entering the "High Radiation Zone" to perform critical tasks such as saving of lives and property. Serves as a buffer zone/transition area.
Low Radiation Zone	Low Radiation Boundary	≤10 mR/hr	Access restricted to essential individuals. Initial decontamination of first responders should occur near the "outer boundary" (i.e., "Low Radiation Boundary") of this area. Victims with only lower body contamination have a low likelihood of prior radionuclide inhalation and internal contamination, since they were probably exposed walking across the zone and not from the plume.

 

Shelter-in-Place

• Sheltering during the short-lived plume (about 20-30 min) may be beneficial, but evaluation of the incident and public messaging may not occur in time for this to be effective.
• Protection from radiation is also afforded by the building itself, but this is variable.
• Since air handling in some buildings may concentrate radiation, it is not easy to have simple guidelines for shelter-in-place recommendations during and after the plume passes by. Given the short-lived duration of most airborne radionuclides (about 20-30 min), it is not likely that shutting down a building ventilation system will be effective. After the plume has passed, the inside of some buildings may have higher air concentrations than outside, depending on the air system, filtration, etc.
• Evacuation routes from the affected zones need to be planned, with radiological monitoring of victims at exits to see which victims need decontamination and possible treatment.

Decontamination

• For uninjured people, ambulatory decontamination is primarily removal of outer garments and showering. The size of the event will help determine whether ambulatory decontamination will be done primarily in formal decontamination sites or at home. Contaminated garments and personal property require proper disposal for potential forensic evaluation and safety. Removed personal effects and clothes should be bagged, labeled, and kept away from people and animals.
• Injured victims also need decontamination. Some may be transported through decontamination tents on a litter. Decontamination for others will be improvised, understanding that life-saving measures always take precedence over decontamination.
• Victims with only lower body contamination have a low likelihood of prior radionuclide inhalation and internal contamination, since they were probably exposed walking across the zone and not from the plume.

Determining the Radionuclide

Identification of the radionuclide is essential. This information will help determine the possible physical damage from the event, as isotopes can only be “weaponized” in certain ways, based on their physical properties (Harper 2007). In addition, the appropriate medical countermeasure for those who need treatment is generally radionuclide-specific.

• Health physicists/safety officers will determine the radionuclide(s).
• Multiple radionuclides may be used in one event.
• Sampling of the environment using specialized radiation detectors will ordinarily detect the radionuclide(s) involved. Various governmental agencies will do that.
• Laboratory analysis of human samples (nasal swabs, feces, urine), may be necessary to evaluate which victims need treatment and evaluate the efficacy of that treatment. State labs may be used as well as those from CDC and other resources.
• Most likely radionuclides for an RDD or RED event include Cesium chloride, Cobalt, Americium, Iridium, although others may also be used. Multiple agents may be used in a single event (Harper 2007).

Table A3- Examples of radioactive material that might be used for RDD (Armed Forces Radiobiology Research Institute)
Radionuclide	Half-Life	Typical Activity	Use
Cobalt-60	5 years	15,000Ci	Cancer Therapy
Cesium-637	30 years	1.5x106Ci 10mCi	Food Irradiation Medical Source
Iridium-192	74 days	150Ci 1mCi	Industrial Radiograph Medical Source
Plutonium-238	80 years	varies	Satellite Power Source
Strontium-90	29 years	40,000Ci	Radio-Thermal Generator (RTG)
Iodine-131	8 days	0.015Ci	Cancer Therapy
Americium-241	432 years	1.5x10-6Ci	Smoke Detector
Amount of radionuclide is determined by disintegrations per second (Curies, Ci) 1 Ci (Curie) = 3.7 x 1010 disintegrations per second (dps) 1 Ci = 3.7 x 1010 Bq 1 Bq (Becquerel)= 2.7 x 10-11 Ci Physical half life describes the length of time it takes for a radioactive substance to lose one-half of its radioactivity. Biologic half life describes time required for the radioactivity of material taken in by a living organism to be reduced to half its initial value by a combination of biological elimination processes and radioactive decay.

Table A4: Analysis of likely RDD materials (Harper 2007) RDD Types and Effects (10kCi Devices)
Nuclide	Primary Radiation Type (Half Life)	Primary Form	Size of Source for calculation in GBq(Ci)	Application that forms the basis for size of source
90Sr	Beta (28.6y)	Ceramic (SrTiO3)	1.11x107 GBq (300,000 Ci)	Large radioisotopic thermal generator (RTG) (Russian IEhU-1)
137Cs	Beta + Ba -137 m Gamma (30.17y)	Salt (CsCl)	7.4x106 GBq (200,000 Ci)	Irradiator
60Co	Beta, gamma (5.27y)	Metal	1.11x107 GBq (300,000 Ci)	Irradiator
238Pu	Alpha (87.75y)	Ceramic (PuO2)	4.92x106 GBq (300,000 Ci)	RTG used for the Cassini Saturn space probe
241Am	Alpha (432.2y)	Pressed ceramic powder (AmO2)	7.4x102 GBq (20 Ci)	Single well logging source
252Cf	Alpha (2.64y)	Ceramic (Cf2O4)	7.4x102 GBq (20 Ci)	Several neutron radiography or well-logging sources
192Ir	Beta, gamma (74.02d)	Metal	3.7x104 GBq (1,000 Ci)	Multiple industrial radiography units
226Ra	Alpha (1600y)	Salt (RaSO4)	3.7x103 GBq (100 Ci)	Old medical therapy sources

Table A5: Types of RDD’s and their general impact (Armed Forces Radiobiology Research Institute)
Type	Isotope	Physical Form	Dispersal Method	Construct Difficulty	Early Deaths	Psychological Effect	Economic Effect
Radiological Exposure Device	Co-60 Cs-137	Metal, Salt	None	L	Maybe	M	L
Food or Water	Cs-137 Pu-238 Sr-90	Salt Solution	Dissolve	L	Food-Yes Water - No	H	M
Fragment RDD	Co-60 Sr-90 Pu-238	Metal Ceramic	HE	M	No	M/H	M
Non-respirable Aerosol RDD	Cs-137 Co-60 Sr-90 Pu-238	Salt, Metal, Ceramic, Solution	HE Sprayer	M	No	H	H
Respirable Aerosol RDD	Sr-90 Cs-137 Co-60	Sat, Metal, Solution	HE Sprayer	M/H	Maybe	H	H
H,M,L- High, Medium, Low, not otherwise defined

Triage System-Organizing the Medical Response

• Conceptual triage approach (see Figure A2-A3) is similar in concept to that of an IND in that the functions at the RTR, MC and AC sites are similar- described below) (Hrdina publication).
• The size of an RDD is such that it is likely the local/regional responders and medical facilities will be able to take care of the most if not all of the victims. However, large events may require substantial support from regional partners and possibly federal resources.
• Multiple simultaneous or closely spaced events may lead to a situation in which regional Emergency Medical Assistance Compacts (EMAC) may not be honored due to concern for additional events. This would accelerate the need for federal resources
• Nonetheless, whatever the size of a radiological event, a national response will likely be initiated immediately, with resources allocated as needed. (they can stand down if not needed)
• Assets of ESF#8 will be alerted and mobilized, including NDMS and other assets
• Radiation Injury Treatment Network (RITN) will be alerted
• HHS SOC will use GIS system (note: MEDMAP project) to identify medical facilities in the area and region

Figure A2 Conceptual Triage System - RTR Sites (See Figure A3 for definitions)
Figure A2 is a diagram of a conceptual triage system near the affected area. Close to the blast site, around the perimeter of the High Radiation zone or “inner radiation boundary” RTR1 site(s) will be set up for victims from the immediate blast site with major contamination, injuries, and/or trauma. Responders may only dwell for a limited time. RTR2 site(s) will be set up near the “outer radiation zone” where responders’ time will still be carefully monitored. Most ambulatory victims will be assessed, and those with ARS (Acute Radiation Syndrome) may receive immediate care, and others will be directed as appropriate to Evacuation Centers and predetermined Medical care sites (MC) for treatment or Assembly Centers (AC) limited care and transport to nearby facilities and victim tracking. RTR3 sites will be set up outside the outer perimeter and act as collection sites for affected persons leaving the blast area; RTR3 sites will provide paramedic acute care, stabilize victims and direct them as appropriate to MCs, ACs, Evacuation Centers, or transport them to outside facilities.

• The zones will be determined by externally measured dose rates.
• In this Playbook, 1 rem/hour (1000 mrem/hr) is used as the “inner boundary” and 0.01 rem/hr (10 mrem/hr) as the “outer boundary”. This is for illustration purposes and is consistent with NCRP (Commentary 19) guidelines. There will likely be intermediate zones established so that time spent and dose received by responders will be limited.
• Relocation guidelines will also be established by local/regional/state/tribal authorities in consultation with federal experts.
• Due to wind currents and other factors, there may be irregular shaped zones and the zones will change over time.

Figure A3. Definitions of RTR zones
RTR sites are functional sites that define TRiage, TReatment, and TRansport functions. Time in zone may be limited by radiation. RTR sites form spontaneously: Victims immediately in the blast site may have injury from the blast, fairly heavy contamination from radiation or combined injury (physical trauma and burn plus radiation). The radiation dose is likely to be limited as there is no detonation effect as with an IND but rather the radiation is being accumulated over time. RTR sites will be identified “on the fly” by responders and coordinated with the Emergency Operations Center (EOC). Health physicists and other radiation protection specialists will provide subject matter expertise to help interpret the readings obtained by emergency responders. RTR1 will have limited time for emergency workers but the high dose zone will be small and most likely a few hundred meters in diameter. RTR2 sites. These will be near the plume/footprint zone, recognizing that the plume will be very short-lived. While there may be some re-suspension of radioactive material most of the residual radiation will be a footprint on the ground and not a plume. RTR3 sites. Collection points with radioactivity screening (using survey meters) to identify those victims requiring decontamination and/or medical management. MC (Medical Care) sites will be the focus of medical management. It is likely that the local hospital network will have adequate resources although regional facilities may be needed. Some hospitals may be off line due to the location of the RDD and plume. Expert centers for trauma or burn care may be needed beyond the region. Acute Radiation syndrome may occur depending on the size of the device. Management and decorporation treatments will be managed locally or possibly through the National Disaster Medical System, the Radiation Injury Treatment Network and/or other expert centers. AC (Assembly Centers) will be used for displaced persons and for those with minor injury. This will be coordinate with ESF #6. Population monitoring (Plans for this are in progress- see Briefing Paper #16) Victim tracking is important. There are various systems in place with work ongoing to establish national standards or at least to try to establish compatibility among systems. The CDC will be called on for this.

Decontamination

Decontamination is a local responsibility.

ESF#8 will assist local authorities with coordination of decontamination of victims, responders, and persons exposed to contamination by an RDD.

Procedures used for decontamination are incident specific and may vary considerably. These procedures will be influenced by various factors including the following:

• Size and type of event
• Location of the event
• Weather conditions
• Availability of local decontamination resources and personnel to carry it out
• Whether or not “time zero” is known (as with a non-explosive RDD)
• Extent of civilian chaos
• Numbers of people self-evacuating before safe zones and decontamination areas can be established
• Concerns of the many people who may be far from the blast but who later worry about having been contaminated and who need reassurance
• Special concerns need to be paid to the following groups and issues:
  • Victims injured on the scene potentially requiring life-saving medical intervention prior to decontamination.
  • At-risk individuals.
  • The need to avoid contaminating transportation vehicles of any kind.
  • The need to avoid contaminating Emergency Departments and other receiving areas including Red Cross shelters.
  • Concerned citizens who are not exposed or contaminated but who need assurance.
• Personal external decontamination could take place in a number of places:
  • At entry points to medical facilities, to avoid contaminating the facility. Those needing life-saving care will require careful handling to minimize impact on care-givers and on the facility.
  • At exit points from control zones, for those who are ambulatory.
  • At entry points to collection sites
  • At home or remote sites for self-decontamination of those who leave the scene before decontamination sites are established or who flee the scene.
• Monitoring/assessment for victim contamination will occur at:
  • Medical facility entry point.
  • Exit points from control zones, as needed.
  • Entry points to shelters such as American Red Cross and other AC collection sites. This is required for ESF #6 care.
  • Various remote sites for concerned citizens (so-called “worried well”).
  • Transportations sites for DOD transportation (no contamination is allowable) or other transportation hubs.
• Referral for surgical or medical internal decontamination may be needed for any victim with the following conditions:
  • Adequate external decontamination does not result in removal of radiation levels to below about 2 times background, thus indicating possible significant internal contamination.
  • Obvious shrapnel wounds containing radioactive materials. Surgical debridement with radiation precautions will be required.
• By history/location during an event, a victim may be at risk for having inhalation or ingestion. In lieu of a complex flow diagram illustrating these many possibilities, Figure A4 is a schematic as to how victim flow may occur at an RDD event, particularly one in which the event is obvious.

Figure A4 Victim Handling Flow at Emergency Scene
Figure A4 illustrates the victim handling flow at the emergency scene. Life-Field triage will separate out the seriously injured, ensuring that life-threatening injuries are treated first and such patients are transported to the hospital immediately, even if contamination survey has not been done. Other seriously injured victims are also stabilized first before addressing contamination. While still within the “outer cordoned area” (or “Outer Zone”) contaminated patients are isolated among the non-critically injured victims. Decontamination protocols are administered before treating for minor injuries and before entering the “clean area” to transport them to other facilities. This will reduce the possibility of spreading contamination beyond the initial perimeter of potential contamination.

Evacuation / Transportation

• Transportation out of the event and transportation towards the event will be needed.
• Medical resources may need to be imported. While this is event dependent, major medical packs from the SNS will not likely be necessary for modest sized RDD events. However, resources and supplies may be needed to support local hospitals over time, possibly including FMS and decorporation agents.
• Emergency personnel: various HHS medical personnel and materiel assets will likely be deployed, at least on a stand-by basis.
• Evacuation may be needed for displaced persons based on the situation at the site. This could be from the explosive damage to infrastructure or to radiation contamination. In a large scale event, medical evacuation will be needed.
• Keeping transport vehicles free from internal contamination is a high priority so that they can remain “on line.” This may not be entirely possible when transporting the critically injured.
• DOD and ESF #1 assets will not transport contaminated individuals. There are no exceptions to this for the DOD. Local governments may operate in the same way.
• Medical Responders May Be At Risk for Significant Dose
  • Life-threatening injuries must be managed before dealing with decontamination (Smith, 2005). Nevertheless, there are settings in which medical personnel might be exposed to a relatively high dose of radiation, as with cobalt radioactive shrapnel embedded in a victim.
  • Removal of outer garments and washing of exposed skin and hair from the victims and showering will usually remove about 90% of the victims’ contamination,.
  • Health physicists/safety officers will provide guidance to medical and other responders. The use of personal dosimeters during work tours will be important. This is a local responsibility. HHS must not give reassurance until data have become available. Information recorded by the dosimeters must be carefully stored during and after the event.
  • First responders should use appropriate Personal Protective Equipment (PPE) to minimize contamination and have appropriate personal radiation dosimeters to guide the time they can be exposed to radiation.

Figure A5 Exposure Rate from an Externally Contaminated Victim
Figure A5 illustrates how medical personnel might be exposed to radiation from shrapnel embedded in a victim. The closer to the source (the victim’s body surface), the more likely doses resulting in ARS could be produced over an hour or so. Exposure rates depend on the radionuclides. For example, Cobalt produces more dose than Iridium, Cesium and Americium at close proximity: Working directly on the victim’s body (i.e., at zero distance), the exposure rate for Cobalt-60 is 3,000 mR/hr, about 1,100 mR/hr for Iridium-192, 750mR/hr for Cesium-137, and under 50mR/hr for Americium. Beyond one meter distance, however, even for Cobalt-60, external contamination produces very little exposure to personnel.

• Exposure rate versus distance for various radionuclides considered likely for an RDD.
• Even for Cobalt-60, external contamination produces very little exposure beyond 1 meter.
• The closer to the source, the more likely doses resulting in ARS could be produced over an hour or so.
• Cobalt produces more dose than Iridium, Cesium and Americium.

Dose limits

• Draft Protective Action Guidelines to guide responses to radiological and nuclear events were published in the Federal Register, January 6, 2006 (Table A6)
• 5 rem total dose is the annual limit for occupational radiation workers doing their normal jobs. This is cumulative dose over time (up to a year). If actual dosimeters are not used, cumulative dose can be estimated based on physical measurements of dose rate by environmental survey meters.
• Higher dose limits are permissible for Emergency Response Workers in certain specific circumstances (Table A6) 25 rem is the guideline limit with only a few exceptions. Above that dose, informed consent is required.
• Local governmental entities and unions may have established different guidelines.
• Pregnant women must avoid exposure. Special counseling will be needed for pregnant victims including efforts to estimate their fetus’ exposure.
• In general, the risk of a radiation-induced cancer is 8% for 100 rem (5 rem is less than 1% and 25 rem is about 2%). This is in addition to the background lifetime risk of 30-40%. Radiation-induced cancer has long latency (10-30+ years) so that younger people are at greater risk.

Table A6- Protective Action Guides (PAGs) (Federal Register, January 2006)
Phase	Protective Action	Protective Action Guide	Reference
Early	Limit Emergency Worker Exposure. Sheltering of Public Evacuation of Public Administration of Prophylactic Drugs.	5 rem (or under exceptional circumstances1 1 to 5 rems projected dose2 to 5 rems projected dose3 For potassium iodide, FDA Guidance dose values4 5	EPA PAG Manual EPA PAG Manual EPA PAG Manual FDA Guidance6
Intermediate	Limit Worker Exposure. Relocation of General Public	5 rem/yr 2rems, projected dose first year Subsequent years: 500 mrem/yr projected dose.	EPA PAG Manual
Late	Food Interdiction Drinking Water Interdiction Final Cleanup Actions	500 mrem/yr projected dose Late-phase PAG based on optimization.	EPA PAG Manual FDA Guidance7

¹ In cases when radiation control options are not available or, due to the magnitude of the incident, are not sufficient, doses above 5 rems may be unavoidable.
² Should normally begin at 1 rem; however, shelter may begin at lower level if advantageous.
³ Should normally begin at 1 rem.
⁴ Provides protection from radioactive iodine only.
⁵ For other information on medical prophylactics and treatment please refer to  http://www.fda.gov/Radiation-EmittingProducts/default.htm, http://www.bt.cdc.gov/radiation/ or http://www.orau.gov/reacts.
⁶ Potassium Iodide As A Thyroid Blocking Agency in Radiation Emergencies, http://www.fda.gov/ForIndustry/FDAeSubmitter/ucm107871.htm, December 2001, Center for Drug Evaluation and Research, FDA, HHS.
⁷ "Accidental Radioactive Contamination of Human Food and Animal Feeds: Recommendations for State and Local Agencies, "August 13, 1998, Office of Health and Industry Programs, Center For Devices and Radiological Health, FDA, HHS. 

Table A7 - Protective Action Guides (PAGs) Response Worker Guidelines
Total Effective Date Equivalent (TEDE) guideline	Activity	Condition
5 rems	All occupational exposures	All reasonably achievable actions have been taken to minimize dose.
10 rems*	Protecting valuable property necessary for public welfare (e.g. a power plant)	Exceeding 5 rems unavoidable and all appropriate actions taken to reduce dose. Monitoring available to project or measure dose.
25 rems**	Lifesaving or protection of large populations....	Exceeding 5 rems unavoidable and all appropriate actions taken to reduce dose. Monitoring available to project or measure dose

 

Personal Protective Equipment

Avoiding inhalation of radionuclides is critical.

• Appropriate Personal Protective Equipment, including respiratory protection, is necessary for responders who may be exposed to any radionuclides. Improvisation may be necessary for people in the affected zones who do not have appropriate PPE. Even victims in the area should use improvised respiratory protection.

Fatality Management

Fatality management and management of radioactive remains will be coordinated through HHS using established guidelines (CDC).

Medical Countermeasures

• Detailed medical management guidelines are included on the web portal Radiation Event Medical Management
• Local responders should be encouraged to use REMM for medical guidelines.
• Diagnostic assessment of victims potentially exposed to and internally contaminated by radiation is essential. This includes but is not limited to:
  • History, physical examination, hematology (blood counts) and blood chemistry evaluation.
  • The CDC Laboratory Response Network may be needed to supplement local/state/regional/tribal resources.
  • Special analysis may be required (e.g. nasal swabs, skin or hair swabs urine or feces) to determine presence of radiation and possibly the identification of the specific radionuclide. Internal contamination requires accurate analysis and usually repeated sampling for appropriate clinical management. The size of the event and potential number of victims will be used to determine how to utilize the limited laboratory assay capabilities. For example, nasal swabs, skin or hair swabs might be done for a small-sized event, but not a large one.
  • These analyses will be coordinated through the Centers for Disease Control (CDC) Radio-bioassay laboratory.
  • Low levels of contamination will not need treatment. Therefore, bioassay (to measure the type of radionuclide) and dose calculation (with biodosimetry) are important in knowing which patients need therapy. If empirical treatment is started before measurements are available, as might be done with DTPA (plutonium, americium) or Prussian Blue (Cesium), the treatment course may be discontinued if unnecessary.
  • Currently, CDC has limited capacity to provide bioassay results. If the number of casualties is large, the laboratory capacity may be insufficient, and patients will be managed clinically.
  • Annual limit on intake (ALI) - is the derived limit for the amount of radioactive material taken into the body by inhalation or ingestion in a year. ALI is the value of intake of a given radionuclide in a year that would result in a committed effective dose equivalent of 5 rem (0.05 Sievert) or a committed dose equivalent of 50 rem (0.5 Sievert) to any individual organ or tissue (adapted from Nuclear Regulatory Commission). In general, treatment for internal contamination is given is 10 times the ALI is calculated.
  • Most authorities do not recommend treatment of internal contamination when the body burden is less than one annual limit of intake (ALI). Treatment is strongly recommended when the body burden exceeds 10 ALI. For internal contamination levels greater than 1 ALI and less than 10 ALI, clinical judgment dictates treatment of internal contamination.
  • If there is concern about a possible diagnosis and need for treatment of Acute Radiation Syndrome, monitoring of blood counts and possibly special biodosimetry analysis (if available) may be needed.
  • Specific treatments are available for particular radionuclides as listed below. The identification of the radionuclide is important so that unnecessary toxicity is avoided.

Table A8. Examples of radionuclides and medical countermeasures (See REMM.nlm.gov for details, also in Briefing papers)
Radionuclide	Medical countermeasure	Procured through
Cesium	Prussian Blue	Local institutions and commercial vendors SNS
Plutonium, Americium	DTPA	Local institutions for Ca-DTPA and some Zn-DTPA SNS can provide Zn-DTPA and restocking
Strontium	Calcium, ammonium chloride, other	Commercial vendors
Iodine	Potassium iodide	Commercial vendors

• Not all victims with internal contamination require treatment. Many countermeasures have an unfavorable risk-to-benefit ratio when used to treat persons having low levels of internal contamination.
• An event with radioactive iodine would require appropriate identification (by determination through, survey or interview of likely proximity or ingestion or inhalation) of exposed children and young adults so KI could be provided to prevent later development of thyroid cancer. Administration must be started promptly, ideally by 4-5 hours. Most of the efficacy is lost if more than 12 hours have transpired. KI is not indicated for other radionuclides.
• The development of Acute Radiation Syndrome severe enough to require countermeasures for treatment is unlikely for those receiving whole body doses below 2 Gy. Individuals who receive a cumulative whole body dose of >2 Gy and < 3Gy need to be monitored very closely, as they may need treatment for ARS. Those suspected of having received a dose above 3 Gy probably need prompt medical intervention with “mitigating agents” such as hematological growth factors for granulocytes. Other ARS agents are in development. Management details are in REMM.

Managing Potential Long-Term Medical Consequences: Fear of Cancer

• The disruptive aspect of an RDD will quickly become the major aspect of this event including health fears, economic loss, and infrastructure disruption. The major health fear is likely to be the “perceived risk” of the inevitability of developing a radiation-induced cancer.
• Fear of damage to fetuses and concerns about genetic mutations that could be passed along to future generations will likely arise as well. These fears are best addressed by education including public media presentations and also by regional face-to-face meetings with medical and epidemiological experts.
• It is possible that there will be suspicion of any comments from government officials who are not medical experts, so HHS will try to use academic and medical radiation experts. These include staff from the National Cancer Institute, CDC, NIH, epidemiologists involved in the Japanese atomic bomb studies including the Japanese Radiation Effects Research Foundation (REFR) and from the Chernobyl studies. Other international experts may be called upon.
• For those victims who had potential for low dose exposure, cytogenetic biodosimetry studies may be conducted. Radiation produces characteristic chromosome changes in white blood cells (called dicentrics) that are stable for many years so that the Radiation Laboratory Response Network (Rad-LRN which is still being established) could study potential victims and correlate the number of dicentrics with estimated dose (see REMM).
• Given the time and expense of these tests, only those who were clearly within a zone in which exposure may have been relatively high and those who had suspected contamination determined by a health physicist will be subject to study. While the exact cut-off would be determined at the time of the event, a suspected dose of less than 50 - 75 cGy (rem) would not require study as this would raise the lifetime risk by about 4% at most. Age would also be a factor in deciding whom to study. Emphasis on studying young people is important because the latency for radiation-induced cancer is usually at least one decade, often 3 or more. Other medical factors would be considered regarding biodosimetry study and the need and type of long-term screening.
• As has been learned with genetic testing for cancer risk, many people do not want to know if they are at increased risk for developing a disease or illness. It may be that lifestyle changes (no smoking) and routine recommended medical screening test (colonoscopy, mammograms) may be the mainstay of medical follow up. There may be insurance coverage issues should a victim be determined to be at higher risk so that legal protection and privacy must be considered.
• Recovery: Decisions about reoccupation of the involved area, clean-up and even transient entry to remove valuables and personal items will be made by the local/regional government, expert consultants and citizens. The relative risks, expense, time, and possibility for site clean up should be determined as clearly and as quickly as possible to expedite the community’s recovery. Agencies involved in these discussions would be EPA, DHS, HHS and others.
• ESF #14 will assume a lead role as the recovery phase ramps up. Interagency PAGs should be consulted as in Table A6 (Draft PAGs from Federal Register).

Population Monitoring

What is the Role Specified in the National Response Framework for HHS?

• The text directly addressing this topic is found in the Nuclear/Radiological Incident Annex (June ’08), page NUC-22, under “Population Monitoring” and “Population Decontamination” (emphasis added):
• “The Department of Health and Human Services (HHS), through ESF #8 - Public Health and Medical Services and in consultation with the coordinating agency, coordinates Federal support for external monitoring of people.
• HHS, through ESF #8 and in consultation with the coordinating agency, coordinates Federal support for population decontamination.
• HHS assists and supports State, tribal, and local governments in performing monitoring for internal contamination and administering available pharmaceuticals for internal decontamination, as deemed necessary by State health officials.
• HHS assists local and State health departments in establishing a registry of potentially exposed individuals, performing dose reconstruction, and conducting long-term monitoring of this population for potential long-term health effects.”

What the Centers for Disease Control and Prevention (CDC) have done to date.

• CDC hosted a roundtable in Atlanta on population monitoring with participants from Federal agencies, state and local health departments, academia and many professional organizations.
• CDC chairs a small interagency working group of technical experts to discuss practical aspects of population monitoring. The working group has provided CDC with significant input on the topic.
• CDC has prepared a planning guide for state and local public health planners highlighting the many challenges in a mass casualty radiation incident and suggesting ways to address those challenges.
• CDC is preparing a public health toolkit with a video segment on population monitoring.
• CDC is planning on developing a planning decision tool (software) for optimizing the design and operation of community reception centers used to screen population in mass casualty radiation emergencies. This is based on the concept of PODs (points of dispensing) and will use field data on radiation screening.

What needs to be done next?

• Identify, and solidify Interagency Agreements with, Federal resources that can be made available to assist with population monitoring, i.e., clarify what constitutes the “Federal support” that HHS is responsible to coordinate.
• Remain proactive in coordinating with all identified resources. This includes the Commissioned Corps, Medical Reserve Corps, or other assets that can be used to assist with population monitoring. Coordination with all these resourced needs to be done proactively in the specific context of population monitoring.
• Conduct a national radiation exercise with an ESF #8 focus on Population Monitoring issues. To date, many radiation exercises conducted locally or nationally lack such emphasis. Population monitoring issues are especially overlooked and challenges underestimated.

Common response phase terminology

• Phases of Response (from Federal Register PAGs, January 2006). These are verbatim definitions. Note: our response plans are tied to hours/days after the event so that these terms are useful but not used specifically in our CONOPS.
  • The early phase (or emergency phase) is the period at the beginning of the incident when immediate decisions for effective use of protective actions are required and actual field measurement data is generally not available.
  • The intermediate phase of the response may follow the early phase response within as little as a few hours. The intermediate phase of the response is usually assumed to begin after the source and releases have been brought under control and protective action decisions can be made based on measurement of exposure and radioactive materials that have been deposited as a result of the incident.
  • The late phase is the period when recovery and cleanup actions designed to reduce radiation levels in the environment to acceptable level area commenced, and it ends when all the recovery actions have been completed.

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