NMDP Basic Radiation Training Presenters name Date

Why learn about radiation? Many agencies think that there will be a radiological incident in our lifetime U.S. government Independent nuclear watch groups www.NTI.org (Nuclear Threat Initiative) http://cns.miis.edu/cns/index.htm (Monterey Institute for International Studies) International Atomic Energy Agency (IAEA) Every year hundreds of radiological sources are stolen worldwide Between 1995-2003, over 612 radiological devices were stolen or lost around the world. Fewer than half were recovered 1. In 2006 alone, 85 incidents were reported to the International Atomic Energy Agency (IAEA), 75% of which had not been recovered at the time of the IAEA report 2. And this is only what is reported to the IAEA. Less than 10 kg of Plutonium is required to create a 10 kiloton Improvised Nuclear Device (IND). If such as device was detonated in a major city, there could be hundreds of thousands of casualties, including more than 30,000 potential patients with a marrow toxic injury 3. As a hematologist, oncologist or transplant physician, you would be called upon to play a vital role in caring for victims with a hematologic toxic injury. References: 1 Dainiak, Nicholas, et al. The Hematologist and Radiation Casualties, American Society of Hematology: Hematology 2003, p. 473-496 2 IAEA, Preliminary 2006 Report from IAEA Illicit Trafficking Database, February 1, 2007 3 Casualty predictions derived from Draft: National Planning Scenarios, April 2006, Department of Homeland Security

Goals of this Presentation Basics of radiation: sources, types, units of measurement Biological and clinical effects of radiation Symptoms of Acute Radiation Syndrome (ARS) Exposure and contamination Protection against radiation exposure: time, distance, shielding Preparedness planning and our role with RITN Between 1995-2003, over 612 radiological devices were stolen or lost around the world. Fewer than half were recovered 1. In 2006 alone, 85 incidents were reported to the International Atomic Energy Agency (IAEA), 75% of which had not been recovered at the time of the IAEA report 2. And this is only what is reported to the IAEA. Less than 10 kg of Plutonium is required to create a 10 kiloton Improvised Nuclear Device (IND). If such as device was detonated in a major city, there could be hundreds of thousands of casualties, including more than 30,000 potential patients with a marrow toxic injury 3. As a hematologist, oncologist or transplant physician, you would be called upon to play a vital role in caring for victims with a hematologic toxic injury. References: 1 Dainiak, Nicholas, et al. The Hematologist and Radiation Casualties, American Society of Hematology: Hematology 2003, p. 473-496 2 IAEA, Preliminary 2006 Report from IAEA Illicit Trafficking Database, February 1, 2007 3 Casualty predictions derived from Draft: National Planning Scenarios, April 2006, Department of Homeland Security

Section 1: Radiation Basics

Types of Radiation Natural Man made Many more sources of natural radiation Insignificant risk associated with typical exposure Man made Fewer sources of exposure BUT…potentially deadly if misused Ionizing radiation is focus of this course

Sources of Radiation Exposure in the U.S. Population Natural (82%) Radon Cosmic (outer space) Terrestrial Rocks/Soil Internal Inside human body Stress that Radon is the largest source of natural radiation. Radon is the result of radioactive decay of minerals deep in the earth. Internally there are multiple sources of radiation: all humans have potasium-40 (K-40) inside their cells, this is harmless radiation that naturally occurs which has a half-life of 1.26 billion years. The second most active radionuclide in the body, carbon-14 (5,730 yr half-life), but it can not be detected easily because it is a beta emitter.

Natural Background Radiation Cosmic Sun (much of this radiation is shielded by Earth’s atmosphere) Terrestrial Sources Materials in soil Break down into radon gas Radioactivity in the Body Very minute quantities We are constantly exposed to radiation. This exposure can increase when at higher altitudes such as being in Denver or when flying in a comercial aircraft.

Sources of Radiation Exposure in the U.S. Population Man Made (11%) - Medical X-rays CT scans - Nuclear medicine/ radiation oncology - Consumer products - Other Man made radiation is a small percentage of the total sources of exposure, yet much more dangerous. Provide specific examples of man made radiation: Diagnostic radiation: Xrays Bone scans Treatment radiation: Cancer treatment (total body irradiation prior to transplant) Radiation sources placed inside the body, wafers for brain cancer or pellets for prostate cancer Consumer products: Tritium causes the illumination in watch faces Americium is used in smoke detectors

Atomic Structure (a VERY basic one) Protons Positive charge Neutrons No charge Electrons Negative charge To understand how radiation is hazardous we need to review a bit of high school physics. An atom is the smallest particle of an element, smaller than an atom and it no longer can be connected to a specific material (like Hydrogen, etc…). An atoms basic composition includes protons, electrons and neutrons. Ionizing radiation is produced by radioactive decay of atoms, also by nuclear fission and fusion…. aka nuclear reactor or a thermonuclear device such as a nuclear bomb.

Radioactivity and Ionizing Radiation Radioactivity or radioactive decay: Emitting excess energy from the nucleus of an unstable atom Radioactive decay results in the decrease of radiation levels over time Ionizing radiation: Energy released from unstable (radioactive) atoms NOTE: Radioactive Atoms Emit Radiation

Three Main Types of Ionizing Radiation Emitted from Radioactive Atoms Alpha Beta Gamma When you think of Alpha particles, think inhalation/ingestion/injury hazard. The particles have to be inside the body to do significant damage. In 2006, Alpha particles resulted in the death of Alexander Litvinenko, a Russian dissident, who was poisoned with Polonium-210. Had he not ingested the radioactive material he would have most likely survived, external contamination at best would result in a burn similar to sunburn. Additional sources of Alpha particles include: americium-241 radon plutonium radium thorium Uranium An alpha particle can be stopped by one sheet of paper.

Ionizing Radiation Alpha Particles Heaviest and most highly charged ionizing radiations Energy is used up quickly; low penetrating ability Cannot travel more than 4 to 7 inches Stopped by a sheet of paper Not a serious hazard outside the body Can be most damaging if inside the body (e.g., ingestion, inhalation) When you think of Alpha particles, think inhalation/ingestion/injury hazard. The particles have to be inside the body to do significant damage. In 2006, Alpha particles resulted in the death of Alexander Litvinenko, a Russian dissident, who was poisoned with Polonium-210. Had he not ingested the radioactive material he would have most likely survived, external contamination at best would result in a burn similar to sunburn. Additional sources of Alpha particles include: americium-241 radon plutonium radium thorium Uranium An alpha particle can be stopped by one sheet of paper.

Ionizing Radiation Beta Particles Smaller and travel much faster than alpha Physically similar to electrons, but do not orbit around an atom Travel faster with less charge than alpha and penetrate further Major hazard when emitted by internally-deposited radioactive material Beta particles are similar to Alpha particles in that while outside the body they are not powerful enough to cause significant damage. These radionuclides all release Beta particles: cesium-137 cobalt-60 iodine-129 &-131 strontium-90 Tritium A beta particle can be stopped by one sheet of aluminum foil.

Ionizing Radiation Gamma Rays Similar to medical x-rays Short wavelength and high frequency Most hazardous from sources outside the body Can travel up to a mile in open air All tissues and organs can be damaged by sources outside the body Gamma rays are the most powerful ionizing radiation we will discuss here today (instructors note: Neutron radiation is a very powerful ionizing radiation that is limited to specific nuclear fission reactions and therefore outside the scope of a potential radiological incident).

Ionizing Radiation Alpha and beta radiation: both are PARTICLES Gamma radiation: is a form of electromagnetic radiation, transmitting energy in the form of WAVES Gamma rays are the most powerful ionizing radiation we will discuss here today (instructors note: Neutron radiation is a very powerful ionizing radiation that is limited to specific nuclear fission reactions and therefore outside the scope of a potential radiological incident).

Electromagnetic Radiation Transmitted in the form of waves Generally higher in energy Originate in the nuclei of atoms Types of electromagnetic radiation include television and radio waves, microwaves and visible light. Gamma radiation, to the far right is a very powerful form of electromagnetic radiation that is also ionizing radiation.

Radiation Penetration Into Skin Exposure to alpha & beta from outside body is slight hazard Long periods of exposure can cause “heat burns” Significant hazard if ingested, inhaled or contaminates a wound Since alpha and beta are not powerful enough to penetrate deeply, they are primarily a hazard only when ingested, inhaled or when in an open wound. Beta particles can cause a nasty skin burn if exposed for a long enough period; and beta particles are extremely hazardous to the unprotected human eye. Where gamma radiation can pass through a human with ease, and therefore interact with sensitive internal organs.

Ionizing Radiation Gamma rays - deadly Beta particles There are three (3) types of ionizing radiation that we will discuss today. Alpha, Beta and Gamma…. We will show you that all are hazardous and can kill a human, but some are significantly more dangerous than others. Beta particles – internally a bit more hazardous Alpha particles – hazardous internally

Shielding Gamma rays pass through you and keep going. You will not be radioactive after being exposed to gamma radiation. Just like you are not radioactive after having an xray. This doesn’t mean it is safe. As it passes through your body it causes significant damage to cell structures. 2-1/2 inches of dense concrete will absorb approximately 50% of typical gamma rays Five inches of water is just as effective

When you are exposed to radiation, your body absorbs a measurable dose Exposure vs. Dose When you are exposed to radiation, your body absorbs a measurable dose

Measurement of Radiation Dose Today we will discuss three (3) ways to measure radiation. Roetegen, rad and rem. All measure radiation, yet each have a specific use. What needs to be known for medical treatment Intensity of exposure Time or duration of exposure

Roentgen The Roentgen is used to express the amount of gamma radiation exposure Abbreviated with a capital “R” after the amount of gamma radiation received Independent of the time of exposure This measurement is not very useful in determining the biological effects on a human since it only states the amount of radiation exposure, not what was absorbed into the body. Therefore it does not lend to quantifying the potential level of cell damage. For instance, if a man is exposed to 5 R of gamma rays on one occasion, and 6 R on another, the sum of the two, 11 roentgens, is his cumulative gamma radiation exposure.

Rad (radiation absorbed dose) Relates different types of radiation (alpha, beta, gamma and neutron) to the energy they impart Basic unit of absorbed dose of radiation One roentgen of gamma radiation exposure results in about one rad of absorbed dose A rad as well as a gray are very important in determining the impact of radiation exposure. Both directly correlate to the potential impact on cells since both rads and grays measure how much radiation was absorbed in the body. 1 rad = 0.01 Gy or 100 rad = 1 Gy

Rem (roentgen equivalent man) Relates the dose of any radiation to the biological effect of that dose For gamma rays and beta particles, 1 rad of exposure results in 1 rem of dose For alpha particles, 1 rad of exposure results in ~20 rem of dose Rem takes into account that different radiological materials impact the body with a variety of effectiveness. Definition from www.epa.gov: Rem relates the absorbed dose in human tissue to the effective biological damage of the radiation. Not all radiation has the same biological effect, even for the same amount of absorbed dose. Therefore, 1 rad from an alpha particle source is not the same as 1 rad from a beta or gamma source. The measurement may seem counterintuitive since alpha particles result in a higher rem dose. This is because alpha particles exposed to human tissue are slow clumsy particles that will collide with human cells, where some beta particles and many gamma rays will pass through the body not impacting any cells.

Exposure Rate The rate at which an individual is exposed to radiation Expressed in terms of roentgen or milliroentgen per hour

International System of Units (SI) SI uses gray (Gy) instead of rad - 1 Gy = 100 rad SI uses sievert (Sv) instead of rem - 1 Sv = 100 rem SI units must be used on labels to identify radioactive materials during transport

Section 2: Biological Effects of Radiation

Biological Effects Dependent upon type of exposure (duration of exposure) Acute (limited time of exposure) Chronic (extended or repetitive exposure) Level of exposure (intensity) Certain biological factors For biological effects think: Time Intensity And, everyone really is special. Meaning we are all different, no one responds to radiation exposure the same way (except for extremely high doses).

Ionizing Radiation Radiation is a form of energy in motion When alpha, beta and gamma radiation enter the body, some or all of their energy is lost in collisions with the body’s cells Collisions strip away electrons from atoms in the body Removal of electrons is called ionization These collisions with the body’s cells results in damage that make humans sick… Acute Radiation Sickness.

Biologic Effects Damage DNA and other structures inside cells Could result in cell death Incorrect repair, resulting in mutations that could cause cancer

Biological Effects Acute Exposure Chronic Exposure Significant dose of radiation over a short period of time Radiation sickness or death shortly after exposure Long-term effects (possibly cancer years later) Chronic Exposure Small dose of radiation continuously or over many years No immediate observable effects May result in long-term effects Acute exposure resulting in sickness is from high level of exposure over a short period of time. Chronic exposure sneaks up on you over many years of minor exposure.

Biological Factors Each person differs in their biological response to a given dose of radiation Age Sex Diet Body temperature Overall medical health

Acute Radiation Sickness Occurs when an individual is exposed to a large amount of radiation in a short period of time Occurs at doses greater than 100 rem (1 Sv), which would be 100 rad (1 Gy) for gamma rays

Acute Radiation Sickness Manifestations Changes in blood cells (lymphocytes decrease first) Vascular changes Skin irritation GI effects (nausea, vomiting, diarrhea) Fever Non specific “flu”-like symptoms Hair loss

Acute Radiation Sickness Severity and course depends on How much total dose is received How much of the body is exposed Sensitivity of exposed individual to radiation May appear shortly after exposure, then disappear for a few days only to reappear in a much more serious form in a week or more (related to amount of exposure)

Four Stages of ARS Prodromal phase (within 48 hours) Latent Phase (days to weeks) Manifest Illness (weeks to months) Recovery or Death

Four Stages of ARS Prodromal phase (within 48 hours) Nausea/vomiting Headache Fatigue Fever, diarrhea Anorexia Fluid shifts Electrolyte imbalance Latent Phase (days to weeks) Temporary improvement Common initial signs of ARS are: Nausea/vomiting Headache Fatigue Fever, diarrhea

Four Stages of ARS Manifest Illness (weeks to months) Intense immunocompromise and symptoms specific to 4 major organ systems (heme, GI, skin, neurovascular) Recovery or Death Note: After lethal dose, victims may go through these phases in a period of hours resulting in early death

Severity Levels Delayed effects after sublethal dose (<250 rem*) may be non-specific Fever Abdominal pain Insomnia Restlessness Blisters Malaise Fatigue Drowsiness Weight loss * For gamma and beta radiation, 1 rem = 1 rad

Delayed effects after potentially Severity Levels Delayed effects after potentially lethal dose (250 to 650 rem*) Significant reduction in production of blood cells Nausea/vomiting which appears to get better in 3 days WBC greatly reduced After two weeks: chills, fatigue, ulceration of the mouth * For gamma and beta radiation, 1 rem = 1 rad

supralethal dose (>650 rem*) Severity Levels Delayed effects after supralethal dose (>650 rem*) Damage to the stomach lining and/or intestine Causing decreased absorption, ulceration and dehydration Seven Days After Exposure Severe infection, fluid loss, blood loss or collapse of the circulatory system and may result in death * For gamma and beta radiation, 1 rem = 1 rad

Severity Levels Acute Doses over 1000 rem* Irreparable damage to the brain and spinal cord Symptoms Agitation Lack of coordination Breathing difficulty Occasional periods of disorientation Death occurs within hours to days * For gamma and beta radiation, 1 rem = 1 rad

Key Symptoms of ARS Reduced number of platelets Nausea Vomiting Itching or altered sensation in the skin Swelling and Edema Diarrhea Fatigue Nausea Vomiting Anorexia Reduced number of white blood cells (lymphocytes, granulocytes)

Severity of Radiation Injury Dose Range (Gy)* Prodrome Manifest - Illness Prognosis (without therapy) 0.5-1.0 Mild Slight decrease in blood cell counts Almost certain survival 1.0-2.0 Mild to Moderate Early signs of BM damage Highly probable survival (>90% of victims) 2.0-3.5 Moderate Moderate-severe BM Probable survival 3.5-5.5 Severe Severe BM damage; mild GI damage Death within 3.5-6 weeks (50% of victims) 5.5-7.5 Pancytopenia and moderate GI damage Death probable within 2-3 weeks 7.5-10.0 Marked GI and BM damage; hypotension Death probable within 1- 2.5 weeks 10.0-20.0 Severe GI damage, pneumonitis, altered mental status Death certain within 5-12 days 20.0-30.0 CV collapse; fever; shock Death certain within 2-5 Abbreviations: Bone marrow (BM); Cerebrovascular (CV); Gastrointestinal (GI). Modified from RI Walker and RJ Cerveny, eds.(reference 21); provided by Dr. J. Waselenko * 1 Gy = 100 rad

What is the standard dose of total body irradiation (TBI) irradiation used for total body irradiation (TBI) in clinical BMT?

Severity of Radiation Injury Dose Range (Gy) Prodrome Manifest - Illness Prognosis (without therapy) 0.5-1.0 Mild Slight decrease in blood cell counts Almost certain survival 1.0-2.0 Mild to Moderate Early signs of BM damage Highly probable survival (>90% of victims) 2.0-3.5 Moderate Moderate-severe BM Probable survival 3.5-5.5 Severe Severe BM damage; mild GI damage Death within 3.5-6 weeks (50% of victims) 5.5-7.5 Pancytopenia and moderate GI damage Death probable within 2-3 weeks 7.5-10.0 Marked GI and BM damage; hypotension Death probable within 1- 2.5 weeks 10.0-20.0 Severe GI damage, pneumonitis, altered mental status Death certain within 5-12 days 20.0-30.0 CV collapse; fever; shock Death certain within 2-5 Abbreviations: Bone marrow (BM); Cerebrovascular (CV); Gastrointestinal (GI). Modified from RI Walker and RJ Cerveny, eds.(reference 21); provided by Dr. J. Waselenko 12 Gy: TBI dose for clinical BMT

- the lungs are usually given a lower The standard dose of irradiation used for total body irradiation (TBI) in clinical BMT is 12 Gy (1200 rad), but…. - this total dose is administered in multiple fractions over several days to allow repair of normal cells and tissues - the lungs are usually given a lower total exposure (e.g., 9 Gy) to reduce risks of pulmonary toxicity

Treatments Exposure results in a full range of injuries, from changes in the blood cells to skin burns to serious radiation sickness Analysis of peripheral blood may diagnose exposure before other effects appear Treatment depends upon the nature and severity of the injury

Long-Term Effects Probability increases as level of exposure increases Three most notable effects Cancer Cataracts Acute exposure of 200 rads (2 Gy) Chronic exposure (months) of 1,000 rads (10 Gy) Shortening of lifespan Although widely thought of as a cause of cancer, acute radiation exposure only marginally increases cancer risk. For example, 82.000 Japanese atomic bomb survivors who received and average of approximately 28 rads (0.28 Gy), only 0.2 percent experienced a radiation-induced cancer. Fibers that comprise the lens of the eye are specialized to transmit light. Damage to these fibers, and particularly to the developing immature cells that give rise to them, can result in dark spots in the lens called cataracts that interfere with vision.

Long-Term Effects Animal experiments Same disease, earlier age Data from populations of Hiroshima and Nagasaki Very slight risk (i.e., <1 years per 100 R)

Long-Term Effects

Section 3: Exposure versus Contamination

Contamination versus Radiation Contamination: the deposition of radioactive material in undesired locations NOTE: one can be exposed to radiation without becoming contaminated (e.g., radiation therapy treatments) Radioactive contamination on a surface does not make the surface itself radioactive - Remember that radioactive materials emit radiation - Once the contaminated surface is cleaned of the radioactive material, there is no longer a threat of

Sources of Radioactive Exposure and Contamination Direct radiation Inhalation Skin contamination Direct ingestion Radiation from contaminated surfaces Secondary ingestion (e.g., food, water, milk) Briefly discuss these means of exposure to radiation: Direct radiation: exposed like in radiotherapy Inhalation: as a result of a radioactive plume (cloud containing radioactive particles), plumes are associated with fallout, nuclear power plant releases, and dirty bombs Skin contamination: radioactive particles that are temporarily deposited on the skin, once washed off during decontamination the radiation will be gone Direct ingestion: if there are radioactive particles on food or in a beverage they can be very dangerous once ingested (this is how Litvenenko received a lethal dose of Polonium-210) Radiation from contaminated surfaces: radioactive particles on surfaces emit radiation that can be harmful to the body Secondary ingestion (e.g., food, water, milk): If a cow ingests radioactive particles, some of these will be transferred to the milk which can be dangerous if ingested

Control of Radiation Exposure Protective Measures Time Less time = less exposure Distance Further away = less exposure Shielding Intensity is reduced by absorption and scattering by the material between you and the source These should all make sense. Time- You want to be exposed to the radiation for a short a period of time as possible. Less time means a lower absorbed dose at that exposure level. Distance- Would you want to be next to a nuclear detonation or in the next state over? The farther away the lower the exposure level. Shielding- Would you rather hide behind a fence or a 4 foot thick concrete wall? The more material between you and the source the less radiation that will get to you.

Section 4: Preparedness Planning

Types of Radiological Incidents Orphaned source Lost/stolen radiation source that exposes people Can be purposely placed to injure Radiological Dispersal Device a.k.a. “dirty bomb” Improvised Nuclear Device (IND) a.k.a. “terrorist nuke” could fit into a suitcase

Orphaned Source Case Study

Dirty Bombs Conventional bomb attached to a source of radioactivity (e.g., Cobalt-60) Explosion spreads radioactivity resulting in widespread contamination Result in few casualties Public panic is greatest danger Economic impact is far reaching when compared to INDs or military weapons

Radiological Dispersal Device Case Study No explosion, but it is an excellent example of how the public would react in response to the potential contamination. Anxiety and panic.

Improvised Nuclear Device (IND) Estimates based on a 1 kiloton or 10 kiloton IND Worst case scenario: Victims will outnumber BMT community resources

Improvised Nuclear Device (IND) INDs are not only in James Bond (Goldfinger) and George Clooney (Peacemaker) movies. The left picture is an example of what a IND could look like when created to fit in a briefcase. On the right is a US Military SADM man portable nuclear device. The US and Russian military both had “backpack” nukes in their arsenals (they weighted upwards of 150 lbs, but were still easily maneuverable by military ground and Airborne units).

Contingency Planning The Radiation Injury Treatment NetworkSM (RITN) provides comprehensive evaluation and treatment for victims of radiation exposure or other marrow toxic injuries. RITN develops treatment guidelines, educates health care professionals, works to expand the network, and coordinates situation response. RITN is a cooperative effort of the National Marrow Donor Program® (NMDP) and The American Society for Blood and Marrow Transplantation (ASBMT).

RITN Centers RITN provides: Existing facilities with practicing specialists for intensive supportive care and treatment Infrastructure and process for transplant if needed Training of physicians and other health care workers Assistance during an emergency Donor search support IRB - approved data collection plan Increases transplant community awareness about potential need of their services in time of crisis Involves transplant community in emergency preparedness

Available through RITN Website www.nmdp.org/ritn RITN Acute Radiation Syndrome treatment guidelines RITN center standard operating procedure templates Donor selection criteria NMDP data collection protocol Training resources Pertinent publications

What is RITN Doing to Prepare? Standard Operating Procedures Basic radiation training completed by staff Grand rounds presentation in development Additional training resources provided on RITN Web site Conduct an annual tabletop exercise Emergency communications tests GETS cards and satellite telephones Coordinating with government (DHHS-ASPR)

RITN Distribution Across USA UMC

What if there is a disaster? If an improvised nuclear device (terrorist nuclear bomb) is detonated, what will happen? The federal government will: Setup outside the hazard area Receive, decontaminate and triage victims Forward them on for appropriate care Any victim with trauma or burns would be treated for that before being evaluated for treatment due to marrow toxicity This leaves a smaller subset for marrow reconstitution Stress that: Unless it is your city that has the incident all patients will be decontaminated prior to presenting for treatment.

Possible Casualty Levels The U.S. government is planning to respond to a 10 kiloton improvised nuclear device (terrorist nuclear bomb) There most likely will not be many transplants as a result of a terrorist nuclear device detonation. Low level exposure victims will self recover with minimal medical support. High level exposure victims will die no matter what care they are given. Between these two extremes will be many patients that require intensive medical support.

Timelines for Activity - Transplants Not all of these patients will be ready for treatment at day one. It will take time to evacuate, decontaminate and triage all the victims involved. Even if there is a small chance of requiring a transplant the NMDP expects and is prepared for a significant initial load of search activity, this will result in many matches but as stated previously it is expected that there will be many less transplants.

RITN Centers Admission to RITN several days after event (unless hospital is in the vicinity of the event) Initial triage and decontamination is completed by first responders Identifying a destination for each victim Health & Human Services working with RITN Initial treatment and diagnosis Conducted by RITN, NCI and NDMS centers NDMS – National Disaster Medical System: hospitals that signed agreements with HHS to receive patients resulting from a mass casualty event

Urgent BMT Small subset of patients will require transplantation Expediting the evaluation of donor(s) is key Housing needs for donors and patients Expect that altered standards of care will be implemented by the Dept. of Health and Human Services during this time to facilitate treatment

“By failing to prepare you are preparing to fail.” Contingency Planning “By failing to prepare you are preparing to fail.” Benjamin Franklin

Some Online References RITN: www.nmdp.org/RITN HHS Radiation Event Medical Management (REMM): http://www.remm.nlm.gov CDC: Radiological Terrorism: Medical Response to Mass Casualties: http://www.bt.cdc.gov/radiation/masscasualties/training.asp Radiological Terrorism: Just in Time Training for Hospital Clinicians: http://www.bt.cdc.gov/radiation/justintime.asp Medical Response to Nuclear and Radiological Terrorism: http://www2.cdc.gov/phtn/webcast/radiation-04/default.asp The Role of Public Health in a Nuclear or Radiological Terrorist Incident: http://www2.cdc.gov/phtn/nuclear05/default.asp National Planning Scenarios: http://media.washingtonpost.com/wp-srv/nation/nationalsecurity/ earlywarning/NationalPlanningScenariosApril2005.pdf