Radiation Injury Treatment Network: Leveraging existing expertise to provide radiation casualty management David Weinstock, MD Dana-Farber/Harvard Cancer Center Radiation Injury Treatment Network

Radiation Injury Treatment Network (RITN): Definition Voluntary network of 47 academic medical centers, 7 blood donor centers and 7 umbilical cord blood banks Organized by National Marrow Donor Program and American Society of Blood and Marrow Transplantation Supported by the US Navy Coordinated with the Office of the ASPR, DHHS

Education and training: –REAC/TS mini-course –Grand rounds and online presentations (<2300 trained) –REMM ( treatment algorithmswww.remm.nlm.gov Annual tabletop exercises International consensus guidelines National planning –Scarce Resources project –National Planning Guidance –State and Local Planners Playbook for Medical Response to a Nuclear Detonation Radiation Injury Treatment Network (RITN): Pre-event

0-76, Be aware of the Radiation Injury Treatment Network (RITN) I-19, HHS activation of National Disaster Medical System (NDMS) and other HHS assets (DMATs and burn teams). HHS to activate AABB TF for blood supports through Assistant Secretary for Health (ASH) activate RITN II-6, Prepare for air-based transfer of victims to other jurisdictions, NDMS hospitals, RITN and Veterans Administration hospitals. II-36, Support transfer and tracking of victims and potential victims of acute radiation syndrome to regional, NDMS, and RITN centers II-42, Work with hospitals to identify patients for transfer to regional facilities, NDMS, RITN centers or burn facilities. III-6, Continue transfer of victims who may need delayed medical care to National Disaster Medical System (NDMS), RITN and other jurisdictions. State and Local Planners Playbook for Medical Response to a Nuclear Detonation

Surge capacity National guidance – online, teleconsult Coordination of stem cell transplantation: –Donor searches (>10,000 per week) –Product harvesting and transport –Treatment guidelines Radiation Injury Treatment Network (RITN): Response

Ground Zero Evacuation Victim collection points Decon Triage Trauma centers Triage Trauma centers Specialty care & treatment centers Specialty care & treatment centers

Potential for life-threatening exposure during clean-up Radiation events

MC AC MC Evacuation centers RTR3 (collection) AC RTR1 (collection) AC Referral center Modified from Weinstock et al. Blood 2008 RTR1 (blast) RTR2 (plume) MC RTR2 (plume) Ambulatory Critical DHHS evacuation strategy – 2 types of radiation injury

Hiroshima after the bomb Hiroshima before the bomb

New York City 2011 Hiroshima before the bomb

Estimated number of irradiated victims Waselenko et al. Annals Int Med , ,000

Resource demand and availability after a nuclear detonation in Washington DC Symptomatic injured persons or incident demand min - med - max Single hospital CityNation Persons injured (next column) or population of designated area (city, nation) 930,000 – 990,000 – 1,600,000 N/A592, million Hospital beds (unoccupied)70,000 –180,000 – 300, (40)3,670 (920) 947,000 (295,000) ICU beds (unoccupied)24,000 – 61,000 – 110, (1.6) N/A118,000 (9,400) Operating roomsN/A6 30,000 Burn beds (unoccupied)0 – 0 – 1,100N/A32 (5)1,760 (580) AmbulancesN/A 3848,400 Modeling Division of BARDA Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) Blood and Tissue Requirements Working Group Gryphon Scientific

Surge capacity based on tabletop exercises

R. Cassagrande, Gryphon Scientific Combined injury worsens outcome in humans

Hick JL, Weinstock DM et al. Disaster Med Health Prep 2011

Alert and Notification Prepare to receive Patients Earliest patients arrive at distant RITN centers Initiate G-CSF Day: Prodromal symptoms Preparation for HSCT Manifest illness Recovery

~40 radiological accident victims have been reported –More are known to have undergone HSCT after Chernobyl but details are limited –Treated with a variety of approaches and HSC products –Many had multiorgan dysfunction 4 survived more than one year –All 4 reconstituted autologous hematopoiesis –Unclear how many others would have –Almost none received growth factors prior to HSCT 25% died of transplant-related mortality HSCT for radiological injury: the experience

Highly heterogeneous exposure High dose rate - 22 second exposure at sterilization facility (15 Gy/min) Responded to cytokines - Cytokine treatment only Gourmelon et al. Health Physics 2010 Lessons learned from industrial accidents

22 Ongoing Initiatives Strengthen relationships with: State/local/territorial public health NDMS Pediatric treatment guidelines Support planning of outpatient and inpatient capabilities at non-RITN centers Educate non-physician hospital staff