Radiation Injury Treatment Network Cullen Case Jr., CEM, CHEP RITN Program Manager National Marrow Donor Program wk | mbl -Fortuna Favet Paratus- est. 2006

Avera McKenna WorkshopApril 10, “I continue to be much more concerned when it comes to our security with the prospect of a nuclear weapon going off in Manhattan,” -President Obama on March 25, 2014 Reminder of why we are here

Avera McKenna WorkshopApril 10, 2014 Describe the organization and history of RITN Explain RITN program and participant responsibilities Describe the patient profile for RITN Centers Describe the expected response process at the disaster site Describe the anticipated timeline of causality distribution to RITN 3 Objectives

Avera McKenna WorkshopApril 10, Bit of history…. and a little bit of science…. DreamWorks Animation SKG, Inc. From of accessed on 4/2/14http://

Avera McKenna WorkshopApril 10, First the science…. From: Medical Management of Radiological Casualties (Fourth Edition – July 2013) Military Medical Operations, Armed Forces Radiobiology Research Institute, Bethesda, Maryland accessed 4/3/14 From: Accessed 4/3/14http://

Avera McKenna WorkshopApril 10, to1987toToday History of Be The Match registry

7 Path to RITN National Organ Transplant Act of 1984 creates National Bone Marrow Registry Funding from the Office of Naval Research to improve outcomes from transplant includes contingency planning as a desired outcome Reminder of the importance of preparedness and possible threat Leading transplant organization champions need for preparedness of Hematology/Oncology physicians 13 Hospitals form as RITN in 2006 NMDP established 1987

8 Now: 69 Hospitals, Cord Blood Banks & Blood Donor Centers

RITN Center Locations 9

10

11 DHHS-ASPR: State and Local Planners Playbook for Medical Response to a Nuclear Detonation RDD Playbook RITN is Incorporated into Federal Plans

Avera McKenna WorkshopApril 10, RITN Centers are not 1 st Responders or trauma care specialists In the aftermath of a marrow toxic incident, RITN centers may: –Accept patient transfers to their institutions –Provide intensive supportive care to victims –Provide treatment expertise to practitioners caring for victims at other locations –Travel to other centers to provide medical expertise –Provide data on victims treated at their centers –Facilitate marrow transplant for those who require it RITN Center Staff are Cancer Specialists

Avera McKenna WorkshopApril 10, 2014 Network to treat casualties with radiological injuries 13 Military grade nuclear weapon Improvised Nuclear Device (IND) Radiological exposure device (RED) Radiological Dispersal Device (RDD) Industrial/nuclear power plant accident

Avera McKenna WorkshopApril 10, Hollywood or Hype?

Avera McKenna WorkshopApril 10, Wikipedia, June 2011

Avera McKenna WorkshopApril 10, From: Wikipedia Damage will not be as Catastrophic as a Military Nuclear Device

Avera McKenna WorkshopApril 10, Expected damage from 10 kT Device

Avera McKenna WorkshopApril 10, Effects of a 10 kT in Minneapolis (surface det.) Simulation created using NukeMap: nuclearsecrecy.com/nukemap/‎ Fireball 3 rd Degree Burns

Avera McKenna WorkshopApril 10, Fallout from 10 kT in MPLS

Avera McKenna WorkshopApril 10, 2014 Waselenko et al. Annals Int Med , ,000 Estimated Total Casualties

Avera McKenna WorkshopApril 10, 2014 US recent experience with Mass Casualties is limited to hundreds at most –Airplane crashes –Train wrecks –Oklahoma City 1995 –Loma Prieta earthquake 1989 –Aurora CO 2012 –9/11/ Are we ready? From: accessed 31Oct2011http://1918.pandemicflu.gov

Avera McKenna WorkshopApril 10, 2014 Radiation Casualty Estimates for an Improvised Nuclear Device 22 Radiation Dose (Gy)Care Requirement High Casualty Estimate (95 %tile) Mild ( )Outpatient monitoring91,000 Moderate ( ) Supportive Care and possible inpatient admission 51,000 Severe ( ) Intensive Supportive Care (most possibly including HCT) 12,000 Expectant (>8.3)Comfort Care47,000 Combined Injury and Radiation (>1.5) Stabilization and monitoring, pending resource availability 44,000 Table adapted from: Knebel AR, Coleman CN, Cliffer KD; et al. Allocation of scarce resources after a nuclear detonation: setting the context. Disaster Med Public Health Prep. 2011;5 (Suppl 1):S20-S31 ***Radiation doses are estimates based on clinical presentation and laboratory values.*** Estimate of 63,000 casualties for RITN

Capacity Survey Results Radiation-only casualties requiring monitoring, supportive care and possible transplant (~63,000) 2011capacity of RITN (13,000)

Avera McKenna WorkshopApril 10, Illustration from: Knebel AR, Coleman CN, Cliffer KD; et al. Allocation of scarce resources after a nuclear detonation: setting the context. Disaster Med Public Health Prep. 2011;5 (Suppl 1):S20-S31 Fallout May Cause the Most Radiation Injuries Dangerous Fallout Zone The dose in the Dangerous Fallout zone could cause marrow injury Sheltering-in-place is key to reducing dose, as the hazard dissipates relatively quickly

Avera McKenna WorkshopApril 10, 2014 Critical Concern from a Smaller Device or RDD? 25

Avera McKenna WorkshopApril 10, – Waste facility contamination of workers 2013 – Mexico stolen radioactive Cobalt Fukushima –Citizens stockpiled Potassium Iodide –Called public health officials as far away as Vermont and Massachusetts Goiania, Brazil –Scrap metal recyclers steal abandoned cancer radiation device –Open device and release Cesium –4 die & ~250 people contaminated –117, ,000 panic and request screening 26 Critical Concern: Public Panic

Avera McKenna WorkshopApril 10, 2014 Conceptual Flow of Victims to a RITN Center 27 Ad hoc First Aid Sites First Responder Medical Aid Stations State/Local Public Health Community Reception Centers NDMS Contracted Transportation FCC/NDMS Patient Reception Area Specialized Medical Care Facilities (burn, RITN, etc…) NDMS Contracted Hospitals Radiological Survey & Spot Decontamination Radiological Survey & Gross Decontamination Survey & Decon *** This model does not account for victims with trauma or no injuries.

Avera McKenna WorkshopApril 10, Timeline of RITN Response Day 1 Day 3 Day 30+ Day 7 Alert and Notification Early Symptoms – e.g., nausea and vomiting RITN Centers - review capabilities & prepare to receive casualties Earliest casualties arrive at RITN Centers near incident Daily/Periodic CBCs Discharge and return to home region Expected initial surge of casualties for RITN Centers Initiate G-CSF as soon as possible when indicated Clinical management Patient collection and transport to FCCs

Avera McKenna WorkshopApril 10, Only small portion of all casualties would be appropriate for RITN care 85% of casualties will have trauma or combined injuries and receive treatment elsewhere 15% will have “radiation only” injuries and be sent to RITN centers for definitive medical care Illustration of the small percentage of casualties with “radiation only” marrow-toxic injuries that likely would be moved through NDMS to RITN centers. Calculated from data provided in Knebel AR, Coleman CN, Cliffer KD; et al. Allocation of scarce resources after a nuclear detonation: setting the context. Disaster Med Public Health Prep. 2011;5 (Suppl 1):S20-S31

Avera McKenna WorkshopApril 10, Of the 15% there is further breakdown of what care would be provided From: Medical Management of Radiological Casualties (Fourth Edition – July 2013) Military Medical Operations, Armed Forces Radiobiology Research Institute, Bethesda, Maryland accessed 4/3/14 Level of severity is due to the level of exposure

Avera McKenna WorkshopApril 10, 2014 Daily CBCs to determine clinical need for treatment Follow standard approaches for patients with bone marrow toxicity from chemotherapy –Blood products - irradiated and leukoreduced –Antibiotics, IV fluid, other support and G-CSF (cytokines) –Hospitalization when indicated Critical stopgap is access to pharmaceuticals (JIT) Biodosimetry using online algorithms (REMM) –Blood counts (before and after arrival at hospitals) –Geographic dosimetry –Opportunity to apply new biodosimetry approaches 31 Casualty Care

Avera McKenna WorkshopApril 10, RITN Initiatives

Avera McKenna WorkshopApril 10, Preparedness Efforts Standard Operating Procedures at each center Site readiness assessments Annual tabletop exercise Annual training/education requirement Emergency communications equipment at each center

10,293 total Totals since 2006: 265 REAC/TS 2,981 GR 3,680 BRT 2,826 Overview 541 Conference

Avera McKenna WorkshopApril 10, 2014 Site Assessments Tabletop exercises attended Web based training released ( 1.Intro to RITN 2.RITN Concept of Operations 3.GETS Satellite telephone Basic Radiation Training 6.Non-medical Radiation Awareness Training Mayo Full-scale Exercise 2 x Web based tabletop exercises Mobile REAC/TS held at Duke University 2 x resident REAC/TS courses New Partnership with CMCRs 4 th biennial conference w/ 175 attendees Highlights

Avera McKenna WorkshopApril 10, 2014 Addition of 5+ transplant centers Release RITN Referral Guidelines mid 2014 Collect triage guidelines for release late 2014 Regional collaboration meeting for NY-NYC G-CSF distribution project with ASTHO and CDC 2 x Mobile REAC/TS training sessions (Boston & Chicago) Review of updated REMM ARS guidelines Medical staff risk communications training development Exercises: Full-Scale Exercise in Boston, 3 x Web based TTX, Communications drill with DHHS-ASPR Projects

Avera McKenna WorkshopApril 10, RITN Preparedness Efforts Readiness exercises/events –Annual RITN directed tabletop exercise –Top Officials IV (TOPOFF) (2007) - DHS –Pinnacle 07 (2007) – DHHS-ASPR –ConvEX 2008 – IAEA –Democratic National Convention (2008) –Republican National Convention (2008) –National Level Exercise 2010 (NLE 2010) Emergency communications equipment at each center –Government Emergency Telecommunication Service (GETS) calling cards –Satellite telephones

Avera McKenna WorkshopApril 10, Resources

Free Resources  &seriesId=0&issueId=S1   ear/Documents/statelocalplaybook-v1.pdf  

Avera McKenna WorkshopApril 10,

Avera McKenna WorkshopApril 10, Additional References:

Avera McKenna WorkshopApril 10, accesses 6/3/2011 Conclusion

Avera McKenna WorkshopApril 10, 2014 Magnitude would overwhelm the nation –The response will be chaotic; no matter what –Still need to prepare, educate and exercise –Work smart so efforts are a “twofers” –Dangerous fallout injuries could be majority of IND casualties History shows that a bomb isn’t necessary; as panic will ensue following any radiological incident There is apathy at many levels of the planning process –This is due to a lack of understanding, competing priorities and lack of funding Cancer Treatment Centers are often overlooked –Essential to response to a mass casualty radiological incident Logistical Nightmare: just in time inventory of Rx 43 Conclusions: Blinding Flashes of the Obvious

Avera McKenna WorkshopApril 10, Not 1 st Responders or trauma care 2.Expect to see surge 7-10 days after incident 3.If incident is local: the local RITN centers focus is on incident response not RITN 4.Casualties should not be significantly contaminated when they arrive at a RITN center 5.Affiliated with National Disaster Medical System: a)Casualty distribution is through NDMS b)Reimbursement is through NDMS 5 key things to remember about RITN

Avera McKenna WorkshopApril 10, accesses 6/8/2011