1. Polonium-210: International follow-up HPA Overseas Advice Team Babatunde Olowokure, Karen Shaw, Jennifer R H Smith, Katie Anders, Sue Frossell, Kenny Yap, Barry Evans November 2007

2. Polonium-210: International follow-up Overview Process : what happened ?  Communication  Workload  Challenges Results : what do they show ? Public Health planning : what have we learned ?

3. Polonium-210: International follow-up Process: communication – information flow Bar & Hotel cohort Individuals contacting OAT independently Overseas Advice Team (OAT) overseasadvice@hpa.org.uk Liaison point for all international queries Foreign and Commonwealth Office Briefed Ministry of Health Briefed Representatives of Countries and Territories Briefed Public Health and/or Radiation Departments Contacted to Initiate Follow-up

4. Polonium-210: International follow-up Process: communication – risk assessment & testing OAT/IPH risk assessment Potentially at risk Not at risk No further action Reassurance given by IPH colleagues International Public Health and/or Radiation Departments Contacted to Initiate Follow-up Urine Test Test conducted overseas Test conducted in UK Test refused Results given to individuals and copied to HPA Results sent to individuals and copied to IPH colleagues OAT database (used to produce daily situation reports and country summaries)

5. Polonium-210: International follow-up Process: workload More than 2500 emails received between November 2006 and March 2007 At the height of the incident 21 staff – 8 full time Continuous liaison with international public health and radiation colleagues to communicate risks and guidance Maintaining up to date and accessible records of status of each country Daily briefings for HPA CEO, Cabinet Office, Police

6. Polonium-210: International follow-up Process: challenges Striking the right balance…  In ensuring effective communication with appropriate people  Encouraging countries to keep us informed of progress of follow-up  Between being too directive (“this is what you must do”) and not directive enough (“what do you expect us to do ?”) Nature of a dynamic rather than static incident …..  Changing risks as a result of police investigation lead to new people identified for follow-up  Criminal investigation meant rationale for changing risk assessments was sometimes confidential

7. Polonium-210: International follow-up

8. Results: distribution of individuals by continent Continent No. of Countries Individuals initially identified for follow-up Self- identifiers Total North America216356219 Central & South America2415 Africa410111 Asia149815113 Europe28166130296 Australasia218119 Unknown-101 Total52460204664

9. Polonium-210: International follow-up Results: who underwent urine testing? EXPOSURE CATEGORY NUMBER OF INDIVIDUALS URINE TESTED n (%) Exposed (e.g. contaminated rooms, Hotel Bar) 15748 (31%) Risk not known (not known whether visited Hotel Bar) 16260 (37%) Not Exposed (e.g. Sushi Bar, or hotel guests that did not visit contaminated areas) 34568 (20%) TOTAL664176 (27%)

10. Polonium-210: International follow-up Results: urine test results Below RL = Below reporting level, 30 mBq/day. Includes those reported as ‘negative’. Continent Total Number Not At Risk Urine Test Result Reported Declined Testing or Lost to follow up Below RL >RL and <1mSv 1 - 6 mSv ≥6 mSv Africa11140006 Asia112404712022 Australasia191520002 Europe2971328552073 North America2198225210109 Central & South America 5300002 Unknown1000001 Total664273163850215

11. Polonium-210: International follow-up Public health planning: what lessons have we learned Difficulties with international communications  Time zones necessitated mainly email contact  Appropriate named contacts were not always known  Time taken for follow-up in some countries lead to lack of complete information at HPA Confidentiality  A secure system is needed for transmitting patient identifiable information via email  Aspects of the criminal investigation relevant to the public health response can not always be communicated

12. Polonium-210: International follow-up Public health planning: what lessons have we learned Intelligence and Data management  A good information system is essential and needs to be available early in the incident  Management of email correspondence requires robust systems of filing and tracking progress Surge Capacity  Consistent and sufficient staff are required from early on and for the duration of the incident  Adequate cover must be provided for the day jobs of incident staff  Plan for it to go longer than expected Public health implications of radiological incidents  International significance not as well understood as for microbiological incidents

13. Acknowledgements International Public Heath and Radiation Colleagues HPA The Overseas Advice Team HPA Centre for Infection HPA London Regional Epidemiology Unit HPA Local and Regional Services HPA Radiation Protection Division Professor Nigel Lightfoot Foreign and Commonwealth Office Metropolitan Police Counter Terrorism Unit Thankyou