1. Daniel Kollek, MD, CCFP(EM)
Public Health CBRN course
CBRN overview
Daniel Kollek, MD, CCFP(EM)
Questions
Which of the following is not a chemical agent class
1- Hallucinogenic agent
2- Blister agent
3- Pulmonary agent
4- Blood agent
What class of bioterror agent is Glanders?
1- A
2- B
3- C
4- D
Of the following radiation source which is ionising?
1- Radiation from microwaves
2- Radiation from television
3- Radiation from the sun
4- Gamma rays

2. Goals of session
To provide an overview of the categories and actions of CBRN agents and the roles of Public Health in responding to them

3. Outline of session Definitions Chemical overview Biological overview
Radiological overview
Nuclear overview
Roles of public health

4. Definitions Chemical Biological Radiological Nuclear Public Health role

5. (1) Definitions
Disaster
The Merriam-Webster dictionary definition of disaster is "a sudden or great misfortune."
The Medical definition if a disaster is "when the destructive effects of an event overwhelm the ability of a given area or community to meet the demand for health care."

6. Mass Casualty Incident
(1) Definitions
Mass Casualty Incident
A disaster that is typified by a large number of patients that outstrip resources on the basis of numbers of individuals requiring care.

7. (1) Definitions
CBRN
Disasters contaminated by an agent that can be Chemical Biological Radioactive or Nuclear. Each one of these has specific response needs .
Also known as NBC or ABC

8. (1) Definitions
Terrorism
A terror attack is defined as an attack targeted at civilian non-combatants for the purpose of affecting the government that represents them. A successful terror event involves large number of casualties, may involve CBRN contaminants, causes infrastructure damage and has a psychological impact
From a planning viewpoint the issue of the target is key because it determines what type of casualty will be involved and where they will occur. Let me give you an example of how, in a very concrete way this affects emergency planning.
An military attack on an armed compound will involve military casualties, mainly healthy male, young, trained fighters with a support system usually on site to provide them with help when injured.
In contract a terrorist bomb in a supermarket will kill shoppers. These will involve a mix of genders and ages though they would tend to be most often women, sometimes with children in tow. So the EMS system has to be able to intake elderly, women, children, possibly pregnant victims, all of who will never be seen in combat zone.
Also in a military compound the medical support is on site. This is as opposed to a bomb in a disco for example where all the seriously injured need to be transported to medical care.
So the planning issues are very different for terrorist attacks and we need to consider these carefully.
Large number of casualties
May involve NBC contaminants
Infrastructure damage
Psychological impact
That is all I am going to say about the definition of terrorism. It is not a political definition, it is not a historical definition, it is a practical matter of who was the assailant trying to kill.

9. Definitions Chemical Biological Radiological Nuclear Public Health role

10. Chemical Agents What is a hazardous material?
How do we classify chemical agents?
What are the chemical agents we worry about (and why)?
What type of incidents might we face?

11. Hazardous Material A substance is considered hazardous when,
(2) Chemical
Hazardous Material
A substance is
considered
hazardous when,
because of its quantity,
concentration, or
physical
characteristics, it
poses a real hazard
to human health or the environment
Accidents occur even in the safest of environments.
The USA produces 60,000 chemicals of which 57,500 are in the workplace and 53,000 are potentially hazardous.
Every year 4 billion tons are transported between 100,00 north American locations.
In 1994 CHEMTREC(Chemical Manufacturers Emergency Response phone service) logged over 200,000 calls, 4% of which were directly related to HAZMAT emergencies
Mississauga train derailment 1979

12. Chemical Agent Classification
Nerve agent
– organophosphate based, insecticides
Blister agent
– Vesicants
Pulmonary agent
– Choking (ie Phosgene, Chlorine)
Blood agent
- Cyanide
Other agents
Pepper spray, Tear gas, CS, OC
Nerve agent – organophosphate based
Tabun GA, Sarin GB, Soman GD, VX, insecticides
Blister agent – Vesicants
Mustard agents HD, Lewisite L
Pulmonary agent – Choking
Phosgene, Chlorine
Blood agent
Cyanide
Other agents
Pepper spray, Tear gas, CS, OC

13. (2) Chemical
“TICs and TIMs”
Toxic Industrial Chemicals
Irritants (chlorine, phosgene, hydrogen chloride, ammonia, isocyanates)
Pharmacologic-like agents (cyanide)
Hydrocarbons
Alcohol-based solvents
Corrosives (acids & bases)
Pesticides (organophosphates and others)
Smoke
Riot Control (Tear Gas & Pepper Spray)
Industrial chemicals are present in large quantities in every community They are a significant hazard to nearby populations both from accidental or deliberate release. Some industrial chemicals, like phosgene and chlorine, have been used successfully in chemical warfare. These chemicals are principally an airborne hazard and cause acute respiratory injury. Cyanide and agricultural organophosphates act pharmacologically and may require antidotal therapy. All these chemicals can exacerbate preexisting disease, such as asthma, chronic obstructive pulmonary disease or coronary artery disease. Persons with a history of reactive airway disorders may, in fact, be sentinel cases for exposures to chemicals which lack reliable warning properties (phosgene is an example).
Toxic smokes are complex mixtures with a variety of effects. They contain strong respiratory irritants which can injury respiratory tissue form the upper airways to the alveoli. They contain carbon monoxide which is a potent inhibitor of oxygen transport. Aerosols and particles in smoke can deposit on skin a create local injury.
Riot control agents are powerful mucosal irritants that are disseminated as particulates. CS and other riot control agents that include arsenic can produce serious chemical burns.
Extremely toxic chemical warfare agents like sarin have no commercial purpose, but they can be manufactured and disseminated as happened in Japan.
Industrial Chemical and Terrorism; Human Health Threat Analysis, Mitigation and Prevention” ATSDR
Pesticides – most common agent causing ED closure
Toxic Smoke – intentional releases of different agents (environmental terrorism)
Riot Control Agents (pepper spray, mace)
Chemical Warfare Agents (vesicant & nerve agents)

14. Incident Types (2) Chemical Small, localized HazMat Incident
84% of incidents occur at fixed sites
70% involve 1 or 2 victims
90% are ambulatory
Liquid contamination more common
Greater need for showering
Chemical MCI
Most commonly gas or vapor exposure
Most exposures are mild with few significant toxic effects
Beware of incidents in enclosed spaces
Clothing removal is the focus of decontamination

15. Response to chemical agents
Decontamination
Antidotal therapy
2PAM,
Atropine,
Benzodiazepines
Decontamination:
Vapour exposed patients are usually not a hazard to others as compared to liquid exposure. Most patients who arrive in hospital after liquid exposure will be only slightly exposed otherwise they would not have survived.
Patients can off-gas so until decontamination staff should wear self contained breathing apparatus (did not happen in Tokyo).Usual masks have no value.
Strip & seal clothes and belongings
Regular gloves, even double gloves provide no protection - need rubber
Patients must be copiuosly washed down (bleach and cool water to avoid vasodilation). No abrasives, recommendation is to shave off hair.
Rapid assessment
Difficult assessment because of potential for delayed symptoms and difficulty differentiating from psychogenic illness.
Triage is “on basis of likelihood of survival with the available resources”
Antidotal therapy
Supportive therapy
Disposition

16. (3) Biological
Definitions Chemical Biological Radiological Nuclear Public Health role
-Biological agents are living organisms ( or the toxins & byproducts produced by living organisms ) that can cause disease (deliberately or through a natural outbreak) in the target population
-Biological warfare is mentioned in the bible
Black Plague spread across Europe along trade routes
-Plague victims were catapulted over castle walls during war
Europeans traded infected goods with indigenous people
During WWII the Japanese were the leaders in their biological weapons program
-After the war the United States used a lot of the Japanese research and refined, “improved upon” and then expanded their biological weapons programs
-In 1972 an international treaty banned the development or use of biological weapons
-Many nations continued to develop biological weapons including the former Soviet Union and Iraq
-Today one of the biggest threats is the dissemination of information on the internet. Numerous groups and individuals have posted biological agent information on the internet. Including production, development and manufacturing.
Many of the Biological pathogens also occur in nature and are easily transmitted to humans by vectors. Many biological agents are not restricted or monitored by any agency. They can easily be acquired by any individual. Example Ricin plants can be purchased at many gardening centers.

17. Types of Bio-agents Bacterial Viral Toxins (3) Biological Bacteria
Self-sustaining organisms that do not require a host to reproduce
Viruses
Require a host to function and survive
Toxins
Biologic toxins are non-living, poisonous chemical compounds that are produced by living organisms (animals, plants, and microorganisms)

18. Characteristics of Bio-agents
(3) Biological
Characteristics of Bio-agents
Low visibility
High potency
Latency
Easy accessibility
Simple delivery
Good sustainability and propagation
Does Not Affect Structures
Low visibility - Usually odorless, tasteless and delayed onset
High potency -1/1,000,000th gram of anthrax is a lethal dose.
Easy delivery -Simple aerosolisation is sufficient
Substantial accessibility – you can grow your own!
What does this mean in the real world? The latency means that there may be a lot of patients but the onset of the crisis will be gradual, the bed consumption can be divided between hospital and community. They are easy agents to spread and are naturally occurring so access is not an issue.
The major problem with bio agents is that their latency makes them hard to detect as well as making it difficult to collect epidemiologic data to verify an outbreak. The mainstay of our emergency response has to be detection. The sooner we know that there is something going on the sooner we can respond, be it by invoking a pandemic plan or isolation or vaccination or military response. The longer it takes us to ramp up our response the more people will be infected and thus the more lives put at risk and more resources expended
=======================================================================
Most modern armies, despite denial, likely have stockpiles of bio-agents. In 1979 there was an accidental release of Anthrax from a military depot in the Soviet Union with a down-wind epidemic.
The, latency, ease of acquisition and delivery makes these agents excellent terror or sabotage weapons.
And again, in case you think we only need to be ready for a malicious bio attack let me remind you of this recent event: Beef is perfectly safe and a good product” Douglas Hogg, British Agriculture Minister, November I995
For example, if you had a biotoxin on your hand, lets say you sneezed and wiped your nose without thinking twice, then you went about at this conference shaking hands with people you meet and contaminating them. These people are now carriers of the bioweapon you delivered and will pass it on to the individuals they meet. Within a few coffee breaks – where most of the handshaking occurs –a sizeable portion of the delegates are carriers and some may be infected. Then they go home. After a while doctors in Kelowna, Oshawa, Winnipeg, Calgary, are all seeing patients with a cold that “just happened”. You can see the problem in trying to make a coherent picture out of this. If the agent you transferred was Ebola and the initial presentation was a non specific illness it would take a few deaths to be able to realise there may be a problem and by that time the dissemination phase of the bioattack has already happened.

19. Entry Modes Inhalation Ingestion Injection Absorption (3) Biological
Particle Size
0.5 – 1.0 um smoke like, too small and will be exhaled
um weapons grade, inhaled down to alveoli
5.0 – 10 um stops in upper airway
The particle size is very important determining factor for an agent effectiveness. To small or big and it is less effective. There are biological agents naturally that do not cause disease in humans. These ranges are not absolute as particles of any size can be infective dependant on the organism involved and the location of the release i.e. indoors in a confined space vs. outdoors.

20. Bioterrorism agents (3) Biological Category A Diseases/Agents
Organisms that pose a risk to national security because they:
can be easily disseminated or transmitted from person to person;
result in high mortality rates and have the potential for major public health impact;
might cause public panic and social disruption; and
require special action for public health preparedness.

21. A level bioterrorism agents
(3) Biological
A level bioterrorism agents
Anthrax (Bacillus anthracis)
Botulism (Clostridium botulinum toxin)
Plague (Yersinia pestis)
Smallpox (variola major)
Tularemia (Francisella tularensis)
Viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo])

22. Bioterrorism agents Category B Diseases/Agents
(3) Biological
Bioterrorism agents
Category B Diseases/Agents
Second highest priority agents include those that:
are moderately easy to disseminate;
result in moderate morbidity rates and low mortality rates; and
require specific enhancements of laboratory diagnostic capacity and enhanced disease surveillance.

23. B level bioterrorism agents
(3) Biological
B level bioterrorism agents
Brucellosis (Brucella species)
Epsilon toxin of Clostridium perfringens
Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella)
Glanders (Burkholderia mallei)
Melioidosis (Burkholderia pseudomallei)
Psittacosis (Chlamydia psittaci)
Q fever (Coxiella burnetii)
Ricin toxin from Ricinus communis (castor beans)
Staphylococcal enterotoxin B
Typhus fever (Rickettsia prowazekii)
Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis])
Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)

24. Bioterrorism agents Category C Diseases/Agents
(3) Biological
Bioterrorism agents
Category C Diseases/Agents
Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of:
availability;
ease of production and dissemination; and
potential for high morbidity and mortality rates and major health impact.

25. C level bioterrorism agents
(3) Biological
C level bioterrorism agents
Emerging infectious diseases such as Nipah virus and hantavirus

26. (4) Radiological
Definitions Chemical Biological Radiological Nuclear Public Health role
Radioactivity is present in nature and all around us. It is in our food, water, and even in our bodies. We live in a naturally radioactive world.
Natural radiation was discovered in 1896 and was soon being used for medical research purposes with the invention of the X-ray.
1934 the first man made radioactive substance was manufactured
Quickly thereafter, radiation was discovered to have devastating effects on living tissue in high doses
Many uses for radiation have been discovered and are being used today: cancer treatment, energy production, numerous uses in the manufacturing industry
Many fears and lack of knowledge surround the radiation industry

27. What Is Radiation? Radio/TV Sun Nuclear Heat Light Microwave
(4) Radiological
What Is Radiation?
Radio/TV
Sun
Nuclear
Heat
Light
Microwave

28. Electromagnetic Spectrum
(4) Radiological
Electromagnetic Spectrum
Increasing Energy and Frequency
Radio/TV
Microwave
X-ray
Gamma
Electrical Power
Light UV
IONIZING RADIATION
NON-IONIZING RADIATION
Increasing Harm

29. Health Effects of Radiation Exposure
(4) Radiological
Lethal at high doses
Mutagenic
Carcinogenic
Other biological effects, especially at high doses

30. Decrease Radiation Effects
(4) Radiological
Decrease Radiation Effects
Time: Decrease time spent near the radioactive source
Distance: Increase distance between you and the source
Shielding: Increase the physical shielding between you and the source

31. Dose Reduction Factors
(4) Radiological
Common Shelters
Structure
Dose Reduction Factors
Wood Frame (1st floor)
10%
Wood Frame (Basement)
40%
Masonry
Large building
80%
From the Environmental Protection Agency’s Manual of Protective Action Guides and Protective Actions for Nuclear Incidents, Appendix C

32. Potential Terrorist Scenarios
(4) Radiological
Potential Terrorist Scenarios
Radiological
Radiological dispersion device; e.g., “dirty bomb”
Malicious use of radioactive substances
Nuclear
Attack on nuclear facility
Nuclear weapon
Improvised nuclear device (IND)

33. Mass Radiological Casualties
“For an improvised nuclear device >100,000 patients could require evaluation and treatment.”
Department of Homeland Security Working Group on Radiological Dispersal Device (RDD) Preparedness, Medical Preparedness and Response Sub-Group Report (May, 2003)

34. Radioactive Sources 157,000 licensed users in U.S.
(4) Radiological
Radioactive Sources
157,000 licensed users in U.S.
2,000,000 devices containing radioactive sources
Approximately 400 sources lost or stolen in U.S. every year

35. Sources Around the World
(4) Radiological
Sources Around the World
Recovered transport container
Sources used in mobile cesium irradiators in the former Soviet Union
Photos courtesy of the International Atomic Energy Agency (IAEA)

36. Goiânia Radiological Release
Obsolete radiotherapy machine
Abandoned cancer clinic
Photos courtesy of the International Atomic Energy Agency (IAEA)

37. Photos courtesy of the International Atomic Energy Agency (IAEA)
(4) Radiological
Goiânia Morbidity
249 exposed; 54 hospitalized
Eight with radiation sickness
Four people died
112,000 people monitored (>10% of total population)
Photos courtesy of the International Atomic Energy Agency (IAEA)

38. How do you categorize exposures?
(4) Radiological
How do you categorize exposures?

39. Categorization External contamination Patient is radioactive!
(4) Radiological
Categorization
External contamination
Patient is radioactive!
Remove all clothes is most important part of decontamination
Irradiation - local or whole body
Patient is not radioactive and poses no risk to others!
Ingestion
Body fluids may be radioactive
Combination of above
Method of ingestion and type of isotope will determine the location of the material.
Inhaled small particles are more likely to settle in alveoli
Larger inhaled particles may move to GI tract
Some compounds have enterohepatic circulation
Lugols iodine reduces uptake of some nucleotides
EDTA and Penicillamine chelate some nucleotides
Save all body fluids for dosimetry
Polonium 210

40. (4) Radiological
Remember!
Categorisation determines risk to others and can identify specific therapeutic steps to be taken
Dose determines severity, treatment plan and prognosis

41. (5) Nuclear
Definitions Chemical Biological Radiological Nuclear Public Health role

42. Key Issues in Nuclear Event
Same concerns as radiation event
Added concerns of mass trauma and major system disruption

43. So what have we learned so far?

44. CBRN comparison Onset Slow Rapid Transmission/ infectivity
Biologic
Nuclear/ Radn
Chemical
Onset
Slow
Rapid
Transmission/ infectivity
Slow, Agent dependant
Particulate only, Fast
Fast, Agent dependant
Detection
Difficult
Easier
Resource consumption
Gradual, long term
Rapid, short and long term
Rapid, short term
Some long term
Public Health involvement
Short & long term
Short term
Bed use
Mixed
Hospital
Decon. requirements
Agent dependant
Critical for particulate
Critical for all
Antidote
None
Class dependant
So every agent is different. What we can say with a degree of certainty is that significant Atomic and Chemical events will require a rapid deployment of massive resources while bio-events are more easily responded to because of the latency of onset and case findings

45. (5) Public Health
Definitions Chemical Biological Radiological Nuclear Public Health role

46. Public Health Role Early Detection Mass Patient Care
Mass Immunization/Prophylaxis
Epidemiologic investigation
Communication
Command and Control
– enhanced surveillance for clinical syndromes, real-time data from heterogeneous data sources, early warning alerts, rapid epidemiological assessment and laboratory identification
rapid expansion of health care system, triage, staffing, isolation/quarantine & treatment protocols, integration w/ regional, State & National Disaster Medical Assistance Teams (DMAT)
- access to local, State and National Pharmaceutical Stockpile Program (NPSP), set-up, staffing, security
access to local, State and National Pharmaceutical Stockpile Program (NPSP), set-up, staffing, security
rapid expansion of morgue facilities Disaster Mortuary Teams (DMORT), victim identification, family notification, autopsy processing, decontamination
assessment, sampling, scene management & mitigation, environmental quarantine, bio-hazardous waste management…
known scene vs covert release, County Emergency Operations Center (EOC), public information, quarantine…

47. Public Health Role (2) Mass Fatality Management
Evacuations/sheltering (humans and animals)
Environmental Surety
Community Recovery (rapid health risk assessment, mental health etc)
– enhanced surveillance for clinical syndromes, real-time data from heterogeneous data sources, early warning alerts, rapid epidemiological assessment and laboratory identification
rapid expansion of health care system, triage, staffing, isolation/quarantine & treatment protocols, integration w/ regional, State & National Disaster Medical Assistance Teams (DMAT)
- access to local, State and National Pharmaceutical Stockpile Program (NPSP), set-up, staffing, security
access to local, State and National Pharmaceutical Stockpile Program (NPSP), set-up, staffing, security
rapid expansion of morgue facilities Disaster Mortuary Teams (DMORT), victim identification, family notification, autopsy processing, decontamination
assessment, sampling, scene management & mitigation, environmental quarantine, bio-hazardous waste management…
known scene vs covert release, County Emergency Operations Center (EOC), public information, quarantine…
Promptly investigate original case
Confirm laboratory results
Identify & interview case contacts as needed
Initiate active surveillance for additional cases
Take immediate public health prevention action as needed
Collaborate/notify Provincial Ministry of Health, others as indicated
Alert local medical community/public
Determine need for Rx of contacts/health professionals
Mobilize needed assets at local, provincial, federal level
Maintain contact with case family & reporting MD

48. Questions ???