Judith Monroe, the committee member moderating this August workshop panel, opened by citing two recent examples of public health emergencies that took place in Indiana—a full-scale exercise run by the Indiana National Guard (2007) and an actual event, the emergency evacuation of a hospital in Indiana due to flooding (2008).

The 2007 Ardent Sentry exercise in Indiana was conducted to test the military’s ability to collaborate with nonmilitary emergency responders in responding to a domestic incident of national significance. The scenario was an IND detonation in Indianapolis, tainting the water, destroying seven hospitals, and putting 300,000 people on the roads trying to escape. It was a several-day exercise involving about 5,000 participants, including hundreds of simulated casualties. The exercise revealed communication and coordination problems stemming from the mismatch between the military’s top- down organization and the civilian bottom-up structure. Also, emergency responders found it difficult to develop a common operating picture or implement a common plan, which led Indiana to increase training in these skills. Communication problems led to a delayed activation of the National Disaster Medical System (NDMS).

The 2008 incident in Indiana was an actual public health emergency. Flooding forced the evacuation of a 135-bed hospital, 2 nursing homes, a dialysis clinic, and 8 group homes near Columbus. The hospital basement was flooded, destroying the power generators and the laboratory, and all entrances but one were blocked. The hospital staff learned that there was no time to pull their plans from the shelf and that, in any case, the plans did not fit the circumstances. They found instead that they benefited greatly from a functional exercise that they had conducted a year earlier. Although the exercise was for a mass casualty surge situation rather than an evacuation, the prior experience with the Incident Command System was very valuable. The Indiana National Guard, whose base was nearby, assisted in the evacuation and provided security. The Carolinas MED-1 unit with its mobile hospital was brought in to provide services while the flooded hospital was out of commission.

Monroe introduced the panel, which consisted of U.S. Public Health Service Captain Ann Knebel, deputy director of preparedness planning in the Office of the Assistant Secretary for Preparedness and Response (ASPR) at HHS; Alan Remick, consequence management program coordinator in the Office of Emergency Response of the National Nuclear Security Administration at DOE; Col. Daniel Bochicchio of the National Defense University and, until recently, vice chief surgeon in the National Guard Bureau; and James Blumenstock, who is with the Association of State and Territorial Health Officials.

Ann Knebel began by providing an overview of the medical assets that HHS could deploy in a nuclear event as well as of HHS’s response plans. HHS has a number of medical assets, and she described the major ones among them:

  • Medical Reserve Corps (MRC). MRC is composed of more than 160,000 medical and public health professionals organized in approximately 700 units across the country who serve as volunteers in responses to natural disasters and emergencies.

  • Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP). ESAR-VHP is composed of individual health professionals who volunteer to help in emergencies.

  • National Disaster Medical System (NDMS). NDMS is a cooperative effort of HHS, DHS, DoD, and the Department of Veterans Affairs (VA) to supplement state and local medical resources during major disasters or emergencies.37

    NDMS has three components: (1) approximately 5,000 volunteers in 93 response teams, most of them disaster medical assistance teams (DMATs) for general disaster medical assistance, but some specializing in areas such as burns, pediatrics, and mental health; (2) approximately 1,800 nonfederal hospitals that have volunteered to provide approximately 110,000 acute care beds in a national emergency, along with VA hospitals; and (3) aeromedical evacuation services provided by DoD using Air Force assets and, if needed, the Civil Reserve Air Fleet (CRAF).

    A fully operational, or Level One, DMAT response team has 35 medical and paramedical members, is ready to deploy in 6 hours, can be on the ground and operational within 48 hours, and is equipped to treat 250 ambulatory patients a day (or 125 patients a day including approximately 8 inpatients at a time and limited laboratory and pharmacy services) for 3 days without resupply. A National Medical Response Team with 50 members is trained to provide medical care following a nuclear, biological, or chemical incident, including mass casualty decontamination, medical triage, and primary and secondary medical care to stabilize victims for transportation to tertiary care facilities in a hazardous material environment.

  • U.S. Public Health Service commissioned corps teams. There are five rapid deployment force (RDF) teams, one of which is on 12-hour notice at any given time. Each RDF team has 105 officers with clinical, public health, or mental health expertise.

  • Radiation Event Medical Management (REMM). REMM is an online tool developed by ASPR and the National Library of Medicine. REMM can be accessed for just-in-time information and treatment protocols for radiation exposure (Bader et al., 2008).

  • Radiation Injury Treatment Network (RITN). RITN was established by ASPR, the National Marrow Donor Program, and the National Cancer Institute. It is composed of transplant and cancer centers familiar with treating bone marrow suppression and other aspects of radiation injury (Weinstock et al., 2008).

  • Radiation Treatment, Triage, and Transport (RTR) system. The RTR system is being developed by HHS as a model for medical response to a nuclear detonation. The concept is to collect victims in three types of locations by type of medical problem: (1) those with major trauma who were in the high radiation zone around ground zero, (2) those without traumatic injury but at high risk of developing ARS, and (3) those with minimal or no radiation exposure and no significant trauma who do not require immediate medical care. Victims would then be directed to medical care sites, if they need immediate medical care, or assembly centers, if they do not need immediate medical care (Coleman et al., 2008; Vanderwagen, 2008).38

Under the NRF, HHS is the lead federal agency for public health and medical services in a national emergency. In this role HHS coordinates the activities of the other federal agencies with relevant assets and programs under Emergency Support Function #8 (ESF-8), “Public Health and Medical Services.” HHS also has a broad public health and medical services role under the Nuclear/Radiological Incident Annex to the NRF.39

ASPR, under the broad guidelines of the NRF and related policy documents, such as ESF-8 and the NRF nuclear/radiological annex, has been developing “playbooks” for each of the 15 NRF National Planning Scenarios, including Scenario 1, which is the detonation of a 10-kt IND. Each playbook includes sections on the scenario, a concept of operations (CONOPS) for the response, action steps, pre-scripted mission subtasks, and essential elements of information. CONOPS specifies the role of each agency, and the action steps include a trigger for each step, a recommended strategy to follow, and specific actions to take. ASPR has put the playbooks for hurricanes and aerosolized anthrax attacks on its website so that state and local planners can see what federal capabilities might be deployed and how.40 ASPR plans to publish each of the playbooks, with the ones for RDD and pandemic influenza events as the next to be posted.41

Alan Remick summarized DOE’s resources for responding to a nuclear event such as a terrorist IND attack. The mission of DOE’s Office of Emergency Response in the National Nuclear Security Administration is to provide expert technical information and advice in a nuclear radiological event. Specifically, DOE has a number of rapidly deployable capabilities that it can use in responding to a broad range of radiological incidents, such as those involving nuclear power or nuclear weapons production facilities, a nuclear weapons accident, or lost or stolen radioactive materials.42 The capabilities most relevant to consequence management in response to a large-scale radiation event such as the detonation of an IND include the following:

  • Atmospheric Release Advisory Capability (ARAC). ARAC, located at Lawrence Livermore National Laboratory, has sophisticated computer models that can provide near-real-time assessments of the consequences of actual or potential radiation releases by modeling the movement of hazardous plumes. The plume models are based on real-time weather data, a terrain database, and a three-dimensional transport and diffusion model. The model results are presented in terms of ground deposition plots, instantaneous and time-integrated doses, and airborne concentrations, which can be used to inform protective action decisions. ARAC is available 24 hours a day.

  • Aerial Measuring System (AMS). AMS has aviation-based equipment capable of surveying large areas in response to radiological emergencies. An all-weather fixed-wing aircraft can arrive quickly to perform quick radiation surveys of an area where fallout has been deposited and where exposure rates are very high. Helicopters arrive more slowly but can conduct detailed aerial surveys over the course of several days and produce exposure-rate contour maps and determine which isotopes are involved.

  • Radiological Assistance Program (RAP). Seven-person RAP teams are based around the country, with at least three in each of nine regions (with most team members working in one of the national laboratories). The teams would arrive within 6 hours of an event to assist state, local, and other federal agencies in the detection, identification, and analysis of radioactive materials (such as fallout) and with the appropriate response to an event involving radiological or nuclear material. The teams’ expertise includes assessment, area monitoring, air sampling, and exposure and contamination control. They would be a resource for the local incident commander.

  • Radiation Emergency Assistance Center/Training Site (REAC/TS). Located at Oak Ridge, Tennessee, REAC/TS is staffed with physicians and health physicists who conduct training on the medical aspects of radiation exposure and who are available at all times to deploy and provide EMS at radiation incidents. In the event of an IND detonation, REAC/TS is not large enough to deploy and treat people, but it would provide advice and consultation on radiation emergency medicine. It has one of the few U.S. cytogenetic dosimetry laboratories, but these laboratories would be quickly overwhelmed in a mass casualty nuclear situation. It has a stockpile of DTPA and Prussian Blue, but the stockpile is very small compared with the amounts in the SNS. Perhaps its main contribution in the immediate response to an IND detonation would be the state and local responders it has trained in emergency radiation medicine, some of whom would likely be onsite or nearby.

  • Federal Radiological Monitoring and Assessment Center (FRMAC). FRMAC would integrate the various DOE assets to provide a common operating picture of the radiological environment for whoever is managing the incident. FRMAC is a multiagency organization that would also include response personnel from EPA, DoD, National Guard, and other agencies.

Ideally, the DOE response would take place according to the following pattern:

  • ARAC would provide an initial predictive plot of the plume based on actual weather conditions and what is known about the location and size of the explosion within 15 minutes and then update the plot as information about the actual deposition and radiation levels was received.

  • An AMS aircraft would be dispatched immediately from Nellis or Andrews Air Force Base and begin transmitting rough radiation survey data soon after arrival.

  • RAP teams would be dispatched from the nearest region or regions within a few hours and begin arriving within 12 hours.

The FRMAC response would be phased:

  • A Consequence Management Home Team, physically based at Nellis Air Force Base in Las Vegas, Nevada, would gather available data within 2 hours and provide whatever information it could to the incident command.

  • A Phase 1 Consequence Management Response Team (CMRT) of 26 people would leave Nellis Air Force Base within 4 hours and be on site within 6-10 hours with some equipment to establish the FRMAC and conduct some gross field monitoring and data assessment in order to understand better the locations of the radiation and fallout.

  • A Phase 2 CMRT with much more equipment and supplies (15 tons) would arrive within 24 hours and begin more extensive field monitoring and sampling of air, water, and ground concentrations of radiation; map the actual path of the fallout plume; and provide exposure-rate and dose-projection contour maps for officials managing the response.

  • A full interagency FRMAC would be operational within 24 to 36 hours and consist of up to 500 people as the situation warranted, which an IND incident surely would. Eventually, when the situation had stabilized and attention turned to recovery and clean-up, EPA would take over FRMAC from DOE.

In summary, DOE would send specialized personnel and equipment to determine where and how much radiation was produced by an IND detonation, provide this information and expert advice to those managing the response, and through REAC/TS provide expert advice on medical matters. The total number of DOE people involved in the emergency response would be approximately 1,200.

Daniel Bochicchio reviewed the assets and expected role of the National Guard in an IND event. The Army National Guard has about 355,000 members and the Air National Guard has approximately another 106,000. More than half of them are available for domestic emergencies at any given time, while one quarter are deployed in Iraq and Afghanistan and another quarter are preparing for deployment.

National Guard medical capabilities include the following:

  • Medical triage

  • Emergency medical treatment

  • Patient evacuation

  • Preventive medicine and critical incident stress management teams

  • Limited hospitalization

The National Guard has

  • seven multifunctional medical battalion command and control headquarters (one of which is deployed overseas);

  • sixteen air ambulance companies (five of which are deployed or getting ready to deploy). Each air ambulance company has 12 helicopters capable of short-range medical evacuation;

  • six ground ambulance companies, each with 24 ambulances;

  • twenty-two area support medical companies, each with eight ambulances, able to provide emergency medical treatment (six companies are deployed or are getting ready to deploy);

  • twenty-eight brigade support medical companies, each with eight ambulances, able to provide emergency medical treatment (six companies are deployed or are getting ready to deploy). These companies are part of a combat brigade and would deploy with their brigade if it were called on to respond to an IND event;

  • nine Expeditionary Medical Support+25 (EMEDS+25) rapid response packages in Washington State, Kansas, and Pennsylvania, which can be transported in a C-130 (an EMEDS+25 cares for a population at risk of 2,000-5,000 with 9 tents, an Air National Guard Medical Service staff of 85, 25 critical care beds, and laboratory, radiology, pharmacy, and dental ancillary services. The purpose of EMEDS is to provide initial surge capacity while other facilities are being ramped up); and

  • ten aeromedical evacuation squadrons, each with a mobile staging facility able to prepare about 40 patients an hour for aeromedical transport.

In addition,

  • Each state has a WMD Civil Support Team (CST).43 Each CST consists of 22 people (4 of them medical and 8 emergency responders), a command vehicle, an operations van, a communications vehicle, and an analytical laboratory van to test environmental samples. CSTs are on constant standby and can deploy an advance party within 90 minutes and the rest of the team within 3 hours. The CST commander advises the civilian incident commander on the type and level of chemical, biological, radiological, nuclear, or explosive (CBRNE) hazard; current and projected consequences; possible response measures; and availability of additional National Guard assets.

  • Seventeen states have a CBRNE Enhanced Response Force Package (CERFP). Each CERFP has four elements: search and extraction, decontamination, medical, and command and control. The medical element consists of 30 to 45 physicians, physician assistants, nurses, and medics from the Air National Guard Medical Service.

CSTs are intended to augment local first responders by assessing and identifying CBRNE threats. CERFPs are intended to provide extraction, decontamination, and medical triage and treatment in the period from 6 hours post-incident to the time when substantial National Guard and military forces arrive 72 to 96 hours after detonation. These capabilities would be relatively small, however, relative to the needs generated by an IND event, with 22 and up to approximately 200 personnel, respectively. Barring additional incidents, however, a state’s CST and CERFP could be supplemented by those of nearby states under the Emergency Management Assistance Compact (EMAC).44

James Blumenstock reviewed the preparedness of the state and territorial public health departments—especially the five states containing the six Tier 1 UASI cities—for the medical consequences of an IND detonation. The state health departments would adhere to the NRF, its Nuclear/Radiological Incident Annex, and ESF-8, and they are cognizant of National Planning Scenario 1, “Nuclear Detonation—10-Kiloton Improvised Nuclear Device” (as well as Scenario 11, “Radiological Attack—Radiological Dispersal Devices”).

The states are engaged in all-hazards emergency preparedness, which does not necessarily guarantee that they will be prepared for every incident-specific issue associated with an IND or any other specific threat. Blumenstock emphasized that the states do not know the relative threat posed by INDs and that the 15 National Planning Scenarios are not ranked by importance. There is growing awareness of the possibility of and some planning for RDD attacks, but many states are generally just beginning to consider preparedness for an IND detonation. Currently, state public health departments are most focused on preparedness for anthrax attacks and for an influenza pandemic, as well as for hurricanes, earthquakes, and other traditional natural hazards.

The priority given to anthrax and pandemic preparedness has been reflected in federal funding programs. The largest source of federal funding for public health preparedness, CDC’s Public Health Emergency Preparedness (PHEP) grant program, provided approximately $5.5 billion in grants to states and localities between fiscal year (FY) 1999 and FY 2008 plus another $765 million in categorical grants in recent years. Most of the categorical grant funding has been specifically for pandemic influenza preparedness ($424 million) and preparedness for an anthrax attack through the CRI ($243 million).

Although in FY 2008 the PHEP program no longer included categorical grants for pandemic influenza, continued eligibility is tied to having an acceptable operations plan to address it based on guidance provided by HHS. There has been no PHEP funding specifically for radiological or nuclear event preparedness, although states (and localities) could allocate funds for them—or any other threat—from their basic PHEP funding, if it was a local priority. Similarly, the second largest source of funding for emergency preparedness, ASPR’s Hospital Preparedness Program (HPP), does not make radiological or nuclear preparedness a priority. In fact, until FY 2008 HPP was the National Bioterrorism HPP.

State public health departments have competing priorities and they do not have the funding or staffing to deal with all of them. Furthermore, federal assistance for preparedness has been declining. PHEP funding fell by 30 percent from its high in FY 2002 to FY 2008, HPP funding fell by 20 percent from its high in FY 2004 to FY 2008, and the administration has again requested less funding for both programs for FY 2009.

Blumenstock did not advocate earmarking funding in PHEP or HPP for preparedness for an IND or any other specific threat; he made the point that other potential threats have been seen as relatively higher priority by the federal as well as the state governments.

Blumenstock stated that an IND detonation in a major metropolitan area would pose some incident-specific challenges:

  • The effects would be catastrophic. Hundreds of thousands of people would be casualties and more than a million would be displaced by lingering radiation.

  • There would be little to no warning before detonation.

  • Local response capacity would be overwhelmed immediately.

  • Local infrastructure would be destroyed.

  • Federal assets would be needed and requested immediately.

  • There would be unique long-term recovery and reentry issues.

The states with Tier 1 UASI cities contain among them approximately 35 nuclear power reactors, about a third of the nation’s total, which they monitor and for which they prepare emergency response plans in case there is an accidental release of radiation. This gives them a head start on preparing for an IND detonation. They also have strengthened their all-hazards response capacity, most of which would be relevant in an IND incident. Regarding an IND event, Blumenstock says these states have begun to move beyond awareness to building more specific operational capacity and capability, and they have moved beyond the planning-to-plan stage to developing tangible plans. They are revising radiological response plans to include possible IND events. They are acquiring radiation detection and dosimetry equipment and modest stockpiles of radiation countermeasures and PPE. There is an effort to establish an East Regional Burn Consortium of health care facilities in the Mid-Atlantic and New England.

Blumenstock offered several recommendations to advance public health preparedness for the consequences of an IND event.

  • Clarify the seriousness of the IND threat relative to current priorities (e.g., pandemic influenza and anthrax preparedness).

  • Provide adequate funding, including federal, for preparedness.

  • Improve federal coordination and find a federal agency leader or champion of IND event preparedness.

  • Enhance the transfer of military knowledge, procedures, and experiential learning to the civilian public health sector.

  • Improve medical countermeasures and related technologies.

  • Strengthen the NDMS program to provide mass casualty care in the event of an IND detonation.

Discussion of Federal and State Medical Resources for Responding to an IND Event

The first topic was the level of interest on the part of states in developing their own pharmaceutical stockpiles for an IND event and the barriers they would face. Blumenstock said that there is interest and that the principal limiting factor is the lack of funding for acquiring and storing the stockpile. Furthermore, because the pharmaceuticals have a limited shelf life, state public health departments would be asking state legislators to commit to replacing the stockpile every 3 to 5 years with funding that could be used for more immediate needs, such as medical and social services.

A participant who works with state and local health departments said that, from his experience, few local emergency response managers in major U.S. cities know what federal assets would be available from the federal government. Moreover, there does not seem to be a point of contact at the federal level to determine what array of federal assets—civilian, National Guard, and military—would be brought to bear in particular kinds of emergencies. Knebel acknowledged that this is a problem, but she said that there has been incremental progress, citing the interagency process involved in developing the nuclear detonation playbook as a step toward providing the kind of transparency the participant wanted to see.45 Additionally, there are 35 emergency coordinators stationed in the 10 Federal Emergency Management Agency (FEMA) regions who routinely engage in state-based exercises so that state and local officials understand what assets the federal government could provide in a public health and medical emergency. Federal funds are provided to support exercises that bring people together in order to discover gaps in preparedness. She noted that part of the problem is the high rate of turnover in state and local government personnel. Bochicchio said it was disappointing to find that the National Guard is not mentioned in some state pandemic influenza plans. On the other hand, in about 15 states, the adjutant general of the state’s National Guard is also the state’s emergency manager.

A participant with military experience said that for many years DoD planning focused on preventing nuclear events because to survive a Cold War nuclear exchange was considered impossible. Another scenario for which planning took place was a nuclear reactor accident. The current scenario is totally different. If an IND were used, survival would be considered feasible, but the consequences would be far more serious than a nuclear reactor accident. The infrastructure destruction would make it much more difficult to respond quickly and effectively. As seen in Hiroshima and Nagasaki, many people would have to rely on their own resources and response efforts. The participant pointed to the need for a massive public awareness campaign, perhaps similar to the duck-and-cover campaign of the 1950s.

Other participants doubted that people are ready to hear that the best way to defend themselves would be to stock up a shelter in a basement. Most people are not as concerned about such a low-probability event, despite the drastic consequences, as they are about an influenza pandemic or anthrax attack.

A participant suggested placing federal liaison officials in each major city in order to improve communication. ASPR has been reaching out with meetings in the states to build awareness of federal assets but it does not have funding for local liaison officers. A response was that appointing liaison officers in the six Tier 1 cities might be affordable.

A local public health preparedness official said he was aware that HHS and DOE have developed playbooks but that they have not been widely shared with the locals. He expressed a strong interest in sitting down with federal partners and looking at their playbooks ahead of time. This would be important because, for example, when federal officials attending a recent state meeting on catastrophic earthquake planning said where they planned to establish collection points and landing sites for aeromedical evacuations, they discovered that there were major conflicts with that state’s evacuation plans. State and local planners are determining where to put alternate care sites, points of pharmaceutical distribution, and other emergency arrangements, and broader plans up the line should be in harmony with the local plans. Or local plans might need to be adjusted to take advantage of federal plans and assets. Knebel said this was the purpose of posting the two (so far) playbooks online—so that local planners would know what HHS is planning.

A state emergency official said that one of the disconnects occurs when federal program officials bypass the state in dealing directly with localities, which creates confusion and conflict.

Bochicchio offered the military’s practice of nesting plans, in which the tactical (i.e., local) plan or plans are nested within the operational (i.e., state or regional) plan, and the operational plan or plans are nested within the strategic (i.e., national) plan. What is not wanted, he said, is national planners conducting local tactical planning, which might not meet local reality or needs.


NDMS also provides backup medical support to the military and VA medical care systems during an overseas conventional conflict.


After the workshop, more details about RTR were released (EOP, 2009:65-67).


The NRF, Nuclear/Radiological Incident Annex to the NRF, and ESF-8 can be found at http://www​.fema.gov/emergency/nrf/ (accessed June 23, 2009).


The playbooks are at http://www​.hhs.gov/disasters​/discussion/planners/Playbook/ (accessed June 23, 2009).


As of June 29, 2009, the pandemic influenza playbook had been added to the ASPR website and the RDD playbook was indicated as “coming soon” (http://www​.hhs.gov/disasters​/discussion/planners/playbook/).


These include, for example, the Nuclear/Radiological Advisory Team (NRAT), which provides advice and limited technical assistance (e.g., search, diagnostics, effects prediction) as part of a Domestic Emergency Support Team; Search Response Teams (SRTs), which, using local support, engage in initial nuclear search activities; and the Accident Response Group, which provides technical response to U.S. nuclear weapons accidents. The purpose of NRAT and SRT is detection and interdiction of a nuclear release before it happens, and they were not discussed at the workshop, although presumably they would be searching for possible additional INDs if one were detonated somewhere in the United States.


There are 55 total. California has two. The District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands also have teams.


After the workshop, NORTHCOM (United States Northern Command), DoD’s command and control organization responsible for responding to terrorist attacks on the United States, established the first of three Chemical, Biological, Nuclear, or Radiation Consequence Management Response Task Forces. The 4,700-person task forces will have three units, whose jobs are to (1) conduct assessment and reconnaissance of an event to determine what agent or element is involved and to perform some emergency medical evacuations; (2) provide more significant medical assistance, patient decontamination, and evacuation; and (3) provide logistical support (Kreisher, 2008).


As noted in footnote 41, the IND playbook has not been released publicly.


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