Radiation Injury Treatment Network: Leveraging existing expertise to provide

radiation casualty management

David Weinstock, MDDana-Farber/Harvard Cancer CenterRadiation Injury Treatment Network

dweinstock@partners.org

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 (www.remm.nlm.gov) treatment algorithms

• 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

Deco

n

Triage

Trauma centers

Triage

Trauma centers

Specialty care & treatment centers

Specialty care & treatment centers

Potential for life-threateningexposure during clean-up

Radiation events

MC

MC

MC

ACAC

MC

Evacuationcenters

RTR3 (collection)

AC

RTR1 (collection)

AC

Referral centerModified 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 bombHiroshima before the bomb

New York City 2011Hiroshima before the bomb

Estimated number of irradiated victims

Waselenko et al. Annals Int Med 2004

300,000

600,000

Resource demand and availability after a nuclear detonation in Washington DC

Symptomatic injured persons or incident demandmin - med - max

Single hospital

City Nation

Persons injured (next column) or population of designated area (city, nation)

930,000 – 990,000 – 1,600,000

N/A 592,000 300 million

Hospital beds (unoccupied) 70,000 –180,000 – 300,000

165 (40) 3,670 (920)

947,000 (295,000)

ICU beds (unoccupied) 24,000 – 61,000 – 110,000

20.5 (1.6) N/A 118,000 (9,400)

Operating rooms N/A 6 N/A 30,000

Burn beds (unoccupied) 0 – 0 – 1,100 N/A 32 (5) 1,760 (580)

Ambulances N/A N/A 38 48,400

Modeling Division of BARDAPublic Health Emergency Medical Countermeasures Enterprise (PHEMCE) Blood and Tissue Requirements Working GroupGryphon 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: 0 3 10 21 35 60+

Prodromal symptoms

Preparation for HSCTManifest

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

www.REMM.NLM.gov

www.RITN.net