Introduction toIntroduction toLarge Scale Disasters &Large Scale Disasters &

Weapons of Mass Weapons of Mass DestructionDestruction

A course developed

for

School Based Personnel/School Based Personnel/First RespondersFirst Responders

New Jersey Preparedness New Jersey Preparedness Training ConsortiumTraining Consortium

An association of public health agencies An association of public health agencies tasked by the federal government with tasked by the federal government with providing Weapons of Mass Destruction providing Weapons of Mass Destruction and Terrorism education to health care and Terrorism education to health care providersproviders

Traditional WMD education targets have Traditional WMD education targets have been physicians, nurses and EMS workersbeen physicians, nurses and EMS workers

New Jersey Preparedness New Jersey Preparedness Training ConsortiumTraining Consortium

Consortium MembersConsortium Members Saint Barnabas Health Care SystemSaint Barnabas Health Care System University of Medicine and Dentistry of New JUniversity of Medicine and Dentistry of New J

erseyersey Rutgers, the State UniversityRutgers, the State University New Jersey Primary Care AssociationNew Jersey Primary Care Association New Jersey Hospital AssociationNew Jersey Hospital Association Liberty HealthLiberty Health

““This program is funded by the U.S. Department This program is funded by the U.S. Department of Health and Human Services, Health Resources of Health and Human Services, Health Resources and Services Administration, Grant No. and Services Administration, Grant No. T01HP01407.”T01HP01407.”

The Center forThe Center forHealth Care PreparednessHealth Care Preparedness

Established as a Established as a center of excellencecenter of excellence, , furthering education and research in the furthering education and research in the

field of health care disaster readinessfield of health care disaster readiness

Why you need to be Why you need to be prepared:prepared:

Catastrophic Natural Catastrophic Natural DisastersDisasters

Emerging/Re-emergingEmerging/Re-emerging Infections Infections

Why you need to be Why you need to be prepared:prepared:

Technological DisastersTechnological Disasters Chernobyl, Bhopal, Three Chernobyl, Bhopal, Three

Mile IslandMile Island TerrorismTerrorism

ConventionalConventional explosives, incendiariesexplosives, incendiaries

Non-conventionalNon-conventional nuclear, biological, chemical nuclear, biological, chemical

attacksattacks

Role of RespondersRole of RespondersAwareness !!!!!!!!Awareness !!!!!!!!

maintain a high index of suspicion… be on the alertmaintain a high index of suspicion… be on the alert Case Examples – Filming Facilities, Residential Case Examples – Filming Facilities, Residential

Warehousing, Hospital Surveillance, Approach to Buy Warehousing, Hospital Surveillance, Approach to Buy Ambulance Equipment/UniformsAmbulance Equipment/Uniforms

ResponseResponse Personal protection and infection controlPersonal protection and infection control Meet patient’s emergency needsMeet patient’s emergency needs Implement facility response protocolImplement facility response protocol Notifications:Notifications:

Clinical / Psychosocial referralClinical / Psychosocial referral Law enforcementLaw enforcement Public healthPublic health

ParticipationParticipation Drills and exercisesDrills and exercises

Weapons of Weapons of Mass Mass

DestructionDestruction

WMD IntroductionWMD Introduction

Terrorism involving weapons of mass Terrorism involving weapons of mass destruction is an ever-present threat destruction is an ever-present threat in today’s worldin today’s world

As a provider, you may be called on to As a provider, you may be called on to deal with people / patients involved in deal with people / patients involved in an incident involving WMDsan incident involving WMDs

Weapons of Mass Destruction:Weapons of Mass Destruction: are chiefly designed to incite terror, are chiefly designed to incite terror,

not to killnot to kill consist of a variety of different agentsconsist of a variety of different agents can be delivered through a variety of can be delivered through a variety of

different meansdifferent means can be extremely difficult to controlcan be extremely difficult to control are designed to cause are designed to cause widespreadwidespread and and

indiscriminate indiscriminate death and destructiondeath and destruction

WMD IntroductionWMD Introduction

Categorization ofCategorization ofWeapons of Mass DestructionWeapons of Mass Destruction

Useful mnemonics to categorize Useful mnemonics to categorize WMDs:WMDs:

B NICEB NICE CBRNECBRNE

B B Biological Biological CC Chemical Chemical

NN Nuclear Nuclear B B Biological Biological

I I Incendiary Incendiary RR RadiologicalRadiological

CC Chemical Chemical NN Nuclear Nuclear

EE Explosive Explosive EE Explosive Explosive

ChemicalChemicalWeapons of Mass Weapons of Mass

DestructionDestruction

Why CW are attractive to Why CW are attractive to terrorists:terrorists:

They are inexpensive to manufacture to obtainThey are inexpensive to manufacture to obtain Simple technology is needed to produce themSimple technology is needed to produce them They are difficult to detectThey are difficult to detect They are highly efficient (little quantity is They are highly efficient (little quantity is

needed)needed)

Nerve Agent LethalityNerve Agent Lethality

An amount of VX equal in size to one An amount of VX equal in size to one column of the Lincoln Memorial on column of the Lincoln Memorial on

the back of a penny would be the back of a penny would be lethallethal to you to you

Sources of CW AgentsSources of CW Agents Foreign governmentsForeign governments Internet recipesInternet recipes ““Black Market” of the former Soviet UnionBlack Market” of the former Soviet Union U.S. chemical plants (Chlorine, Phosgene, etc.)U.S. chemical plants (Chlorine, Phosgene, etc.) U.S. Military StockpileU.S. Military Stockpile

30,600 tons of nerve agents and vesicants at 8 sites 30,600 tons of nerve agents and vesicants at 8 sites across U.S.across U.S.

1985 law directed DoD destroy stockpile by 20041985 law directed DoD destroy stockpile by 2004 Outdated and recovered CW are buried at 215 sites Outdated and recovered CW are buried at 215 sites

across U.S.across U.S.

Recent Chemical Terrorism Recent Chemical Terrorism EventsEvents

1995: Aum Shinrikyo cult releases 1995: Aum Shinrikyo cult releases Sarin vapor into Tokyo subwaySarin vapor into Tokyo subway 12 deaths and 5,500 casualties12 deaths and 5,500 casualties 4,000 w/o clinical manifestation of 4,000 w/o clinical manifestation of

injuryinjury

1993: World Trade Center 1993: World Trade Center BombingBombing Explosive contained sufficient Explosive contained sufficient

cyanide to contaminate entire cyanide to contaminate entire buildingbuilding

Cyanide destroyed in blastCyanide destroyed in blast

Classification of Chemical Classification of Chemical WeaponsWeapons

Chemical agents are classified by Chemical agents are classified by the toxic effects they have on the the toxic effects they have on the bodybody

Chief Categories of Agents:Chief Categories of Agents: Nerve AgentsNerve Agents Vesicants or Blistering AgentsVesicants or Blistering Agents Choking or Pulmonary AgentsChoking or Pulmonary Agents Blood AgentsBlood Agents Incapacitating or Riot-Control AgentsIncapacitating or Riot-Control Agents

S.L.U.D.G.E.S.L.U.D.G.E.

Muscarinic Effects of Nerve AgentsMuscarinic Effects of Nerve Agents

SSalivationalivation

LLacrimationacrimation

UUrinationrination

DDiaphoresisiaphoresis

GGI distress (diarrhea, I distress (diarrhea, vomiting)vomiting)

EEmesismesis

Nerve Agent Antidote: Nerve Agent Antidote: MARK I KitMARK I Kit Self-injectable needleSelf-injectable needle Pralidoxime Chloride Pralidoxime Chloride

(600 mg)(600 mg) Atropine (2 mg)Atropine (2 mg)

Case Study: RussiaCase Study: Russia October 26, 2002October 26, 2002 50 heavily armed Chechen insurgents 50 heavily armed Chechen insurgents

hold hundreds of civilians hostage in a hold hundreds of civilians hostage in a Moscow theaterMoscow theater

Russian Special Forces use fentanyl Russian Special Forces use fentanyl derivative to incapacitate the terroristsderivative to incapacitate the terrorists

Over 100 hostages die from the gasOver 100 hostages die from the gas

General Treatment General Treatment GuidelinesGuidelines

for all classes of Chemical for all classes of Chemical WeaponsWeapons

Move to fresh airMove to fresh air Supplemental oxygenSupplemental oxygen Remove clothingRemove clothing Decontaminate skinDecontaminate skin Restrict physical activityRestrict physical activity Hospitalization/medical attentionHospitalization/medical attention

BiologicalBiologicalWeapons of Mass Weapons of Mass

DestructionDestruction

What is What is Bioterrorism?Bioterrorism?““Intentional or threatened use of Intentional or threatened use of viruses, bacteria, fungi or toxins viruses, bacteria, fungi or toxins from living organisms to produce from living organisms to produce

death or disease in humans, animals death or disease in humans, animals or plants”or plants”

1918 2004

Why Biologics are attractive Why Biologics are attractive to terrorists:to terrorists:

Some can be obtained from Some can be obtained from naturenature

Potential dissemination over Potential dissemination over large geographic arealarge geographic area

Creates panic and chaosCreates panic and chaos Can overwhelm medical Can overwhelm medical

servicesservices Civilian populations may be Civilian populations may be

highly susceptiblehighly susceptible High morbidity and mortalityHigh morbidity and mortality Difficult to diagnose and/or Difficult to diagnose and/or

treattreat Some are transmitted person-Some are transmitted person-

to-person via aerosolto-person via aerosol

Characteristics of Characteristics of Biological AttacksBiological Attacks

Incident may not be recognized for Incident may not be recognized for weeksweeks

Responders and health workers are at Responders and health workers are at risk of becoming casualties themselvesrisk of becoming casualties themselves

Continuing effect with re-infectionContinuing effect with re-infection Require special training and equipment Require special training and equipment

to handleto handle Large numbers of “worried well” (30:1 Large numbers of “worried well” (30:1

ratio)ratio) Fear of the unknownFear of the unknown

History of SmallpoxHistory of Smallpox

Most deadly germ in all of human historyMost deadly germ in all of human history First recorded case of biowarfareFirst recorded case of biowarfare Last natural case in U.S.: 1947Last natural case in U.S.: 1947 U.S. phased out vaccination from 1968-U.S. phased out vaccination from 1968-

19721972 Last natural case in world: 1977 Last natural case in world: 1977 ““Eradicated” from the globe in 1980Eradicated” from the globe in 1980 Two live cultures kept for researchTwo live cultures kept for research Only 10% of Soviet stockpile accounted Only 10% of Soviet stockpile accounted

forfor

Variola majorVariola major (Smallpox) (Smallpox)

Highly contagious virus (Attack rate: Highly contagious virus (Attack rate: 90%)90%)

Person-to-person spread (by Person-to-person spread (by inhalation)inhalation)

Mortality rate: 35%Mortality rate: 35% Vaccine ~95% effective, can be Vaccine ~95% effective, can be

administered up to 4 days after administered up to 4 days after exposureexposure

No effective anti-viral agentsNo effective anti-viral agents

Smallpox VaccineSmallpox Vaccine

Made from live Made from live VacciniaVaccinia virusvirus

Intradermal inoculation Intradermal inoculation with bifurcated needlewith bifurcated needle

Scar (permanent) Scar (permanent) demonstrates successful demonstrates successful vaccinationvaccination

Immunity Immunity notnot life-long life-long Adequate vaccine for all of Adequate vaccine for all of

U.S. populationU.S. population

Anthrax: OverviewAnthrax: Overview

Forms highly stable spores Forms highly stable spores No person-to-person transmissionNo person-to-person transmission Easy to manufacture, difficult to Easy to manufacture, difficult to

aerosolizeaerosolize History:History:

1979:1979: Accidental release of spores from a Accidental release of spores from a USSR Bioweapons factory, at least 66 deadUSSR Bioweapons factory, at least 66 dead

2001:2001: Anthrax attacks in the United Anthrax attacks in the United States, 11 contract inhalational anthrax, 5 States, 11 contract inhalational anthrax, 5 dieddied

Anthrax: VaccineAnthrax: Vaccine Current U.S. vaccineCurrent U.S. vaccine

For persons 18 - 65 years of ageFor persons 18 - 65 years of age Protective against cutaneous anthrax and Protective against cutaneous anthrax and

possibly inhalational anthrax (animal data)possibly inhalational anthrax (animal data) 6 dose regimen over 18 months6 dose regimen over 18 months Limited availabilityLimited availability Not currently administered to the civilian Not currently administered to the civilian

populationpopulation

Radioactive and NuclearRadioactive and NuclearWeapons of Mass Weapons of Mass

DestructionDestruction

Penetration Abilities of Penetration Abilities of Different Types of Different Types of

RadiationRadiationAlpha ParticlesStopped by a sheet of paper

Beta ParticlesStopped by a layer of clothingor less than an inch of a substance (e.g. plastic)

Gamma RaysStopped by inches to feet of concreteor less than an inch of lead

RadiationSource

Methods of protectionMethods of protection

TimeTime

DistanceDistance

ShieldingShielding

Potassium Iodide (KI) Potassium Iodide (KI) TabletsTablets

Only helpful in certain casesOnly helpful in certain cases Only protects the thyroid from Only protects the thyroid from

radioactive iodineradioactive iodine KI saturates the thyroid gland with KI saturates the thyroid gland with

stable iodinestable iodine KI must used prior to exposure to KI must used prior to exposure to

radioactive iodineradioactive iodine

Radioactive/Nuclear Radioactive/Nuclear WMDs:WMDs:

Possible ScenariosPossible Scenarios Nuclear power plant Nuclear power plant

incidentincident Nuclear weaponNuclear weapon Improvised Nuclear Device Improvised Nuclear Device

(IND)(IND) ““Dirty bomb”Dirty bomb”

Nuclear Power Plant Nuclear Power Plant IncidentIncident

Attack by air fairly Attack by air fairly easy for terroristeasy for terrorist

Would result in little Would result in little release of radioactive release of radioactive material, if anymaterial, if any

Redundant safety Redundant safety systems make systems make catastrophic catastrophic radiation leak highly radiation leak highly unlikelyunlikely

Nuclear WeaponNuclear Weapon Manufacture requires extraordinary Manufacture requires extraordinary

degree of scientific expertisedegree of scientific expertise Requires constant maintenanceRequires constant maintenance Unlikely that a terrorist organization Unlikely that a terrorist organization

has the resources to effectively has the resources to effectively accomplish a NW attackaccomplish a NW attack

Improvised Nuclear Improvised Nuclear DeviceDevice

Weapons made from small devices Weapons made from small devices that trigger uncontrolled nuclear that trigger uncontrolled nuclear reactionsreactions

Difficult to manufactureDifficult to manufacture Require frequent maintenanceRequire frequent maintenance

Chairman Dan Burton Committee – Demonstration of example “suitcase nuke” made from US nuclear shell

““Dirty Bomb”Dirty Bomb” Radioactive/Nuclear weapon of Radioactive/Nuclear weapon of

greatest concerngreatest concern Relatively easy to manufactureRelatively easy to manufacture Consists of radioactive material Consists of radioactive material

coupled with a conventional coupled with a conventional explosiveexplosive

Immediate effect: Blast injuriesImmediate effect: Blast injuries Long term effect: chronic Long term effect: chronic

radiation exposureradiation exposure Would require massive decon Would require massive decon

effort (of people, buildings, effort (of people, buildings, environment)environment)

Explosive/IncendiaryExplosive/IncendiaryWeapons of Mass Weapons of Mass

DestructionDestruction

Conventional Weapons and Conventional Weapons and Incendiary DevicesIncendiary Devices

Conventional weapons: BombsConventional weapons: Bombs Incendiary devices: Fire-Causing DevicesIncendiary devices: Fire-Causing Devices The Most Widely Used WMDs!The Most Widely Used WMDs!

Conventional Weapons and Conventional Weapons and Incendiary DevicesIncendiary Devices

ExplosivesExplosives Ignite special fuels that burn Ignite special fuels that burn

extremely rapidlyextremely rapidly Cause a shock wave or a blastCause a shock wave or a blast Cause injury by:Cause injury by:

Pressure wave that damages air Pressure wave that damages air containing organs in the bodycontaining organs in the body

Throwing the body into the Throwing the body into the ground or other objectsground or other objects

Propelling debris that strikes a Propelling debris that strikes a patient causing a traumatic patient causing a traumatic injuryinjury

Causing building collapseCausing building collapse

Incendiary DevicesIncendiary Devices Designed to burn at Designed to burn at

extremely high extremely high temperaturestemperatures napalm, thermite, white napalm, thermite, white

phosphorousphosphorous

Cause thermal burnsCause thermal burns Patients exposed to an Patients exposed to an

incendiary device are incendiary device are treated as any other person treated as any other person suffering thermal burnssuffering thermal burns

Conventional Weapons and Conventional Weapons and Incendiary DevicesIncendiary Devices

Personal ProtectionPersonal Protection

Personal ProtectionPersonal Protection

Proper PPEProper PPE should be worn at all times should be worn at all times Disposable, non-sterile glovesDisposable, non-sterile gloves GownsGowns Eye shieldsEye shields N95 Respirator Face MasksN95 Respirator Face Masks

No eatingNo eating, , drinkingdrinking, applying , applying cosmeticscosmetics or handling or handling contact lensescontact lenses in in clinical areasclinical areas

Do not touch your Do not touch your eyeseyes, , nosenose or or mouthmouth

Infection Control: GlovesInfection Control: Gloves

Discard gloves in biohazard bags Discard gloves in biohazard bags after patient care is completed or after patient care is completed or when soiled or damagedwhen soiled or damaged

Wash hands immediately after Wash hands immediately after removal of glovesremoval of gloves

Patient Respiratory Patient Respiratory ProtectionProtection

Patient may wear a paper surgical Patient may wear a paper surgical mask to reduce droplet production, if mask to reduce droplet production, if toleratedtolerated

NRB masks offer some protection in NRB masks offer some protection in reducing droplet spreadreducing droplet spread

CPR should never be performed using CPR should never be performed using mouth-to-mouth or mouth-to-maskmouth-to-mouth or mouth-to-mask

The N95 The N95 RespiratorRespirator

Why a Respirator Is Why a Respirator Is NecessaryNecessary

You work in an environment You work in an environment where there is a high risk of where there is a high risk of disease transmission through disease transmission through infectious airborne infectious infectious airborne infectious particulatesparticulates

Respirators, such as the N-95, Respirators, such as the N-95, provide protection from provide protection from airborne infectious particulates airborne infectious particulates when properly fitted and wornwhen properly fitted and worn

The Strategic National StockpileThe Strategic National Stockpile

(SNS)(SNS)

MissionTo meet the nation’s pharmaceutical and medial supply needs in the event of a

chemical, biological, radiological, nuclear or explosive mass casualty event by delivering adequate medications and medical materiel to the site of a national emergency.

Strategic National Strategic National Stockpile:Stockpile:ContentsContents

Oral AntibioticsOral Antibiotics Intravenous SuppliesIntravenous Supplies Nerve Agent Antidotes and Nerve Agent Antidotes and

AntitoxinsAntitoxins Airway Maintenance SuppliesAirway Maintenance Supplies Medical/surgical itemsMedical/surgical items

Push Package being loaded on to an 18 wheel truck

Push Package configured to fit within a commercial aircraft

The clock is ticking…The clock is ticking… Governor and Commissioner of Health Governor and Commissioner of Health request therequest theSNS from the CDC (zero hour)SNS from the CDC (zero hour) Within 12 hours, SNS arrives in the Within 12 hours, SNS arrives in the statestate In 12-24 hours, SNS is distributed to In 12-24 hours, SNS is distributed to hospitals, counties, the military and hospitals, counties, the military and prisonsprisons In 24-36 hours, goal is to have “Pills in In 24-36 hours, goal is to have “Pills in People”People”

Thank You!Thank You!

Robert J. Bertollo, M.I.C.P., L.R.C.P., M.B.A.Robert J. Bertollo, M.I.C.P., L.R.C.P., M.B.A.

Associate Director, Associate Director,

Center for Health Care PreparednessCenter for Health Care Preparedness

95 Old Short Hills Road95 Old Short Hills Road

West Orange, NJ 07979West Orange, NJ 07979

973-322-4581973-322-4581

rbertollo@sbhcs.comrbertollo@sbhcs.com