Nation readies health care system to respond to nuclear terror
Nation readies health care system to respond to nuclear terror
Agency to spur development of prevention products and treatments
Amid growing concern that terrorists may strike with a nuclear weapon instead of a biological one, the government is fast-tracking programs to develop medical countermeasures against radiological and nuclear threats.
The National Institute of Allergy and Infectious Diseases (NIAID) has issued more than $47 million for grants, contracts, and interagency agreements as part of a new National Institutes of Health research program on medical countermeasures against radiological and nuclear threats. NIAID is trying to spur development of prevention products and treatments for radiation sickness following a terrorist attack.
Eight universities or research institutes have received grants to establish Centers for Medical Countermeasures Against Radiation. "The primary goal of the centers is to develop new medical products that would be needed in the event of radiation released in a terrorist attack," says NIAID program officer Narayani Ramakrishnan, PhD.
The centers will focus on basic and applied research to develop new products for measuring radiation exposure, to protect against exposure, and to minimize and treat the effects of exposure to a wide range of radioactive compounds. The research centers are being asked to develop "biodosimetry" devices to measure radiation exposure, therapeutics to treat short-term and long-term symptoms of radiation exposure, as well as products that can prevent or mitigate the effects of radiation exposure, he explains.
Each center will be led by a principal investigator and may include a consortium of other research institutions. Funding for the centers totals about $28.7 million for fiscal year 2005. NIAID plans to fund the centers for five years. The principal investigators and approximate funding for fiscal year 2005 for each center are as follows:
- Paul Okunieff, MD, University of Rochester (NY) Medical Center, $4.3 million.
- David J. Brenner, PhD, DSc, Columbia University Medical Center, New York City, $5 million.
- Nelson J. Chao, MD, Duke University, Durham, NC, $4.4 million.
- George Georges, MD, Fred Hutchinson Cancer Research Center, Seattle, $4.5 million.
- John Moulder, PhD, Medical College of Wisconsin, Milwaukee, $3.7 million.
- William H. McBride, PhD, DSc, University of California, Los Angeles, $2.8 million.
- Alan D. D’Andrea, MD, Dana-Farber Cancer Institute, Boston, $2 million.
- Joel S. Greenberger, MD, University of Pittsburgh, $2 million.
In addition, the University of Maryland School of Medicine has received a $9.3 million contract to evaluate promising compounds to prevent, reduce, or treat symptoms of radiation exposure. For example, under the contract, the university may develop products to protect first responders, speed healing of bone marrow, measure radiation exposure, and decontaminate the body following exposure.
Because different types of radiation and differing levels of exposure can damage the body in a variety of ways, an assortment of medical products is needed, explains Bert Maidment, PhD, NIAID associate director for product development for radiological and nuclear countermeasures.
The University of Kentucky, Lexington; Nano-therapeutics of Alachua, FL; and SRI International of Menlo Park, CA; also have received contracts for development of improved DTPA (diethylenetriaminepentaacetate). Administered intravenously, DTPA can be used to remove radioactive compounds from the body. The thinking is that a terrorist attack will warrant rapid administration of the chemical, so researchers are working on inhalation, liquid and pill delivery systems.
NIAID also earmarked funds to support projects focused on protecting the immune system from radiation or restoring the immune system following radiation exposure. Products that provide pre-exposure protection could be used by first responders to prevent bone marrow damage, while post-exposure products would help restore immune system cells that are formed within bone marrow.
Disconcerting signs
The research push comes as reports surface that the United States remains vulnerable to nuclear terror. The Sept. 11 Commission recently used the term "insufficient progress" in assessing the federal government’s efforts to thwart nuclear or radiological terrorism. In a follow-up report into its original inquiry into 9/11, the commission urged the Bush administration to make preventing nuclear terror the "top national security priority." The commission has completed its formal investigation into 9/11, but remains active in tracking the recommendations of its 2004 report. According to published reports, the commission expressed concern that nuclear materials may be insufficiently secured in countries that comprised the former Soviet Union. "The most striking thing to us is that the size of the problem still totally dwarfs the policy response," commission chairman Thomas Kean said. "We have no greater fear than a terrorist who is inside the United States with a nuclear weapon."
Despite the warnings, some progress is being made. The Nuclear Threat Initiative — which is tracking loose nukes globally under the leadership of former Sen. Sam Nunn — recently announced a major development in the former Soviet republic of Kazakhstan. The country eliminated nuclear fuel containing 2,900 kg of highly enriched uranium. The material could have been used to make up to two dozen nuclear bombs. Instead, it is being blended down to safe, nonweapons usable forms of uranium for use in commercial and scientific activities, the NTI reported. In addition, over the past year the United States and other countries have made significant steps in the effort to prevent nuclear terrorism, according to a recently published report.1 Developments of note include:
- The U.N. Security Council unanimously passed Resolution (UNSCR) 1540 in April 2004, legally obligating every country in the world to put in place effective security and accounting for nuclear stockpiles, and thus providing the base for an accelerated nuclear security upgrade effort worldwide, not just in the former Soviet Union.
- In May 2004, the U.S. Department of Energy launched the Global Threat Reduction Initiative (GTRI), offering the potential to accelerate and expand efforts to remove and secure potential nuclear bomb material from insecure sites around the world.
- At their February 2005 summit in Bratislava, Slovakia, President George W. Bush and Russian president Vladimir Putin issued a summit statement calling for intensified cooperation to secure nuclear stockpiles in Russia, and for joint United States-Russian leadership of nuclear security upgrade efforts elsewhere around the world.
Preparing for the worst
Despite the ongoing efforts to locate and lock down all weapons grade nuclear materials, the medical community must prepare for a possible attack. To assist in the medical response to a nuclear or radiological incident, the Centers for Disease Control and Prevention has created a training film and pocket guide materials. (See Pocket Guide.)
The purpose of the CDC program is to provide in-hospital health care providers with on the spot, just-in-time training on caring for patients exposed to radiation. The program assumes that a radiological terrorism event has occurred and mass casualties are a likely consequence. It also assumes that the viewer is a responding clinician.
"Terrorists seek to create fear and panic above all else," narrator Jim Smith, MD, a health physicist and assistant director for radiation at the Centers for Disease Control and Prevention, says in the program. "The threat of exposure to radiation is particularly frightening to people. [Clinicians] can play a vital leadership role in minimizing this fear," he pointed out.
For example, it is important to know that when appropriate personal protective equipment is worn, there is minimal risk to hospital staff who care for patients after a radiological event. "Even if a patient is contaminated, it is highly unlikely that the levels of radioactivity would be high enough to pose a significant risk to health care providers," Smith said.
In general, the same principles of barrier precautions used in hospitals for protection from microbes apply to protection from radiological contamination. The CDC advises workers responding to a radiation incident to wear a waterproof apron, cap, booties, and gloves. Waterproof chemical suits may be more practical for use in wet areas, such as the decontamination zone, Smith said. Workers should double glove and change gloves frequently. Surgical masks are adequate, but N-95 respirators are recommended if available. Due to fetal sensitivity to radiation, medical workers who are suspect or know they are pregnant should seek an alternate assignment.
"There is one instance in which additional staff protection precautions may be needed," Smith said in the program. "Fortunately, it is a highly unlikely occurrence. It is feasible that fragments of radioactive shrapnel could become imbedded in wounds, generating higher radiation levels. This rare condition would be quickly diagnosed by a radiological survey upon the patient’s arrival. Radioactive fragments should be promptly removed with forceps and sealed in lead containers."
How should radiological contamination influence patient treatment? Patients without life-threatening injuries should be decontaminated before treatment, the CDC advises. However, for those patients with life-threatening injuries, medical stabilization should take priority over radiological decontamination.
Surveying for contamination is another important procedure because radiological contamination cannot be detected by the human senses. However, its presence is quickly assessed by radiation detection devices, such as survey meters. Most hospitals will want to establish a hot zone/cold zone approach, screening workers as they leave the former. Only trained staff, as designated by the hospital’s emergency response plan, should perform the screening, the CDC recommends.
Exposure vs. contamination
Radiation exposure occurs when a person is near a radiation source, as in, for example, a patient receiving a chest X-ray. To prevent occupational harm, the radiology technician is protected through distance and shielding. To prevent harm to the patient, the duration of exposure is carefully controlled. Of course, people do not become radioactive after exposure to common radioactive sources.
"Consider the impact of a terrorist incident involving an unshielded radioactive source in a public place," Smith said. "Similar to a chest X-ray, people would be exposed to radiation. Those closest to the source for the greatest length of time would receive the highest exposure. Although they may become ill if the exposure is high enough, they would not become radioactive or pose any risk to others."
Exposure is different than contamination. By CDC definitions, to become contaminated, radioactive material must get on a person’s skin or clothing, or inside the body. For example, people could become contaminated if they were near an explosion of a dirty bomb, such as dynamite laced with radioactive material.
Radioactive material on the outside of the body is called external contamination. Simply removing the clothing may remove the majority of the contamination. Gently washing the skin and hair can remove most of the remaining contamination. If a person ingests or inhales radioactive material, it can become incorporated in the organs of the body as internal contamination.
"When treating a radiological contaminated patient, it is important to contain the radiation," Smith said. "It may be helpful to think of the radiation as mud. When caring for an injured patient covered in mud, you would first ensure medical stability. When cleaning up the mud, you would handle it carefully, containing it rather than contaminating wounds or the surrounding area."
(Editor’s note: To learn more about the NIAID research program on medical countermeasures against radiological and nuclear threats, visit the program’s web site, http://www3.niaid.nih.gov/research/topics/radnuc/. The CDC training film can viewed on the web at: http://www.bt.cdc.gov/radiation/justintime.asp.)
Reference
- Bunn M, Wier A. Securing the Bomb 2005: The New Global Imperatives. Washington, DC: Project on Managing the Atom. Harvard University and Nuclear Threat Initiative; May 2005.
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