BIOLOGICAL RELATED/DISEASE SURVEILLANCE

1. Disease surveillance and nonprescription medication sales can predict increases in poison exposure.

*Krenzelok E, MacPherson E, Mrvos R J Med Toxicol. 2008 Mar;4(1):7-10.

*Pittsburgh Poison Center, University of Pittsburgh Medical Center, Pittsburg, PA, USA. krenzelokep@upmc.edu

INTRODUCTION: Real-time Outbreak and Disease Surveillance (RODS) is a national real-time syndromic surveillance system that classifies hospital registration chief complaints into one of seven syndromic categories. The National Retail Data Monitor (NRDM) is a public health surveillance tool that is designed to collect and analyze the daily sales of 18 categories of nonprescription medications. The goal of RODS and NRDM is to provide early warning of disease outbreaks, such as biological terrorism. The purpose of this study was to determine whether peak syndromic activity and the consequential purchase of nonprescription medications could predict an increase in poisoning exposures involving NRDM-monitored medications. METHODS: Data from the RODS and NRDM databases were plotted graphically to portray activity that occurred during 2003. Data from a regional poison information center electronic medical record system that involved all human exposure calls related to NRDM monitored medications in 2003 were extracted and graphed. Analysis included comparisons between the data sets. RESULTS: Poison center exposure volume correlated predictably and simultaneously with the peak activity in both the RODS and NRDM databases. Discussion: There was no delay between the onset of an influenza outbreak in December 2003, the sale of nonprescription palliative mediations, and the increase in poison center exposure call volume. Increased availability of and access to nonprescription medications resulted in more poisoning exposure calls. CONCLUSIONS: Real-time surveillance using other databases can help to forecast poison center activity. This knowledge allows the poison center to provide anticipatory guidance to the residents of its region.

2. Responding to suspected smallpox cases in the Los Angeles County from 2002 to 2006 identifying areas for education.

Kim M, Terashita D, Borenstein L, Mascola L.. Am J Emerg Med. 2009 Jan;27(1):55-62

Acute Communicable Disease Control Program, Public Health Laboratory, Los Angeles County Department of Public Health, Los Angeles, CA 90012, USA. mokim@ph.lacounty.gov

INTRODUCTION: Although smallpox has been eradicated, health care providers in emergency departments (EDs) need to remain vigilant to its recognition. Smallpox can be confused with chickenpox. We describe suspected smallpox cases reported in Los Angeles County from 2002 to 2006 and highlight areas for education. METHODS: We retrospectively reviewed suspected smallpox reports from 2002 to 2006. Laboratory testing was performed. Photographs of rashes were taken. RESULTS: Five suspected smallpox cases were reported. Two presented first to an ED. Smallpox was suspected based on rash features. Previous history of chickenpox or varicella vaccination may have caused increased suspicion for smallpox. All 5 were determined to have a final diagnosis of chickenpox. Health care providers notified public health appropriately and responses were immediate. CONCLUSIONS: Public health investigated 5 suspected smallpox cases in the past 5 years. Two presented initially to EDs. Education differentiating smallpox from chickenpox and collaboration between public health, EDs, and health care providers remains important. The ability to respond rapidly to a potential bioterrorism emergency was tested.


CHEMICAL RELATED

1. Adjuncts and alternatives to oxime therapy in organophosphate poisoning — is there evidence of benefit in human poisoning? A review.

Peter JV, Moran JL, Pichamuthu K, Chacko B. Anaesth Intensive Care. 2008 May;36(3):339-50.

Department of Medical Intensive Care, Christian Medical College and Hospital, Vellore, India.

Organophosphate poisoning is common in developing countries. The morbidity and mortality with organophosphate poisoning is relatively high despite the use of atropine as specific antidotal therapy and oximes to reactivate acetylcholinesterase. Several adjunct and alternative therapies have been explored in animal and human studies. We reviewed the literature to ascertain if there was evidence of benefit of such therapies. Adjunct and alternative therapies included treatments to reduce poison absorption by topical application of creams, enhance toxin elimination by haemoperfusion or bioremediation and neutralise the poison by scavenging free organophosphate with cholinesterase-rich human plasma. In addition, magnesium, clonidine, diazepam,

N-acetyl cysteine and adenosine receptor agonists have also been used to counteract poison effects. Detailed assessment was limited by the paucity of trials on adjunct/alternative therapies. The limited evidence from the review process suggested potential benefit from the use of human plasma infusion, early initiation of haemoperfusion and intravenous magnesium, in addition to standard therapy with atropine and pralidoxime. There appeared to be no additional benefit with alkalinisation or use of glycopyrrolate instead of atropine in human trials. Diazepam administration has been advocated by military authorities if symptoms developed following exposure to organophosphate. Bioremediation, clonidine, N-acetyl cysteine and adenosine receptor agonists have been evaluated only in animal models. The impact of adjunct and alternate therapies on outcomes in human poisoning needs to be further explored before implementation as standard treatment.


2. Therapy against organophosphate poisoning: the importance of anticholinergic drugs with antiglutamatergic properties.

Weissman BA, Raveh L. Toxicol Appl Pharmacol. 2008 Oct 15;232(2):351-8. Epub 2008 Jul 18.

Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel. aviw@iibr.gov.il

Potent cholinesterase inhibitors (e.g., soman, sarin), induce a wide range of deleterious effects including convulsions, behavioral impairments and ultimately, death. Due to the likelihood of various scenarios of military or terrorist attacks by these and other chemical weapons, research has to be aimed at finding optimal therapies. Early accumulation of acetylcholine in synaptic clefts was suggested to trigger an array of toxic events including an excessive release of glutamate, culminating in the activation of its receptors. Stimulation of the N-Methyl-D-Aspartate (NMDA) subtype of these receptors was associated with the neuronal injury that initiates organophosphate-induced brain damage. The notion of a stepwise mechanism yielded treatments based on a combination of an immediate administration of enzyme reactivators and anticholinergic drugs. This strategy dramatically increased survival rates but did not abolish convulsions and failed to prevent the ensuing cognitive dysfunction. Efforts to improve this paradigm by adding anticonvulsants or antiglutamatergic drugs with anti-epileptic characteristics produced dubious results. Under these conditions, benactyzine and caramiphen, agents with anticholinergic and antiglutamatergic properties, provided improved protection when introduced as adjunct agents to oximes, reversible cholinesterase inhibitors and/or specific antimuscarinic drugs such as atropine. In contrast, the specific antimuscarinic drug scopolamine failed to block soman-induced changes in glutamatergic and behavioral parameters even when given prophylactically. These findings along with a large number of additional reports led towards the conclusion that the therapeutic advantage of drugs such as benactyzine and caramiphen could derive from their ability to modulate central cholinergic and glutamate neurotransmission.

3. Efficacy of antidotal treatment against sarin poisoning: the superiority of benactyzine and caramiphen

Raveh L, Rabinovitz I, Gilat E, Egoz I, Kapon J, Stavitsky Z, Weissman BA, Brandeis R. Toxicol Appl Pharmacol. 2008 Feb 15;227(1):155-62.

Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel. lili@iibr.gov.il

Sarin, a potent cholinesterase inhibitor, induces an array of toxic effects including convulsions and behavioral impairments. We report here on the protection provided by post-exposure antidotal treatments against a lethal dose of sarin (1.2xLD50) by scopolamine, benactyzine, trihexyphenidyl or caramiphen, administered 5, 10 or 20 min after the initiation of convulsions. A mixture of the oxime TMB4 and atropine (TA) was injected 1 min following poisoning a paradigm that may represent a scenario reminiscent of a terror incident. Surviving TA-treated rats exhibited marked tonic-clonic convulsions, weight loss, poor clinical status and abnormal cognitive performance as assessed by the Morris water maze. Additionally, a dramatic increase in the density of peripheral benzodiazepine receptors (PBRs), a faithful marker for neuronal damage, was noted. Animals treated 5 min after the development of toxic signs with benactyzine, trihexyphenidyl or caramiphen demonstrated control levels of PBR values, whereas scopolamine produced binding densities significantly above basal levels. Examined at the 10-min time point, scopolamine and trihexyphenidyl afforded no protection against brain damage and did not differ from TA-injected rats. All four drugs failed to significantly prevent the alterations when applied 20 min after onset of convulsions. Assessment of learning processes yielded similar results, where caramiphen exibited some protection at the 20-min time point. Our results show that caramiphen and benactyzine, agents with combined anticholinergic and antiglutamatergic pharmacological profiles, offer considerable shielding against sarin, even when their administration is delayed.

4. Angiotensis-converting enzyme genotype and late respiratory complications of mustard gas exposure

Hosseini-Khalili AR, Thompson J, Kehoe A, Hopkinson NS, Khoshbaten A, Soroush MR, Humphries SE, Montgomery H, Ghanei M. BMC Pulm Med. 2008 Aug 14;8:15.

UCL Institute for Human Health and Performance, Ground Floor, Charterhouse Building, UCL Archway Campus, Highgate Hill, Archway, London N19 5LW, UK. alireza_hosseini50@yahoo.com

BACKGROUND:
Exposure to mustard gas frequently results in long-term respiratory complications. However the factors which drive the development and progression of these complications remain unclear. The Renin Angiotensin System (RAS) has been implicated in lung inflammatory and fibrotic responses. Genetic variation within the gene coding for the Angiotensin Converting Enzyme (ACE), specifically the Insertion/Deletion polymorphism (I/D), is associated with variable levels of ACE and with the severity of several acute and chronic respiratory diseases. We hypothesized that the ACE genotype might influence the severity of late respiratory complications of mustard gas exposure. METHODS: 208 Kurdish patients who had suffered high exposure to mustard gas, as defined by cutaneous lesions at initial assessment, in Sardasht, Iran on June 29 1987, underwent clinical examination, spirometric evaluation and ACE Insertion/Deletion genotyping in September 2005. RESULTS: ACE genotype was determined in 207 subjects. As a continuous variable, FEV1 % predicted tended to be higher in association with the D allele 68.03 +/- 20.5%, 69.4 +/- 21.4% and 74.8 +/- 20.1% for II, ID and DD genotypes respectively. Median FEV1 % predicted was 73 and this was taken as a cut off between groups defined as having better or worse lung function. The ACE DD genotype was overrepresented in the better spirometry group (Chi2 4.9 p = 0.03). Increasing age at the time of exposure was associated with reduced FEV1 %predicted (p = 0.001), whereas gender was not (p = 0.43). CONCLUSION: The ACE D allele is associated with higher FEV1 % predicted when assessed 18 years after high exposure to mustard gas.

5. Estimates of percutaneous toxicity of sulfur mustard vapor suitable for use in protective equipment standards

Dickson EF.

Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, Ontario, Canada. Dickson-e@rmc.ca

An analysis was performed of historical human chamber data for exposure to sulfur mustard vapor, in order to correlate skin exposure dosages with effects in a manner specifically suitable for use in protective clothing standards. Data were reanalyzed to take into account (1) body region variability of skin responses to a single acute exposure to sulfur mustard vapor, (2) effect of hot/humid versus cooler exposure, and (3) influence of clothing. This approach permits deriving predicted skin responses pertinent to a protective clothing wearer, for a relatively short single acute exposure to vapor (up to a few hours) under the hot/humid conditions expected within a protective ensemble. Values for permissible dermal exposure to sulfur mustard vapor are proposed for protected emergency responders or military serving in combat theaters that may be used in standards intended to be employed in conjunction with evaluation of vapor protection provided by individual protective equipment for protection against chemical warfare agents by Man-in-Simulant vapor test methods.


6. The poison gas debate in the inter-war years

van Bergen L. MED Confl Surviv. 2008 Jul-Sep;24(3):174-87.

Department of Medical Humanities (Metamedica), VU Medical Centre, Amsterdam, The Netherlands. l.vanbergen@vumc.nl

Poison gas, together with nuclear and biological weapons, has been classified as a 'weapon of mass destruction'. This has not always been the case; in the years after World War I it was claimed that poison gas was the most humane weapon thinkable, as it did not kill in the numbers that machine guns and artillery did - today's 'conventional' weapons. Gas only made soldiers unconscious, so that they could be taken prisoner, and when the war was over could return safely to their friends and families. This stand was fiercely disputed in the inter-war years by those who saw gas as one step, even the final step, crossing the boundaries of civilization. Moreover, gas showed clearly that medical intervention to cure the agonies of war was senseless; prevention could be the only answer. Nevertheless, the fact remains that almost all of the nine million deaths of World War I - now mostly remembered as a war of gas and madness - were due to shells and bullets.


7. Implications of chemical biological terrorist events for children and pregnant women

Teran-Maciver M, Larson K. MCN Am J Matern Child Nurs. 2008 Jul-Aug;33(4):224-32; quiz 233-4

Agency for Toxic Substances and Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA. Mnt0@cdc.gov

During the past decade, the world has become more aware that chemical and biological weapons could be used on civilians as terrorism and that casualties could include children. It is essential that nurses who care for children and pregnant women know how to recognize the effects of this type of weapon on the population and how to alleviate or mitigate their impact. This article reviews key aspects of chemical-biological agents, the consequences of their use, the potential impact of a chemical-biological attack on children and pregnant women, and issues to consider in the event of such a catastrophe.


8. Comparison of the Intramuscular, Intranasal or Sublingual Routes of Midazolam Administration for the Control of Soman-Induced Seizures*

McDonough JH, Van Shura KE, Lamont JC, McMonagle JD, Shih TM.

Basic Clin Pharmacol Toxicol. 2008 Nov 14. [Epub ahead of print]

Pharmacology Branch, Research Division, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD, USA.

This study evaluated the anticonvulsant effectiveness of midazolam to stop seizures elicited by the nerve agent soman when midazolam was administered by different routes (intramuscular, intranasal or sublingual) at one of two different times after the onset of seizure activity. Guinea pigs previously prepared with cortical electrodes to record brain electroencephalographic activity were pre-treated with pyridostigmine (0.026 mg/kg, intramuscularly) 30 min. before challenge with a seizure-inducing dose of the nerve agent soman (56 microg/kg, subcutaneously), and 1 min. later, they were administered 2.0 mg/kg atropine sulfate admixed with 25.0 mg/kg 2-PAM Cl (intramuscularly). Groups of animals were administered differing doses of midazolam by the intramuscular, intranasal or sublingual route at either the onset of seizure activity or 40 min. after the onset of seizure activity that was detected in the electroencephalographic record. When given immediately after seizure onset, the anticonvulsant ED(50) of intramuscular midazolam was significantly lower than that of intranasal midazolam, which in turn was significantly lower than sublingual midazolam at that time. At the 40-min. treatment delay, the anticonvulsant ED(50)s of intramuscular or intranasal midazolam did not differ and both were significantly lower than the sublingual route. Higher doses of midazolam were required to stop seizures at the 40-min. treatment delay time compared to immediate treatment. The speed of seizure control for intramuscular or intranasal midazolam was the same while sublingual midazolam acted significantly slower. Midazolam was effective in treating soman-induced seizures when given by all three routes, but with differences in potency and speed of action.


9. Clinical findings and cholinesterase levels in children of organophosphates and carbamates poisoning

El-Naggar AE, Abdalla MS, El-Sebaey AS, Badawy SM.

Eur J Pediatr. 2008 Nov 8. [Epub ahead of print]

National Center for Clinical and Environmental Toxicology, Faculty of Medicine, Cairo University, Cairo, Egypt.

INTRODUCTION: Exposure to organophosphate and carbamate insecticides inhibits cholinesterase activity and interferes with synaptic transmission both centrally and peripherally at muscarinic receptors and nicotinic receptors. The study reported the usefulness of plasma cholinesterase ChE activity assays for diagnosis and the management of organophosphate and carbamate toxicity in children. METHODS: A retrospective study was conducted on children with organophosphate and carbamate poisoning. Forty-seven patients were included. The diagnosis was confirmed by measuring plasma cholinesterase levels. Atropine was given intravenous (0.02 mg/kg) and repeated until secretions were controlled. Obidoxime chloride was administered as 4-8 mg/kg/dose for children with organophosphate poisoning and to those in whom the ingested material was unidentified on admission. DISCUSSION: Most of the patients showed marked reactivation in plasma ChE within several hours and recovered completely within 24 h of admission. Complications were observed in 17 patients (36%). Mechanical ventilatory support was required in six patients. The duration intensive care stay was 3 +/- 2.4 days. CONCLUSION: Low plasma ChE levels support the diagnosis of insecticides poisoning, but no significant association is present between the severity of poisoning and plasma ChE levels. Atropine should be used as soon as possible to counteract the muscarinic effects. Appropriate management and early recognition of the complications may decrease the mortality rate.


10. The effect of HI-6 on cholinesterase and on the cholinergic system of the rat bladder

Soukup O, Pohanka M, Tobin G, Jun D, Fusek J, Musilek K, Marek J, Kassa J, Kuca K.

Neuro Endocrinol Lett. 2008 Oct;29(5):759-62.

Department of Toxicology, Faculty of Military Health Sciences, University of Defence, Hradec Kralove, Czech Republic.

OBJECTIVES: The current standard treatment of organophosphate poisoning consists of an administration of anticholinergic drugs and cholinesterase reactivators (oximes). Oximes can react - except their reactivating effect on cholinesterases - directly with cholinoreceptors. HI-6 is an oxime that may have an inhibitory effect on the muscarinic receptors, too. METHODS: In our work, we have investigated an influence of HI-6 on the acetylcholinesterase (AChE), butyrylcholinesterase (BChE) and on the muscarinic receptors in vitro. The study was conducted using biosensor technique and on the rat bladder using in vitro test (tissue bath; methacholine as muscarinic agonist). IC50 for BChE from human serum was determined to be 1.01x10-6 M and for human erythrocytes AChE 3.31x10-6 M, respectively. CONCLUSION: We assume that the demonstrated contractile response can be attributed to the inhibition of the AChE at the lower concentration and to a predominant inhibition of muscarinic receptor at higher concentration of compound tested.


ANIMAL/ZOONOSIS RELATED

1. Animals as early detectors of bioevents: veterinary tools and a framework for animal-human integrated zoonotic disease surveillance.

Gubernot DM, Boyer BL, Moses MS.

Public Health Rep. 2008 May-Jun;123(3):300-15.

The George Washington University School of Public Health and Health Services, Washington, DC, USA. Gubernot@alumni.gwu.edu

The threat of bioterrorism and emerging infectious diseases has prompted various public health agencies to recommend enhanced surveillance activities to supplement existing surveillance plans. The majority of emerging infectious diseases and bioterrorist agents are zoonotic. Animals are more sensitive to certain biological agents, and their use as clinical sentinels, as a means of early detection, is warranted. This article provides design methods for a local integrated zoonotic surveillance plan and materials developed for veterinarians to assist in the early detection of bioevents. Zoonotic surveillance in the U.S. is currently too limited and compartmentalized for broader public health objectives. To rapidly detect and respond to bioevents, collaboration and cooperation among various agencies at the federal, state, and local levels must be enhanced and maintained. Co-analysis of animal and human diseases may facilitate the response to infectious disease events and limit morbidity and mortality in both animal and human populations.


2. Zoonoses likely to be used in bioterrorism

Ryan CP. Public Health Rep. 2008 May-Jun;123(3):276-81.

Veterinary Public Health and Rabies Control, Disease Control Programs, Los Angeles County Department of Public Health, 7601 E. Imperial Hwy., Bldg. 700, Ste. 94A, Downey, CA 90242, USA.
pryan@ph.lacounty.gov

Bioterrorism is the deliberate release of viruses, bacteria, or other agents used "to cause illness or death in people, animals, or plants. Only modest microbiologic skills are needed to produce and effectively use biologic weapons. And biological warfare has afflicted campaigns throughout military history, at times playing an important role in determining their outcomes. There is a long list of potential pathogens for use by terrorists, but only a few are easy to prepare and disperse. Of the infectious diseases, the vast majority are zoonoses. The Centers for Disease Control and Prevention's highest-priority bioterrorism agents are in Category A. The only disease that does not affect animals in Category A is smallpox, which was eliminated by a worldwide vaccination program in the late 1970s. Because these diseases can infect animals and humans, the medical and veterinary communities should work closely together in clinical, public health, and research settings.


PREPAREDNESS RELATED

1. Analysis of disaster response plans and the aftermath of hurricane Katrina: lessons learned from a level I trauma center

Brevard SB, Weintraub SL, Aiken JB, Halton EB, Duchesne JC, McSwain NE Jr, Hunt JP, Marr AB.

Departments of Surgery, and Emergency Medicine, Louisiana State University Health Science Center, New Orleans, Louisiana, USA.

BACKGROUND: The purpose of this study was to compare disaster preparedness of a Level I Trauma Center with performance in an actual disaster. Previous disaster response evaluations have shown that the key to succeeding in responding to a catastrophic event is to anticipate the event, plan the response, and practice the plan. The Emergency Management Team had identified natural disaster as the hospital's highest threat. The hospital also served as the regional hospital for the Louisiana Health Resources and Service Administration Bioterrorism Hospital Preparedness Program. METHODS: The hospital master disaster plan, including the Code Gray annex, was retrospectively reviewed and compared with the actual events that occurred after Hurricane Katrina. Vital support areas were evaluated for adequacy using a systematic approach. In addition, a survey of 10 key personnel from trauma and emergency medicine present during Hurricane Katrina was conducted. The survey of vital support areas were scored as adequate (3 pts), partially adequate (2 pts), or inadequate (1 pt). RESULTS: Ninety-three percent of the line items on the Code Gray Checklist were accomplished before landfall of the storm. The results of the survey of vital support areas were water-3.0, food-2.4, sanitation-1.5, communication-1.4, and power-1.5. CONCLUSION: Despite identifying the threat of a major hurricane, preparing a response plan, and exercising the plan, a major medical center can be overwhelmed by a catastrophic disaster like Hurricane Katrina. We offer our lessons-learned as an aid for other medical centers that are developing and exercising their plans.


2. Scientists urge DHS to improve bioterrorism risk assessment

Parnell GS, Borio LL, Brown GG, Banks D, Wilson AG.

Biosecur Bioterror. 2008 Oct 31. [Epub ahead of print]

Department of Systems Engineering, United States Military Academy, West Point, New York.
In 2006, the Department of Homeland Security (DHS) completed its first Bioterrorism Risk Assessment (BTRA), intended to be the foundation for DHS's subsequent biennial risk assessments mandated by Homeland Security Presidential Directive 10 (HSPD-10). At the request of DHS, the National Research Council established the Committee on Methodological Improvements to the Department of Homeland Security's Biological Agent Risk Analysis to provide an independent, scientific peer review of the BTRA. The Committee found a number of shortcomings in the BTRA, including a failure to consider terrorists as intelligent adversaries in their models, unnecessary complexity in threat and consequence modeling and simulations, and a lack of focus on risk management. The Committee unanimously concluded that an improved BTRA is needed to provide a more credible foundation for risk-informed decision making.


3. Clinical care in the “Hot Zone”

Byers M, Russell M, Lockey DJ.

Emerg Med J. 2008 Feb;25(2):108-12.

Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Selly Oak Hospital, Birmingham, UK.

The threat of chemical, biological, radiological and nuclear incidents is unlikely to decrease and preparations to deal with this type of incident are well established in most European emergency medical systems. In the UK medical care is not currently provided in the "Hot" or contaminated zone. This article discusses the background to the current threat and suggests that, where survivors are present in the "Hot Zone", medical care should be started there to minimise delay and maximise the chances of survival.


RADIATION/NUCLEAR

1. Implementing RFID technology in a novel triage system during a simulated mass casualty situation

Jokela J, Simons T, Kuronen P, Tammela J, Jalasvirta P, Nurmi J, Harkke V, CastrV©n M. Int J Electron Healthc. 2008;4(1):105-18

Centre for Military Medicine, Finnish Defence Forces, P.O. Box 2, 15701 Lahti, Finland. jorma.jokela@mil.fi

The purpose of this study is to determine the applicability of Radio Frequency Identification (RFID) technology and commercial cellular networks to provide an online triage system for handling mass casualty situations. This was tested by a using a pilot system for a simulated mass casualty situation during a military field exercise. The system proved to be usable. Compared to the currently used system, it also dramatically improves the general view of mass casualty situations and enhances medical emergency readiness in a military medical setting. The system can also be adapted without any difficulties by the civilian sector for the management of mass casualty disasters.


2. Ranking nuclear and radiological terrorism scenarios: the Italian case

Tofani A, Bartolozzi M.

Risk Anal. 2008 Oct;28(5):1431-44. Epub 2008 Aug 5.

Struttura Complessa de Fisicia Sanitaria, Livorno, Italy. a.tofani@usl6.toscana.it

A quantitative criterion for ranking the different scenarios of nuclear and radiological terrorism has been developed. The aim of the model is not to predict terroristic events but only to indicate which scenario has the higher utility from the point of view of a terroristic organization in terms of balance between factors favoring and discouraging the attack, respectively. All these factors were quantified according to a scoring system that takes into account the logarithmic relationship between perceptions and stimuli. The criterion was applied to several scenarios, each of which was modeled in a simple but not trivial way in order to estimate the expected damage in terms of probable life losses from both radiative and nonradiative effects. The outcome from the ranking method indicates that the attractive scenario appears to be the detonation of a low yield improvised nuclear device in the metropolitan area of a major city.


3. Polonium 210 as a poison

Harrison J, Leggett R, Lloyd D, Phipps A, Scott B.

J Radiol Prot. 2007 Mar;27(1):17-40. Epub 2007 Mar 6

Health Protection Agency, Radiation Protection Division, Centre for Radiation, Chemicals and Environmental Hazards, Chilton, Didcot, Oxon, UK. john.harrison@hpa.org.uk

The death of Alexander Litvinenko on 23 November 2006 has brought into focus scientific judgements concerning the radiotoxicity of polonium-210 ((210)Po). This paper does not consider the specific radiological circumstances surrounding the tragic death of Mr Litvinenko; rather, it provides an evaluation of published human and animal data and models developed for the estimation of alpha radiation doses from (210)Po and the induction of potentially fatal damage to different organs and tissues. Although uncertainties have not been addressed comprehensively, the reliability of key assumptions is considered. Concentrating on the possibility of intake by ingestion, the use of biokinetic and dosimetric models to estimate organ and tissue doses from (210)Po is examined and model predictions of the time-course of dose delivery are illustrated. Estimates are made of doses required to cause fatal damage, taking account of the possible effects of dose protraction and the relative biological effectiveness (RBE) of alpha particles compared to gamma and x-rays. Comparison of LD(50) values (dose to cause death for 50% of people) for different tissues with the possible accumulation of dose to these tissues suggests that bone marrow failure is likely to be an important component of multiple contributory causes of death occurring within a few weeks of an intake by ingestion. Animal data on the effects of (210)Po provide good confirmatory evidence of intakes and doses required to cause death within about 3 weeks. The conclusion is reached that 0.1-0.3 GBq or more absorbed to blood of an adult male is likely to be fatal within 1 month. This corresponds to ingestion of 1-3 GBq or more, assuming 10% absorption to blood. Well-characterised reductions in white cell counts would be observed. Bone marrow failure is likely to be compounded by damage caused by higher doses to other organs, including kidneys and liver. Even if the bone marrow could be rescued, damage to other organs can be expected to prove fatal.


4. Death by polonium 201: lessons learned from the murder of former Soviet spy Alexander Litvinenko

McFee RB, Leikin JB. JEMS. 2008 July and Nov;33(11):18-23.

Long Island Regional Poison Information Center, Winthrop University Hospital, Mineola, NY, USA. rbmcfee@pol.net

Radioactive materials are readily available. They’re used in industry, medicine and military settings, and terrorist groups, including Aum Shinrikyo, Al Qaeda and Chechnyan extremists, have expressed interest in obtaining or have tested and attempted to deploy various forms of radiological weapons. Numerous high-profile toxic events have also been associated with radiation, such as the reactor explosion in Chernobyl. 

But it was the death of Alexander Litvinenko on Nov. 23, 2006, three weeks after he presented to a London Hospital, that brought into focus the threat of radioactive materials being intentionally used against individuals or a society, such as Polonium-210 (210Po). Clinicians suspected radiation early on as the cause of his presenting illness, but they pursued other toxic etiologies when initial tests failed to reveal gamma radiation. It’s likely internal radiation was not initially considered. Once Litvinenko was accurately diagnosed, an environmental survey of his last whereabouts was conducted. Numerous individuals–from the worried well to the potentially exposed–presented a public-health challenge.  This case sets the stage for several important considerations for EMS and hospital personnel. Medical response to radiation and radiological weapons remains one of the least emphasized aspects of medical education in general and of current terrorism preparedness specifically. And most EMS providers are ill-prepared to handle events involving radiation. Recently,  JEMS  posed the question on its Web site, “Do you feel prepared to handle victims of a dirty (radioactive material) bomb?” Of the 246 respondents, 82% responded “No.” Along with the lack of education regarding radiation poisoning, the ubiquitous nature of radioactive materials and the potential for their misuse, Litvinenko’s death demonstrates the need for training in recognizing, diagnosing and treating radiologic threats. EMS providers must become familiar with detector technologies and capabilities. And radiation poisoning should be considered in the appropriate setting as part of the differential diagnosis.  Clinicians at health-care facilities are often insulated from the environmental events associated with arriving patients. But EMS providers are critical witnesses and the street-level eyes and ears of the health-care system; they have the unique advantage of surveying the surroundings and circumstances associated with victims and can relay valuable insights, suspicions and concerns to hospital staff. Fortunately, the risk for EMS in treating radiation victims is minimal if proper procedures are followed.

The public’s welfare largely rests upon first responders and hospitals being prepared for radiological emergencies. EMS providers and emergency departments (EDs) must be able to recognize a potential radiation event, identify and treat patients suffering from conventional injuries that may be complicated by radiation exposure or contamination, utilize appropriate personal protective equipment (PPE) and alert the proper authorities to initiate a rapid response. Responding to a radiation incident requires advance planning and continuous training. 

5. Medical Response to a RAdiologica/Nuclear Event: Integreated Plan from the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services

Coleman CN, Hrdina C, Bader JL, Norwood A, Hayhurst R, Forsha J, Yeskey K, Knebel A.

Ann Emerg Med. 2008 Apr 3. [Epub ahead of print]

Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC; National Cancer Institute, National Institutes of Health, Bethesda, MD.

The end of the Cold War led to a reduced concern for a major nuclear event. However, the current threats from terrorism make a radiologic (dispersal or use of radioactive material) or nuclear (improvised nuclear device) event a possibility. The specter and enormousness of the catastrophe resulting from a state-sponsored nuclear attack and a sense of nihilism about the effectiveness of a response were such that there had been limited civilian medical response planning. Although the consequences of a radiologic dispersal device are substantial, and the detonation of a modest-sized (10 kiloton) improvised nuclear device is catastrophic, it is both possible and imperative that a medical response be planned. To meet this need, the Office of the Assistant Secretary for Preparedness and Response in the Department of Health and Human Services, in collaboration within government and with nongovernment partners, has developed a scientifically based comprehensive planning framework and Web-based "just-in-time" medical response information called Radiation Event Medical Management (available at http://www.remm.nlm.gov). The response plan includes (1) underpinnings from basic radiation biology, (2) tailored medical responses, (3) delivery of medical countermeasures for postevent mitigation and treatment, (4) referral to expert centers for acute treatment, and (5) long-term follow-up. Although continuing to evolve and increase in scope and capacity, current response planning is sufficiently mature that planners and responders should be aware of the basic premises, tools, and resources available. An effective response will require coordination, communication, and cooperation at an unprecedented level. The logic behind and components of this response are presented to allow for active collaboration among emergency planners and responders and federal, state, local, and tribal governments.

Don’t forget to sign up to join the WMD SIG, and remember the NACCT 2009 Abstract Deadline….we’ll be selecting a few from among the accepted abstracts to present at our annual meeting.

Happy Holidays to all and we’ll see you in 2009!