Summary of Medical CBRN Planning Response

Summary of Medical CBRN Planning & Response The GAO report [GAO-02-38, Oct 01] stated, “many of the tools and studies for planning conventional medical response lack features required to adequately plan for CB support.” DOD answered this report, “DOD is moving forward…to conduct an assessment of the medical impact of the threat as a way of better defining the medical readiness requirements [of a CBRN event].” ASD(Health Affairs) tasked OTSG to lead this DOD effort, which was – rather inadequately – labeled as “hazard analysis.” The actual result of this effort is a concept of and the procedures for “Medical CBRN Planning & Response,” which includes ALL of the following products:     CBRN Defense operational concept Medical CBRN planning procedures & factors Medical CBRN response operational “rules of thumb” Medical CBRN operational template CBRN Defense Operational Concept An operational concept for CBRN defense (one that adequately encompasses the entire CBRN threat spectrum did not exist before). This operational concept is based upon the World Association of Disaster & Emergency Medicine (WADEM) guidelines for emergency medical response. This operational concept analytically links the stated CBRN threat with an assessment of the potential impact of this threat, by carefully defining the development of the CBRN impact from the originating situation, hazards that either exist within the situation or are introduced into the situation; the event that is the realization of the hazard; the damage that results from the event; and the impact which is the result of the damage as it can be addressed by existing capabilities. Thus, an effective CBRN Defense consists of intervening in these transitions with the goal of ultimately reducing the impact of the CBRN event. The intervention between situation & hazard is planning; the intervention between hazard & event is prevention; the intervention between event & damage is mitigation; and the intervention between damage & impact is response. Each intervention will involve multiple, integrated capabilities; in almost any event, a commander will have to plan and execute multiple interventions simultaneously. For example, immediately after a detected anthrax attack, a commander will act to mitigate the damage (distributing prophylaxis to soldiers); prevent additional attacks; and initiate the appropriate medical response to treat any casualties. b0ca205a-469f-456b-bb71-a8a579935b62.doc 1 Medical CBRN Planning Procedures & Factors Procedures and associated planning factors for medical CBRN planning that address the potential for terrorist use of CBRN, covert 4events, and the differences in planning scope at the national, regional, and local levels. Such procedures did not exist before; the challenge of planning for a nearly infinite number of different potential CBRN attacks – many with very different “impacts” was overwhelming. Consider how different the medical response would be just for the following events: nuclear detonation in a major city; release of a nerve agent in a subway system; large scale aerosol release of anthrax in a metropolitan area; and a smallpox outbreak. The recent fielding of NBC casualty estimation methods [NATO & US ratified Allied Medical Publication P-8, AMED P-8, “Medical Planning Guide of NBC Battle Casualties”] and modeling-simulation tools that apply the Joint Readiness Clinical Advisory Board (JRCAB) treatment protocols to such casualty estimates [NBC CREST], applied in accordance with the operational concept allowed the development of medical CBRN planning procedures and planning factors. When finalized, these would be incorporated into doctrine [FM 8-55, “Planning for Health Service Support”] and would allow medical planners to include CBRN events in their planning. Medical CBRN Response Operational “Rules of Thumb” Operational “rules of thumb” that – in the absence of actual experience – provide decision-makers a better understanding of the relevant constraints or scope of an actual execution of medical CBRN capabilities. The first such operational “rule of thumb” to be developed is the ASD(Health Affairs) policy “Release of Antibiotics,” Apr 02. Medical CBRN Operational Template Finally, a medical CBRN operational template that supports the military decisionmaking process before and after the CBRN event. This operational template includes a detailed laydown of the critical decision points – and associated courses of action – for reducing the potential impact of a CBRN event. b0ca205a-469f-456b-bb71-a8a579935b62.doc 2 Medical CBRN Operational Template Mission To reduce the impact of a CBRN event. Mission Analysis – Facts & Assumptions HAZARD Define the hazard in terms of the following characteristics.  Lethality – the ability of a hazard to cause death without treatment. The lethality of a hazard can be measured by its case fatality rate and by the speed of death. Morbidity – the severity & duration of health effects without treatment Communicability – the ability of the hazard to cause secondary cases without quarantine or barrier nursing. Persistence – the degree of continuing risk of exposure to health individuals related to environmental exposures such as air, water, soil, food, fomites, vectors, animals, bodily fluids, etc.    EVENT Define the event in terms of the following characteristics.        Route of exposure: inhalation, inoculation, ingestion, percutaneous Delivery: default definition for attack (10 km ground spray for BW aerosol) Attack: parameters of attack for default definition (anthrax cloud attack area for 10 km ground spray is approximately ??? sq km) Target: population density; population magnitude; unwarned; unprotected, etc Environment: weather conditions; terrain Secondary events: potential for secondary events or exposures Mechanism of event detection and/or hazard identification: DAMAGE Define the damage in terms of the following characteristics.     % population exposed Maximum casualty load projected Onset of symptoms Distribution of patient conditions b0ca205a-469f-456b-bb71-a8a579935b62.doc 3 Situation. Essentially outlines the projected impact assessment of the event, by defining the following characteristics.     Definition of population @ risk (PAR) Status of existing capabilities (see definition & analysis of capabilities) Medical resource requirements (with & without mitigation) Summation of required interventions, in priority order Course of Action Analysis For each recommended intervention, an analysis of the capabilities required to implement effective mitigation & response interventions. It is at this point that an in depth staff functional analysis is conducted [logistics, personnel, etc] b0ca205a-469f-456b-bb71-a8a579935b62.doc 4 EXAMPLE MISSION ANALYSIS: PLAGUE ATTACK Mission To reduce the impact of a CBRN event. Mission Analysis – Facts & Assumptions HAZARD Define the hazard in terms of the following characteristics. Assessment of plague characteristics drawn from “Medical Risk Assessment of the Biological Threat,” May 01.     Lethality – case fatality rate is between 41-100% and death results in 4-7 days w/o treatment. Morbidity – ICU required; potential residual health effects due to use of antibiotics rather than disease. Communicability – droplet precautions required Persistence – moderate risk for secondary infection to troops through typical endemic form. EVENT Define the event in terms of the following characteristics.     Route of exposure: plague is an inhalation and inoculation threat; maximum threat is through aerosol exposure. NOT an ingestion threat via food or water. Delivery: default definition for attack (10 km ground spray for BW aerosol attacks) Attack: moderate intensity attack (AMED P-8) of 10 km ground spray plague cloud is approx 280 sq km in size. Target: population density at two JTF force locations; local civilian populations. Unwarned, unprotected. Total JTF population is 7,050 personnel; Environment: cloudy overcast with a moderate inversion layer; 10 mph breeze blowing from southwest Secondary events: potential for secondary through vector borne disease transmission as plague is communicated to mammal and flea population. Mechanism of event detection and/or hazard identification: clinical recognition of symptoms, four days post-exposure. Confirmed with clinical lab test (sputum gram negative)    DAMAGE Define the damage in terms of the following characteristics. b0ca205a-469f-456b-bb71-a8a579935b62.doc 5   % population exposed: unknown; must assume 100% PAR exposed. Maximum casualty load projected: 53 cases present on 15 Aug, first indication of a problem. Projected max casualty load, using the “rule of thumb” of 10-50 times initial case presentation estimates maximum casualty load as: 530-2650 (scenario design, with modeled estimates projects 3480 soldiers exposed). Onset of symptoms: for plague, generally 3-5 days for default attack (10 km ground spray) Distribution of patient conditions:   Situation. Essentially outlines the projected impact assessment of the event, by defining the following characteristics.             Definition of population @ risk (PAR): will commander support US citizens? Host Nation? May have to run different COA for each additional population. Status of existing capabilities (see definition & analysis of capabilities) Medical resource requirements (with & without mitigation) Summation of required interventions, in priority order Prevention Increase FPCON Increase physical security to limit additional attacks Enhance (where possible) BW detection capabilities; recommend active surveillance @ 12 hr intervals of remaining population. Initiate – as a lower priority – vector control measures. Mitigation Release 5 DOS of antibiotics to 100% defined PAR within 6 hrs of event declaration. Establish isolation requirements, to include triggers for transition into and out of isolation. Issue surgical masks to all medical personnel Response Initiate mass CBRN care facility, with separate areas for isolation patients (in first 48 hrs of IV treatment, when they are most contagious); recovering (but still contagious); and non-contagious patients. b0ca205a-469f-456b-bb71-a8a579935b62.doc 6 Course of Action Analysis For each recommended intervention, an analysis of the capabilities required to implement effective mitigation & response interventions. It is at this point that an in depth staff functional analysis is conducted [logistics, personnel, etc] b0ca205a-469f-456b-bb71-a8a579935b62.doc 7