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University at Albany Center for Public Health Preparedness

Population Monitoring During Radiological Emergencies

Original Satellite Broadcast: 11/12/09

Moderator- Good morning, and welcome to The University at Albany's Center for Public Health Preparedness Grand Rounds Series. I'm Kris Smith and I'll be your moderator today. Before we start, we'd like to ask you to please fill out your evaluations online. Continuing education credits are available after completing the post test, and your feedback is always helpful to the development of our future programs. We encourage you to participate today and we'll take your calls throughout the hour. The toll free number is 800-452-0662. You may also send your written questions at any time by fax to 518-426-0696 or by e-mail to the address you see on your screen. Our speaker today is Dr. Adela Salame-Alfie of the New York State Department of Health Center for Environmental Health.
Adela, thanks so much for joining us today.

Adela- My pleasure, Kris.

Moderator- Could we start by going over some of the points you'll make during the course of this broadcast?

Adela- Certainly. I want to give a little background as to what population monitoring is, what the key principles are, what do we need to do and what a Community Reception Center is will be a big focus of the talk and I had an opportunity to participate in a drill a few months ago where we actually set up a Community Reception Center (or CRC), so I have a couple slides to show.

Moderator- And I know that was an enormous undertaking and we're going to talk about that a little bit later on. You know, as a layperson, when think about around emergencies, first thing that comes to mind, of course, Three Mile Island and, otherwise, Chernobyl in the Ukraine or the threat nowadays of radioactive weaponry. There probably are other sources of radiological emergencies though, aren't there?

Adela- Well, yes, and if you think about it, because we use radioactive materials in a variety of sources, you can have incidents to transportation, nuclear power plants, weapons, laboratories, industrial accidents. So it can happen in many situations, not necessarily as a result of a reactor or a nuclear weapon. You can find it in many different applications.

Moderator- So you don't necessarily have to think about large structures or events, a radiological emergency can come in many sizes or incidents.

Adela- Correct. And that's why it's really important that communities are prepared. You can't think 'oh, it won't happen here'. You know, we have a lot of material transported through the highways, so you might have to respond at some point to some radiological event.

Moderator- How about rail?

Adela- Rail cars also are used to transport radioactive materials.

Moderator- And would you say that transportation events are what we see most often nowadays?

Adela- Yes, although for the most part, they has been minute consequences because of the packaging of the material and other precautions, but again, you never know when an incident is going to happen, so that's why we try to encourage communities to have a radiological emergency plan.

Moderator- When you hear the word radiation, it just sparks a sense of dread and I know that radiation is useful for many purposes, but I think a lot of the public just fear radiation events. What impact has some of the things like Three Mile Island or Chernobyl? What impact has that had on the general public, do you think?

Adela- Well, unfortunately, because of those events, people fear radiation. People don't realize that we deal with radiation on a day-to-day basis. Every time you go to a hospital, a nuclear medicine procedure, you're dealing with radioactive materials. But people in general terms will be scared, so it's important that we have some tools available if we have to respond to an emergency, that we can inform the public what's going on, how to take care of themselves and things like that.

Moderator- And before the broadcast, we were talking about what I think is just a fascinating case study. It was the incident in Brazil. Could you take us through what happened there?

Adela- Yeah. That was in 1987 in Goiania, Brazil and actually, it was a situation where it was a private radiotherapy institute they moved to a new location. And they had several sources, but they left behind a teletherapy machine that has a cesium source. So a couple of people went in trying to, you know, rescue the material figuring, 'oh this is some good scrap material'. They removed the radioactive source - it took some time but, in the process of removing it, they saw it had a blue glowing powder and Caesium Chloride is a salt and the touched it, they took it into their homes and that resulted in a large contamination event.

Moderator- Were there a lot of people involved in it, though?

Adela- Actually, there were a handful, but, you know, they invited people over to look at the material. It was fun, it would glow, you know, they took different pieces. So, several people got contamination. You know, they touch it, they put their hands in their mouth so they had some internal contamination.

Moderator- They didn't realize what it was.
Adela- They did not, they did not. It was a couple days later that a physician realized that it could initially be radioactive material. So, in that event resulted in a couple hundred people were exposed. About 50, 55 people had to be hospitalized. Eight of them had acute radiation syndrome. Four people died. You know, it generated a lot of waste. The cleanup of this area was very, very involved. But the most striking fact of this is that 112,000 people have to be monitored for contamination. It doesn't mean they were contaminated, but people were so concerned that they may be contaminated that the Brazilian government set up in a soccer stadium and over the course of a couple months, they monitored 112000 people. And if you think about it, 239 people were exposed, you monitor 112,000 people, that really tells us that population monitoring could become a big deal. It could really stress your resources.

Moderator- So, in other words, people who really did not have any part in the incident were just so concerned that they demanded to be monitored? And of course the government had to comply?

Adela- Correct. And the problem too, there were a lot of social impact because people were shunned. And if you were from Goiania, you know, they were restricting access, people couldn't get reservations at hotels, you know. So, it wasn't so much the radiation, but because it was an incident that had radioactive material involved, there was that stigma of radiation and panic. And, people wanted to make sure there was nothing wrong with them so that's why they had to get monitored.

Moderator- To rule it out, almost.

Adela- To rule it out. Exactly. Make sure I don't have contamination.

Moderator- What needs to be in place in order to take on a job like that? To successfully monitor a population?

Adela- Well, a lot of planning. And I'm going to go through some of the elements that you need when you plan for this. But, you know, you want to make sure you have a process where you can identify, screen, monitor people for exposure to radiation. And again, not just those who were potentially affected, but a lot of people that are just concerned. They want to make sure that they are not contaminated. Also, when we do population monitoring, you know, if we have a real event, you want to make sure you can monitor and identify people that need medical treatment. You want to identify people that have contamination in their body or on their clothing so we can address that. You want to make sure if they do have contamination that that contamination is removed quickly because you don't want, you know, to continue with that.

Moderator- Long-term. You have to think about long-term.

Adela- Exactly. Because, you know, even a small amount, people are going to be concerned. So, you know, you might have to set up a registry.
You might have to set up a way that track people for the long time.
We're still tracking people that were affected by Hiroshima and Nagasaki. There is a big registry. And you know, other events, not radiological - The World Trade Center, we're tracking people. So, you know, you have to think about what do I need to know? What do I need to do to make sure that I can protect people and ensure identifying if there's any potential long-term effects?

Moderator- It's pre-event, it's during the event and post-event. You've got a job on your hands. Well, let's hope that no radiological event is going to take place in the foreseeable future. But if it does happen, can't we just use the models we've already got in place? The preparedness protocols that have been tried again and again? Do we need something specific for a radiological emergency?

Adela- Well, certainly, if you had asked me that question five years ago I said, 'Oh, my god, we have a big mountain of things we need to get going'. But we've done so much planning and preparation for pan-flu and other events like that, setting up Points of Dispensing, that I would say probably 80% of what we need, we've already done and practiced and rehearsed and we have plans. The other 20%, the radiological component, the screening people, the identifying if people are contaminated, determining whether people may need to get bioassays that 20% we really need to focus our attention on. And certainly, we want to work with our partners in public health because they've done so much work. I mean, I'm in public health, but I'm in radiation, and the other side of public health, the biological and the preparedness and really building this whole infrastructure to deal with mass casualties, mass dispensation and things like that. So certainly there's a lot of elements that we can use from that.

Moderator- So, I think what you're saying is that even though it looks like a really big job, and it is a big job, we don't need to reinvent the wheel.

Adela- For the most part. Correct.

Moderator- But there are some key planning principles that would be important during a radiological emergency rather than another type of emergency. Maybe you can talk about those.

Adela- Well yes, you know, certainly, you know, the most important is saving lives. You can rescue and treat people first and worry about contamination second. And that's different thinking than we've learned from other contaminants.
So, your first priority is to save lives. Contamination with radioactive materials is not immediately life-threatening. You can decontaminate, you know, it's not like a chemical that, you know, you are in big trouble.

Moderator- You talk about decontaminating? Just washing off?

Adela- You can wash off. Actually, if an event should happen, hopefully it won't, it will be, you know, good for public health officials to advise people to go home, take their clothes off and shower, and then come and get monitored because you can remove it with warm water and soap. You don't need any fancy cleansers or fancy material to decontaminate. And you can remove probably more than 90% of the contamination by just those simple actions of removing your clothing and taking a shower.

Moderator- And you were mentioning before that you need to be able to think on your feet. So, what is it...scalability, flexibility... that's important?

Adela- Yes and you have to know your community.
If you're in a small community, you know, you may not need to plan for large amounts of people. But if you're in a big city, you need to plan for that.
You need to identify locations where you can do these activities. You have figure out transportation. You have to figure out suppliers.
If you have a large community that doesn't speak English you have to make sure you have material available in a second language - that you have it readily available. Certainly you're going to need people to come in and assist with translations but a written material that's thought about in advance in a second or third language, it's going to get you a lot of help.

Moderator- Who is lead agency for responding to a radiological emergency?

Adela- In New York State, it is the New York State Department of Health and the majority of those activities are carried through the Bureau of Environmental Radiation Protection. And it varies from different state, radiation control programs are located in different agencies. Emergency response. Environmental conservation, etc. But in New York, it's the Health Department.

Moderator- And in some instances, and let's hope this never happens, but if the emergency is deliberately induced, if it's terrorism, then we need to get the law enforcement involved right away.

Adela- Certainly. For most of our planning in the past, when we practice and drill for nuclear power plants, the law enforcement component was really not a big component. But in light of our concern for terrorism, we really have been working hand in hand with our law enforcement community. You're worrying now it's not just the response, but the location is a crime scene. It's an active crime scene.
So we need to be aware of their priorities as well as the health and safety so it becomes a little more complicated.

Moderator- So I guess the bottom line is ultimately what does population monitoring help the preparedness teams to do?

Adela- It helps us -- well, the biggest thing I think is protect our hospitals from being overwhelmed. You know, if you have concerns, you go to your local hospital. You want to make sure that people have a place to go other than the hospitals, because hospitals are going to be busy dealing with the casualties or the injured or people that might have imbedded material. So you really want to make sure that you protect your hospitals. We don't want our hospitals to go on lockdown. We want to make sure they can treat whoever needs to be treated.
But this will allow us to really help the population, help people get screened, people that are not contaminated but want to know if there's a problem.
You know, we can take care of them there and really get our hospitals to do what hospitals do best and that's to take care of our people with medical needs.

Moderator- Uh-huh. And you talked about registering people for a long-term follow up.

Adela- Exactly. Exactly, and you need a location where you can set that up.
You have your forms. You know, you have your modules and I'm going to talk a little bit more about it but you want to make sure you think about it in advance so you have the elements you need so at the end of the day we can say, ok, we screened this many people. This many people show contamination.
These people needed to get follow-ups or a bioassay and really have handle on the size of the problem.

Moderator- So certainly in a large-scale event, you're going to have responders from many levels of government. Federal, state, local. What are specific tasks that these groups would do?

Adela- As you know, all events start local and are local.
But certainly a radiological event, we're overwhelmed locally and possibly the state resources, and it's not that we don't know what to do.
We're going to need a lot of people to staff a lot of the activities that we need to do. If we for one moment forget about all the other activities we'll be doing in terms of monitoring the environment and collecting samples and if we just focus on population monitoring, if you use the example from Brazil, you know, Goiania was not a huge city. Just think of the city of Albany. If you have to monitor 100,000 people, you're going to need several locations. You're going to need them in different counties. Because you don't want people to have to come back here to get monitored, they might go to Schenectady or Saratoga. So, you want to make sure you have depth in your resources.

Moderator- Strength. You need the strength, and how do you do that?

Adela- You need to build partnerships. You need to build partnerships between the local health departments, maybe your hazmat team, emergency response.
Some other groups have been very helpful. If you look around, all the hospitals that have a nuclear medicine department, they have people that know how to use instrumentation to detect radiation. So we really need to encourage volunteering.
And actually, as a matter of fact, there's a project now with the center for disease control and prevention and conference of radiation control program directors to give $10,000 to 25,000, I believe, or 2,500, I'm sorry, to partnership in developing a radiation control corps. So we're really trying to strengthen those partnerships because we can't do it alone.

Moderator- You would need to have a pretty good capacity to communicate information to the public, wouldn't you? Wouldn't that be one of your key planning principles?

Adela- Yes, and if you have a chance, or, not have a chance but you really need to develop your message maps and develop some key information that you know, it's going to be standard no matter what and then you can modify depending on the event that you're dealing with. Anything you can build in advance is going to make your job a lot easier because you're going to be busy with so many things, you don't want to have to set time aside to sit down and write something in a way that people will understand.
So you have to test your messages. And there's a lot of information that C.D.C. and all the states including New York would put together to help us at least jump start if we need to get messages out.

Moderator- You talk about everything being a local emergency, and that's so true. I mean, it happens locally and local response are the key responders but they do need some help. And I know that if we're talking about a large scale response, we're gonna be looking to federal agencies: C.D.C., health and human services fir things like strategic national stockpiles.
What would their roles be?

Adela- Certainly, all those agencies you mentioned, our aim is to protect public health. Also, we need to be able to support contamination protection, answer questions from the public, provide medical advice to doctors. You know, their patients are going to go to them and they're going to have questions, so we need to prepare some material. Identify where the contamination is so we can maybe have a map and say if you were in this area, you know, you're more likely to have contamination, to help us with the triage. And people that were far away and are still concerned, they will still be monitored but maybe we will do those in phase 2.

Moderator- You just have to have a lot of information in a hurry and you can't do it alone.

Adela- Yes, and you really need to drill and exercise, because many times, it's not intuitive. The more you do it, the more it becomes second nature, but you have to do it. You have to work with your partners. You have to know who's on the other side of the phone when you call. You have to know what the resources are and they are more likely to need some help.

Moderator- You know we understand what constitutes a radiological emergency and it really is a spectrum of things from a transportation accident to a nuclear power plant accident to, as you said, unfortunately, a spectrum of radiological terrorism. And you also kind of alluded to the fact that we really need to have a place to go to monitor people, like community reception center I think is the terminology. So talk about where you decide where to put one of those. Or do you need more than one?

Adela- Well, I think you need to plan for more than one for many reasons.
One is that you don't know how many people will want to get monitored.
But, two, maybe you have this wonderful arena and you say that will be my location and if something happens and that arena happens to be in the affected area, you no longer have a location for a CRC. So you need to identify the locations throughout your area and you need to be able to scale it up or down. Maybe you have a small number of people, you don't need a huge stadium.
If you have a large number of people, you might need a multiple locations or a couple of very large facilities. You need need to make sure you have a facility that's enclosed, that you can control ingress and egress, that people have a place to sit, that you have bathrooms, that you have showers. If you don't have showers, maybe then you can bring portable showers, but again, planning, planning, planning. I can not emphasize enough, you need to think three or four steps ahead because you can't just think about what do I need now. You need to say ok, I'll resolve this now then I'll have to deal with the next three things.
You really have to think about that when you do your plan.

Moderator- Almost like a game of chess. You've got to keep looking down the board for what could happen next. So, many of the people who are watching this broadcast may be really familiar with a point of dispensing and they know what the staff roles should be at a POD. How is it different at a community reception center? I'm sure there are some similarities but there also may be differences.
What are some of the roles of staff at a community reception center?

Adela- Well, the way we set it up and I'll have some pictures about Empire '09, but we have what we called the contaminated area and the clean area.
And mostly because of concerns from people that are not familiar with radiation and are volunteers and our county health departments, we said 'you stay in the clean area. Most of what you are going to do will be like in a POD. You need a registration area. You need a health and safety officer. You need a mental health provider, you need clinicians that can answer medical questions.
So all those roles are already being planned for when you do the PODs. What do you need on the other side? Well, you need to be able to detect contamination. You might have to set up some portal monitors, have some hand held equipment, have people that know how to interpret the results and be able to direct people that have contamination to go to the showers. You need to identify in the area where they're going to shower, what to do with their belongings. You need to make sure you have clothing available for people that need to shower because their clothes are going to be put in a bag and are not going to be readily available to them.

Moderator- How much clothing? How do you know how many people are going to turn up and then need to be decontaminated? How do you anticipate just how much to have in place?

Adela- Well, you might anticipate for a start up, you might have a supply of scrubs, maybe tyvek suits but really you need to work with your local suppliers, your local stores that provide clothing and say, listen, if it's an emergency, I need you to be able to bring clothing, all sizes, you know, shoes, whatever. Because we can't possibly stock up all that material in a warehouse. I mean, we work with stores all the time for other instances and it will be like a no other emergency.
People get displaced, they have no clothing, you know, you need to be able to provide that.

Moderator- Pets are a big issue now. People want to bring their pets and certainly, I guess if they are service animals they would have to so, do you expect that people are going to be bringing pets to a community reception center? Is that something to plan for?

Adela- You can. The way the guide is developed and the way most of what I'm speaking about is based on the guide that C.D.C. developed and I'll show the reference later on, you can have a module if you want to screen pets.
If you don't think you have the staff or the expertise to do that, that might be done somewhere else or maybe work with your veterinary professionals. But certainly, guide dogs and we had during the exercise a hearing assisted person and had a dog and we had to deal with it. So you need to account for the fact that you might need service animals. And certainly those will be treated with their owners.

Moderator- I want to talk about the lessons learned a little bit later in the broadcast because there were some fascinating lessons learned from that exercise but can we go back to what you said before? You alluded to this.
I think it's such an important point that I'd like you to go over it again. And that fact is that not all communities are created equal. And so you really need to keep in mind your community when planning. Take us through some of those steps again.

Adela- Well, for example, during our exercise, we worked with two counties that don't do anything, they're not near a nuclear power plant, they're not used to drilling and exercising for nuclear power plants, so we really have to start from scratch, which was great. I mean, we built very strong partnerships and we build that partnership with many local health components. But you need to know your community - do they deal with radiation or not, do they have large hospitals or not? You know, what size is the community? Is it a rural community?
Is it an urban community? All those things are going to play a role in determining what kind of facilities to plan for, how many people you need to staff them. What kind of law enforcement you're going to need. Do you need a large police contingent? Do you need National Guard? How are you going to control your crowds? You know, bring 100,000 people to a concert or a football game. You need crowd control. This is going to be no different except people may be a little bit more excited than going to a football game.

Moderator- I would imagine people would, let's just say, concerned, that would be a good word. So much to think about, Adela. What tools do we have to help us to do that?

Adela- Well, in addition to the planning, C.D.C. has put together several tool kits and they're wonderful. There's the tool kit for clinicians and the tool kit for public health professionals, and if you haven't seen those, you should check out and you can get information at the C.D.C. website. And they have just in time training videos. They have key messages that you can use. They have documents for dealing with contaminated disease. They have how to quickly set up radiation screening. So, there's a lot of information that you can do on your own.
You can use that to work with your radiation control program. More and more, we see finally an interaction between public health and radiation control.
We really need to strengthen those partnerships, because we can't do it alone. We need the other side of public health, you know, protecting our food and water, setting up shelters with the radiation detection and contamination control.

Moderator- Definitely it's public health, the spectrum of public health in this type of emergency. You talked about having the right size facility for your community.
You talked about having enough clothing available because people are going to be reluctant to be decontaminated, I would imagine there's no clothing for them to change into. Are there different survey methodologies depending on what type of incident it is?

Adela- Not really. During an event initially, we're going to be taking a lot of environmental measurements and that's going to give us an idea of what are we dealing with. Because we may not know. We may not know that it's a radioactive event. But we would know what is in the environment, what isotopes we're dealing with, and each isotope has certain characteristics.
We will be doing some external screening first to determine if these people have contamination and depending on what we find, you know, people, if they are contaminated, they go to the shower. If they still have contamination, they might be directed to do additional follow-ups. Maybe they'll be candidates for bioassay, you know. So we'll be doing some initial triage based on the contamination levels. Of course, we really will advise people to go home and shower and then come and get screened because we want to make sure we remove that contamination as soon as possible. It's not life threatening but why keep it on your body if you can just go home. And if I may use an example, Kris, you know, people may go home and say 'oh my god what am I doing?' but just imagine your mother just finished the kitchen floor and you've been playing in the mud.
Would you be allowed to come inside? No, you have to strip your clothes, put them in a bag, walk in and take a shower. It's the same principle.
It works the same way.

Moderator- That's a good example, a good, simple way to think about that.
I'm going to mention the mundane, and that's paper work.
Certainly there are a lot of forms that have been developed for things like PODs, Points of Dispensing. What special paper work do you need to have at a community reception center?

Adela- Well, you want to capture some basic information. You want to know name and maybe address or, you know, people may be relocated and e-mail address, a cell phone number. In this day in age, people can be reached even if they're across the country, use the same cell phone number or a web address or an e-mail address. But you need some basic information. You need to be able to track who's been monitored, so maybe you can have a wristband or have some kind of stamp or something, to identify people that have already gone through the screening. And those that might need follow-up, we develop actually a form that's one page, two-sided that can capture a lot of information. Where were you at the time of the event, were you indoors or outdoors, how long were you outside, where you come from? That's going to help us with the triage and it's going to help us interpret the data. Another question that may be important to include is have you had a nuclear medicine procedure done? And that's important because if people show radiation because radiation stays in your body for a while, we want to make sure that we're dealing with the contamination or is it something that someone already had because of a nuclear medicine procedure.

Moderator- You don't want to confound the results.

Adela- Exactly. And especially when it comes to the interpretation so, you don't need to burden people with a hundred questions, they can probably answer four or five questions, and those that need follow up, they will have to complete additional questions. But that's to help us help them.

Moderator- Adela, when we were talking before the broadcast, I asked you a question that was, you know, very simplistic. What's the one thing that people should consider most important, and you said, loud and clear, partnerships, partnerships, and then partnerships. You mentioned it before, you asked me to give me a chance to re-enforce it. Go ahead and talk about how do you start making those partnerships, and who with?
Adela- Certainly with your local health departments, with your local emergency response, with your HazMat teams and one component that we use in our exercise, we reach out to the medical reserve corps - that's a great set of volunteers. And the project I mentioned before, we're really trying to add radiation volunteers to work to work in the same framework as the MRC's because these are people that may be retired, people that work in hospitals, people work in state programs doing, you know, radiation measurements that are going to be an asset because we only have so many of us.

Moderator- You talked about that request for proposals. Where do people find out more information about that again?

Adela- They should contract the radiation control program or go to the conference of radiation control program directors at crcpd.org and that'll have the slide. But just search for conference of radiation control program directors and the information is there.

Moderator- They're giving away some funds to do this so let's not let them go unused.

Adela- Well, we want to make sure we jump start some of the volunteer programs, because we really need to build the radiation volunteers.
There's a lot of people that say they want to volunteer, but you want to make sure you have a system in place to channel those volunteers and bring them where you need. They also need to train with you, they need to fall within, for example, if they're going to assist our program, they need to fall within our plan and within our framework. So they need to be identified in advance and they need to know the plan and how things work.

Moderator- Getting back to setting up the community reception centers, all this public health response planning that's been going on, could you just look to those plans and say x, y and z seem like they could be adapted pretty easily?

Adela- Yes, for example, the registration, the medical advice, health and safety. There's a lot of commonality.

Moderator- The sites?

Adela- Oh yeah, you know, schools, gymnasiums, stadiums.
For the exercise, we used a vacant building on the state campus and it worked perfect.

Moderator- Would you think there might be some concerns on the part of the school districts to allow people that may be contaminated into the building?
How do you work through that?
Adela- Well yeah, that was expressed during our planning that some communities may not want to use schools. You know, schools have been proposed to be used for PODS, when you talk about radiation. But as I mentioned earlier, you can remove contamination, you can plan, you can cover your floors with paper. Set up an area so you minimize contamination.
And certainly if we were to use a school for that purpose, we will come in and we will survey and make sure it's ok before it reopens to the students. We have dealt with many contaminated sites and you can remove the contamination.

Moderator- So it's that advanced education that's so critical.

Adela- Exactly.

Moderator- You hear radiation, automatically you're going to say not in my school. Not in my gymnasium.

Adela- And probably, the preference would be not to use schools for that very same reason. There's a lot of public buildings, armories, hangers.
You want to make sure you have a place that meets the needs for your CRC
That you can provide restrooms and a shower area and some privacy.
And you know, a place to sit down. So, if you're going to go to a hangar, there's a lot more that you have to bring. You can go to a stadium where you have places for people to sit down while they wait.

Moderator- And maybe showers in the locker room.

Adela- And showers in the locker room, exactly. So it depends on what you have available. You might have a very small community and the biggest thing is your school gym. Well, you know, you might have to use your school gym in your planning.

Moderator- Right now of course everybody is responding to H1N1, the swine flu.
And there's alternate care sites that have been identified, things like that.
Take us through some of what might be other options. Modular emergency medical system. What's that about, Adela?

Adela- Those have been set up to address the hospitals, basically with overflow, or search -- I'm sorry. Like I said earlier, we want to make sure that we protect the hospitals so they can do what they need to do. And you might be able to set up a CRC next to a hospital. There are some hospitals that have large parking areas or they might have a location maybe a block away or like a clinic setting.
You may be able to set something up in combination.

Moderator- Might make a lot of sense because I think the first inclination people might have is to run to the hospital and get monitored, or get the magic pill, whatever it is that they think they need. So that makes a lot of sense to consider that.

Adela- And along those lines, if that's the case, you want to make sure in your planning that you arrange for transportation to provide transportation to all those people that decide to walk to the hospital, but now they have to go somewhere else. Make sure that you make it easier for everybody, provide some shuttle service, provide messages saying 'if you want to get monitored, go home, shower, and these are the locations that are going to be set up for you to come and get monitored'.

Moderator- As soon as you can get out that message that there will be a place for you to get what you need, it's going to alleviate a lot of concerns, I would imagine. But there's going to be other concerns. I would also imagine we're going to need help from local law enforcement.

Adela- Definitely. Like I mentioned earlier, you're going to probably expect large crowds. And people you know may not be very patient, and some people may need to be helped. Some people may have mental health issues.
People may be distressed and they may disrupt the flow of your CRC
So it's important to have those people in hand, not just to answer questions, but to be alert, they have their antennas and they can pick up on when a situation may be developing, so they will help the flow of the CRC. So you want to make sure you have your policemen or other law enforcement walking around, your mental health professionals available. You also want to make sure you have a clinician outside because let's face it, you have large crowds, people may fall and break a leg. They might have a heart attack, they might have palpitations, you never know. So, you want to make sure you have somebody that can provide immediate medical assistance, direct people that do need care to a hospital, have an ambulance readily available, that kind of stuff.

Moderator- So would the bottom line be to build on existing resources?

Adela- Definitely. If I have one message, it's see what you have, look at what you can do through the last five, six, seven years, and say ok, what is incremental planning I need to do? You don't need to plan from zero. Like I said, seven or eight on a scale of 10. What are the other two I need to do? And how do I do it? And who do I contact? There's a lot of great resources, like I mentioned, CDC, go to your radiation control program. We've been doing a lot, sometimes we were kind of incommunicative, but we've been building some really great partnerships. I am so thankful in New York State, people know to come to the bureau and ask us questions if they need to buy equipment. If they need to develop procedures. And a lot of states are doing that, so I think it it's very, very important if you don't know where your radiation program is, talk to us, contact CRCPD, we have a listing of where the radiation programs are, and start building those partnerships.

Moderator- You need the staff support from a number of agencies. When you get it, Adela, how long should staff expect to be on site?

Adela- Well, like with any emergency, probably for the first few days, I would expect 24/7. For flooding and other emergencies, people don't want to wait in line to be told oh, come back tomorrow, we're closing for business.
You need to be prepared to run 12 hour shifts 24/7 like we do with other emergencies. That's what's important to have a lot of people available, that you have people that have trained and exercised together so they know each other, they know their strengths and weaknesses, they know how the CRC is supposed to operate. Also that you have the flexibility.
You can move in from one module to another, because say you've got 20 people at registration and nobody monitoring. Well, make sure people help out in registration so that other folks can start moving with the flow. Like when you open a new register at the store, you know, same concept.

Moderator- Or Black Friday when they open the door to the stores.

Adela- We don't want that.

Moderator- No, no so the registration area is the critical component of the CRC.

Adela- That's why, early on, we want to capture the minimum information.
We don't want people spending half an hour filling out a form.
Get the basic information and they can take the clipboard and complete the rest of the information later on. Let's make sure we capture the basics.

Moderator- Get them registered, logged in, information, the identification bands, would they be color coded?

Adela- Different communities, they might have a bracelet, a scanable bar, they might have a code number. Early on, you might just rely on paper and pen until you get set up. But certainly, the more you can automate that, you know, the smoother it's gonna go. Again, you need to plan. You need to plan and think about, ok, I'm going to try 10,000 people in my community, how am I going to do it? How many people do I need? How many people you need per station?
And, Kris, there are some computer programs that can help you in the planning.
Sort of like you do with the PODs. You say 'I have three portal monitors and five people that know how to do radiation screening. You plug them in and they tell you how many people you can process in an hour. So that really helps you identify where your choke points are.

Moderator- Forgive me if this is too basic a question but when you refer to a portal monitor - what does that mean? Portal obviously sounds like a doorway.

Adela- You can think about it, like when you go through airport security.
You just walk by, you stay there for a couple of seconds so they can take a measurement. And I have some pictures of those. But basically that's a quick way for us to determine if you have contamination anywhere in your body. If the portal monitor alarms, and the alarms are usually set up very low, you're not looking for really high numbers, if it alarms, you will have a radiation professional that will come with a hand held instrument, to determine exactly where the contamination is and they might just direct you to the showers. And they will screen you again after the showers.

Moderator- And we just had a picture of that on our screen. I imagine that picture was taken during the exercise that you referred to earlier, which was, what did you call it, Empire '09? Multi-agency exercise.

Adela- Yes, it's Empire '09 because we are the Empire State and it was in 2009. It was a radiological exercise where we simulated the explosion of two dirty bombs, not big, but enough to contaminate and create a lot of concern to a lot of people.

Moderator- They call dirty bombs a weapon of mass disruption just because of all the concern that they would cause. I know you brought a number of pictures and I think the first one really gives you an idea of the flow of a Community Reception Center. Take us through that, that's a lot of information.

Adela- And you probably can't read it on the screen, but basically, the whole point of this slide is to show that it's modular. You have your registration module, you have your triage module, you have your decontamination module, you have your check out module, your clinical module. So, if you think about it in terms of modules, it helps you identify which of those modules you already have done for other applications like the PODs and which ones you need to focus on. Certainly the radiation detection and actually for our exercise, one of the interns developed these lego models. If you can see, it's like a snap shot bird eye's eye view of what a CRC looks like.

Moderator-I was wondering what that was. That's a lego model. I see all the different sort of color coded areas.

Adela- Yes. To identify people that are contaminated and not contaminated.
We want to make sure people that are contaminated follow a path until they are decontaminated, again, to minimize contamination.

Moderator- Then you have, what, a clean lane, and a decon lane?

Adela- Correct.

Moderator- I think we had a picture that showed that as well from the exercise.
Adela- Yes, and if you can see, we can get what you call an express lane, you can ask people a question. Have you gone home and showered?
If they have, they might be more likely to go through the express lane and that might help move things along.

Moderator- You had some pictures of the "victims" that you were going to show us as well. How did you recruit people to play the victims and how real was their role playing?

Adela- Well, actually, during the exercise we handle many V.I.P.'s and we had international visitors that came to tour the facilities. We asked them would you be interested in volunteering to go through this, to give us a first hand experience. We also recruited some volunteers among our families and friends so we had children and elderly people and they were very very interested in doing it. It made the time go by quickly, they learned a lot by just going through the different stations. They were great fun and they were good sports.
Of course they took pictures and, you know, it was a big thing.

Moderator- So they come in, and everybody walks through this portal monitor?

Adela- We had some initial screening.

Moderator- Handheld?

Adela- We had handheld and that's because this particular exercise we have alpha contamination and gamma contamination and the portal monitors that can detect some alpha but we really needed a handheld to detect the alpha contamination and we knew that based on the environmental measurements that why it's important we know in advance, if we can, what we're dealing with so we can set up the CRC to address the specific issues for the specific isotopes.

Moderator- So, the victims who were scanned by the handheld monitor and then walked through the portal monitor and neither of them registered any problem.
They were sent down one path and others had to go another way?

Adela- Yes, and actually, Kris, what we did is we developed some scripts, over 200 scripts. People read their script and the script will say whether they were contaminated or not to kind of force things to go a certain way and try the different stations.

Moderator- Did anybody once they've gone through these monitors and were determined not to be contaminated, did you have any issues where they said I want to be decontaminated anyway?

Adela- We didn't, but I would imagine people that would happen and that would be fine if people wanted to take a shower, you know, that certainly would be fine.
If it's going to give them peace of mind, I think is not a problem. My only concern would be if it's going to delay the decontamination of people that really need to get decontaminated. I would say 'yes, you may shower but you might need to wait a little bit because we have people that have priority because of the contamination.

Moderator- We talked a couple of times about choosing a location that has showers on sight or bringing portable showers in. What did you have to do for this location for Empire '09?

Adela- We had portable showers. We did not run the showers because the HazMat teams, they run enough drills where they know how to set up showers but if we needed to, we could have set up the showers right there. We have a means of collecting the water because we have portable showers. And what we did is we had instructions, you probably can't read them in detail, but they were hand written to say 'place your belongings here, put them in this bag, double bag, take your wallet and put it in this little zip lock bag, make sure you take that with you. They were surveyed after the shower, they were provided type clothing so they could dress after the shower so we simulated all that.
We have male and female showers. For a while, we had mostly male, so in order to expedite, we let them use either shower. But if you need to, you can certainly have that and you know, you want to keep families together, you want to keep kids with their parents. It would be very traumatic if we tried to separate the children. So we need to be aware that we want to keep the families together. So, in your planning make sure you allow for those kinds of things.

Moderator- And I recall seeing before the broadcast one of the slides that really showed a very clear way of indicating what was the contaminated side and what was the clean side. Just a matter of color coding, really.

Adela- We had the green and the red. I think we've been conditioned through our lives, you know, green go, red stop. So it really helps us identify what was a clean area and the contaminated area.

Moderator- Now, in PODs, I'm familiar with PODs, they have a medical screening station where basically they ask you whether you have any counter indications to the medication you're going to get. And oh, I see we have a picture of that screening station there, what are they doing there?

Adela- Well, some people, after go through the shower, if they're still contaminated they will be candidates for a bioassay. And if they have a bioassay, there will be a collection of a urine sample. You want to give them some instructions and also you want to give them some material to take home and read in case results indicate they may need to have some radioprotective medication that they understand what they're getting. And you know, it will help the conversation with their physician. It's an opportunity for us to answer all their medical questions and again, if they have a nuclear medicine procedure, we will note that. If they have any specific questions, sometimes people are more comfortable talking to a nurse or a physician than talking to a radiation professional.

Moderator- And you had your "victims" complete some surveys afterwards.
Is that part of what would be done at a regular CRC or was this just to know how the exercise was going?

Adela- Actually what they were completing was the form. That was a form to tell us how they were, how far they were, how long. We had a map with concentric circles showing the different distances. Even if they didn't know where they were if they can point on the map, we would know how close they were to the event and how to prioritize the need for bioassay. And also, you might collect bioassay on everybody. You still need to triage which ones are going to be dealt with first.

Moderator- You touched on something really important earlier. I didn't mean to interrupt you - did you have something more to say on that?

Adela- No, no that's fine.

Moderator- That was the special needs. You said you had someone who was hearing impaired that participated in your exercise with a service animal.
How much planning needs to go into assisting special needs populations?

Adela- Well, I think you need to make sure you have an area designated.
People with little children, people with guide animals, people that may just be distressed and might need to be pulled away from the area and have somebody to talk and maybe help them with the forms. More like a one-on-one assistance.
People may need to lay down for a few minutes. You need to make sure that you have an area within your CRC that is isolated enough, so you can have some privacy. You know, people may need special help.

Moderator- Oh, I see on the screen here, there's the individual with the hearing guide dog. I know that our New York state health commissioner Dr. Danes participated in this exercise. He was one of your victims as well?

Adela- He was good sport. Yes, he was and we gave him a tour and he wanted to go through the full shower screening. He didn't go through the shower, but you know, we demonstrated how he would do. And you can see him, again, it's sort of like how they do the wand at the airport - they want to make sure they check you. It's no different. The probe is like a wand that you run slow enough that you can defect if there's any residual contamination.

Moderator- When I participated in POD exercises before, I had to take time for a number of briefings throughout the day. Does that happen in a CRC as well?

Adela- Yes, and you need to be prepared to do that. Not just have material ready, but have somebody that's assigned to deal with the media and deal with the questions from the public. Because you can't take people away from their stations to answer questions. They're going to be busy. And you need somebody that's proficient, that understands how the CRC runs and what are we doing. And I mean you may even provide also some instructions to people saying 'this is what happen when you go through a decon line' that they can read while they are waiting so there are no surprises. The more people know what's going to happen, I think, the better off you are. Some of the slides we are showing now, we did just in time training because you know, even if you drill an exercise, you know, during the event you may get nervous, you may forget. So you can do five-ten minute cd and do your just in time training, get a quick refresher on what you need to do. And it gets people right on the same page and it's very, very helpful.

Moderator- I see your health and safety officers are taking part as well.

Adela- Yes, because you're going to have a large number of people working, you need to make sure that their physical as well as their mental health is taken care of. So, you want a health and safety officer, you want mental health professionals.

Moderator- Lessons learned, Adela - what would you say were some of the most important lessons learned in what was arguably just a huge undertaking?

Adela- Well, we simulated just setting up one CRC and that in itself, we had more than 40 people working. We only did it for a couple of hours. If you had to do it for real and you have to set up a dozen, you really need to get your volunteers.
You need to get other people, maybe reach out to other counties that are not affected. Reach out to other states, sort of like mutual aid. You need to develop those partnerships. You don't want to wait until you have to call on, you have to develop those in advance. And I'm showing my two best partners, Rensselaer and Albany County, who really help us make this happen. Like I said earlier, we have two counties that don't deal with radiation, and they stepped up to the plate and we had a very successful CRC demonstration.

Moderator- Didn't you also have the state of Vermont, which is a neighboring state from New York?

Adela- Yes, this event simulated, it was an urban area, multi-county, state, multi-state, we had Vermont and we had federal assistance. It was a big, big exercise.
We had over a thousand players.

Moderator- We've talked about so much during the course of these past few minutes, and I'm sure that people are taking notes furiously but they probably want additional information as well. Can you give us some idea of where people can get additional information?

Adela- Certainly, like I said, go to your radiation control program. There's a very, very good guide that C.D.C. put out in the tool kit, or you can just get it from their website, that's the guide for conducting population monitoring. Like I mentioned earlier, CDC can advise you that there are some computer programs that you can run simulations to figure out how many people you need to staff different types of CRC's. Talk to your radiation program.

Moderator- I'm sure you would be very happy to provide people with some advice if they were to get in touch with you.

Adela- Certainly, certainly. My contact information should be posted with the state health department. You have my e-mail address, my phone number. Certainly, any time, myself, or people in my staff, we've gone through this many, many times. We would be more than happy to answer questions and start building this because we really really need to get this going.

Moderator- Speaking of questions, one was faxed in to us. The question, is do you think partnerships with agencies such as the Salvation Army or American red cross will be useful during a radiological event?

Adela- Certainly, and I am sorry I didn't name those specifically. That's one of the key partners because they know how to run shelters, they provide assistance during floods and hurricanes and other emergencies. They are so well trained, certainly. You need a bill from those groups.

Moderator- What about faith-based organizations?

Adela- You need to rely on those, too. Anything you can think about for a big emergency. You're going to need those partners and then some.

Moderator- Counseling, I assume, would be a really huge component.

Adela- Exactly. The earlier you can bring them in the planning, the more in tune they'll be with what you're trying to do and they will understand. They may be able to answer some questions for you, at least to get the ball rolling until you can have additional details.

Moderator- I want to get back to the tool kit you talked about.
I actually was able to get one of these for public health at a recent conference and it's just chock full of materials. So can you tell us what's in there that would be helpful to people? I was particularly taken by the communications aspect of it.
It has some really good tools for communicating.

Adela- They also have some just in time videos for clinicians as well as for public health professionals.

Moderator- That's a separate tool kit?

Adela- Yes, there's two tool kits. One for clinicians and one for public health professionals. The one for public health professional has a video on the role of public health, because sometimes we say 'well, public health, we don't really have a role in radiological emergency response'. Well, we do.
And that's very clear. There's some videos on understanding the difference between exposure and contamination. Sometimes we get confused.

Moderator- I get confused. You had a simple way of explaining that.

Adela- Like I told somebody earlier, think of exposure as I'm shining a flash light on you. You're not getting anything on you and the farther away you are the less likely you are to get it. And contamination, if I throw talc at you, you know you can walk away and you still have it on you.

Moderator- But you can get rid of it.

Adela- But you can get rid of it if you shower. So it's very simplistic but even those concepts you know, if people can relate to every day things I think it will help us. I'm not saying minimize, but certainly almost reduce some of the fear factor. So, there's a lot people can do to protect themselves. Like I've been saying, I sound like a broken record. Go home, take your clothes off and shower. You can do so much by that simple action. Then you can come and get checked but it's not going to overwhelm everybody because you get people that are just concerned and potentially contaminated.

Moderator- This is just great information. A very complex subject, but something that can be simplified if you take it in steps. A lot of the tools are already in place. What's not in place, there's resources for getting it.

Adela- There's work on the way. We're doing so much as far as developing tools, conference of radiation control directors, C.D.C., national counsel for radiation protection and measurements. We have a document that's ready to come out. They've issued several documents. Just to help in this whole effort.
There's so much we need to do and there's a lot that we know, but we're still building and developing new tools.

Moderator- So, reach out and let's do that. Thank you so much, Adela. It's been a wonderful discussion and so much information. We really want to thank you for joining us today. Of course we would like to ask you to please fill out your online evaluation after completing the post-test. Your feedback is very helpful in planning future programs.
Also, continuing education credits are available if you go ahead and complete that evaluation. This program will be available online via PODcast within a week or so. Please check our website for details. I'm Kris Smith. I'll see you next time on the University at Albany's Center for Public Health Preparedness Grand Rounds series. Thank you so much.

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