CBRN Incidents Research Articles

From investigation of hospital protocols and guidelines to designing a generic protocol for responding to chemical, biological, radiological, and nuclear incidents

Introduction: The awareness of using chemical, biological, and nuclear agents in everyday industrial and nonindustrial incidents has increased recently; release of these materials can be accidental or intentional. Since hospitals are the forefronts of confronting chemical, biological, radiological, and nuclear (CBRN) incidents, the goal of the present research was to provide a generic protocol for CBRN incidents through a comparative review of CBRN protocols and guidelines of different countries and reviewing various books, handbooks, and papers. Methods: The integrative approach or research synthesis was adopted in this study. First a simple narrative review of programs, books, handbooks, and papers about response to CBRN incidents in different countries was carried out. Then the most important and functional information was discussed in the form of a generic protocol in focus group sessions and subsequently confirmed. Results: Findings indicated that most of the countries had various protocols, guidelines, and handbooks for hazardous materials or CBRN incidents. The final outcome of the research synthesis was a 50 page generic protocol whose main topics included introduction, definition and classification of CBRN agents, four major phases of incident and disaster management cycle, hospital response management plan, equipment, and recommended supplies and antidotes for decontamination (radiological/nuclear, chemical, biological); each of these also had subtopics. Conclusion: In the majority of international protocols, guidelines, handbooks and also international and Iranian books and papers, there is an emphasis on the importance of incident command system, determining the safety degree of decontamination zones, maps of decontamination zones, decontamination process, triage classifications, personal protective equipment, and supplies and antidotes for decontamination; these are the least requirements for such incidents and also consistent with the provided generic protocol.

Human biological monitoring – A versatile tool in the aftermath of a CBRN incident

Human biological monitoring (HBM) is a well established tool in occupational and environmental medicine. It allows to determine the internal dose of a chemical absorbed by an individual after acute or chronic exposure. Biological reference and threshold values may be used to evaluate the internal dose and estimate its health impact(s).HBM and its advantages have not been broadly recognized from a civil protection point of view in Germany, therefore we have designed a compendium to define state-of-the-art HBM sampling after a release of chemicals in a civil protection scenario. The compendium integrates the sampling of biological agents and the sampling of radio-nuclear target isotopes, to be analyzed by HBM, in a single sampling approach, thus limiting burden on the potentially exposed persons and facilitating comparison of their individual exposure to different CBRN agents. HBM analysis methods are evaluated and basic toxicity data (including biological reference and threshold values) are given for a list of 50 agents, previously identified as relevant in civil protection.For on scene commanders and healthcare professionals the compendium may help to generate HBM and biological–radio-nuclear (BRN) exposure data after a CBRN incident which can be used to improve risk communication.

Preparedness of Belgian civil hospitals for chemical, biological, radiation, and nuclear incidents

As one of Europe's most densely populated countries with multiple nuclear installations and a prominent petrochemical industry, Belgium is at some reasonable risk for terrorist attacks or accidental chemical, biological, radiation, and nuclear (CBRN) incidents. We hypothesize that local hospitals are not sufficiently prepared to deal with these incidents. All 138 Belgian hospitals with an emergency department (ED) were sent a survey on their preparedness. Data on hospital disaster planning, risk perception, availability of decontamination units, personal protective equipment, antidotes, radiation detection, infectiologists, isolation measures, and staff training were collected. The response rate was 72%. Although 71% of hospitals reported being at risk for CBRN incidents, only 53% planned for the same in their disaster plans. Only 11% of hospitals had decontamination facilities in front of or at the ED entrance and only 6% had appropriate personal protective equipment for triage and decontaminating teams. Atropine was available at all centers, but more specific antidotes such as hydroxycobolamine, thiosulphate, or pralidoxime were less available (47, 47, and 19%, respectively). Six percent of hospitals had radiodetection equipment with an alarm function and 14% had a nuclear specialist available 24/7. Infectiologists were continuously available in 26% of the total EDs surveyed. Individual isolation facilities were present in 36% of the EDs, and isolation facilities capable of housing larger groups were present in 9%. University hospitals were significantly better prepared than community hospitals. There are serious gaps in hospital preparedness for CBRN incidents in Belgium. Lack of financial resources is a major obstacle in achieving sufficient preparedness.

Public health emergency planning for children in chemical, biological, radiological, and nuclear (CBRN) disasters.

Children represent nearly a quarter of the US population, but their unique needs in chemical, biological, radiological, and nuclear (CBRN) emergencies may not be well understood by public health and emergency management personnel or even clinicians. Children are different from adults physically, developmentally, and socially. These characteristics have implications for providing care in CBRN disasters, making resulting illness in children challenging to prevent, identify, and treat. This article discusses these distinct physical, developmental, and social traits and characteristics of children in the context of the science behind exposure to, health effects from, and treatment for the threat agents potentially present in CBRN incidents.

It’s all about the data: Responding to international chemical, biological, radiological, and nuclear incidents

After digesting lessons from US operations during the Fukushima Daiichi accident in Japan, the White House National Security Council staff created several interagency working groups to examine procedural issues associated with responding to international chemical, biological, radiological, and nuclear (CBRN) incidents. What emerged were best practices and lessons learned designed to transform data to decisions across the many levels of government during an international CBRN incident for those people making life-saving and life-sustaining choices. Actions at both the strategic and operational levels are needed to enable a country to more effectively transfer its domestic response capabilities and infrastructure to an international consequence management response. International complications include varying organizational relationships and legal authorities; resource limitations in overseas jurisdictions; nonstandard sources and formats of information; differing public health and protection standards; and language barriers. The technical data needed for emergency personnel to safely and effectively respond to CBRN incidents are especially difficult to obtain, require specialized analytical tools to process, and demand particular procedures for sharing in an international context. Without addressing these issues up front, any country responding to a CBRN event beyond its borders may struggle to effectively respond.

Effects of CBRN Decontaminants in Common use by First Responders on the Recovery of Latent Fingerprints—Assessment of the Loss of Ridge Detail on Glass

Following a CBRN incident, first responders use decontamination procedures to reduce the risk of exposure. The effect of decontamination on forensic trace material has, however, not been fully examined. This study sought to evaluate the effect of five different physical or chemical decontamination materials on the recovery of latent fingerprints. Fingerprints were deposited on glass slides, decontaminated, and assessed on the presence of ridge detail. The results demonstrate that decontamination affects the quality of latent fingerprints substantially. On at least 61% of the fingerprints, a reduced amount of ridge detail was observed upon decontamination. Furthermore, development with cyanoacrylate appeared not to succeed anymore. Instead, the ability of vacuum metal deposition to successfully develop decontaminated fingerprints is demonstrated. The results from this study may contribute to an increased forensic awareness regarding decontamination and emphasize the necessity for further research into new item decontamination procedures or new forensic initiatives prior to decontamination.

Improved CBRN Preparedness and Response Through Teamwork and Knowledge Sharing

Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and ScienceVol. 11, No. S1 Preparedness and ResponseOpen AccessImproved CBRN Preparedness and Response Through Teamwork and Knowledge SharingCecilia VahlbergCecilia VahlbergSearch for more papers by this authorPublished Online:24 Aug 2013https://doi.org/10.1089/bsp.2013.0862AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail The EU CBRN Action Plan is part of the work to strengthen and increase our ability to handle incidents involving CBRN materials. CBRN incidents have attracted a lot of attention, especially during the past decade, and efforts on both national levels (central, regional, and local) as well as the international level should be made to enhance the management of CBRN-related crises. The precautionary measures or preparedness regarding CBRN as well as the response to such an incident are important aspects to consider and are included in the EU CBRN Action Plan.Forensic evidence is critical for the prosecution and conviction of offenders in CBRN-related crimes, and consequently forensic awareness at crime scenes involving CBRN is highly important and an essential subject to consider in CBRN preparedness and response. The knowledge and experience of forensic experts, familiar with how to secure and analyze forensic evidence, can be used to increase the forensic awareness of other authorities involved in CBRN investigations, including legal authorities, CBRN subject experts, rescue services, and health agencies. It is especially important that first responders receive a proper education regarding forensic awareness to guarantee that the evidence at a CBRN crime scene is properly handled and secured.Exchange of information, knowledge, professional experience, and abilities is one approach to ensuring a high degree of expertise and competence in the CBRN area. The exchange of information may include emergency response plans, gained experiences from exercises, research results regarding CBRN agents, CBRN detection methods, knowledge regarding forensic awareness at crime scenes, and improved analysis methods of forensic evidence. Collaboration enables the exchange of information. These collaborations, both on the national and international levels, could include mutual exercises, research projects, conferences, and formation of various networks between organizations involved in the investigation of CBRN-related crime.Emergency plans should include CBRN. This is especially important for places, organizations, and arrangements that can be considered as potential CBRN targets. It is also important that forensic awareness is considered when developing or updating emergency response plans so that forensic evidence can be secured in case of a CBRN incident. Another important issue when considering CBRN preparedness is the ability to perform decontamination procedures. It is essential to have well-established routines and knowledge to be able to decontaminate an environment as well as individuals who have been exposed to CBRN agents. Decontamination procedures also make it possible to analyze forensic evidence at “normal” forensic laboratories.All in all, collaboration and exchange of information between expert agencies and authorities that might become involved in the handling of CBRN crises and the establishment and exercise of joint routines for CBRN incidents are essential for CBRN preparedness and response.FiguresReferencesRelatedDetailsCited byImplications Drawn from a Military Bioterror Exercise in Israel Tamar Berger, Itay Fogel, Lion Poles, Adi Avniel Aran, Omri Shental, and Michael Kassirer8 April 2015 | Health Security, Vol. 13, No. 2 Volume 11Issue S1Sep 2013 InformationCopyright 2013, Mary Ann Liebert, Inc.To cite this article:Cecilia Vahlberg.Improved CBRN Preparedness and Response Through Teamwork and Knowledge Sharing.Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science.Sep 2013.S45-S45.http://doi.org/10.1089/bsp.2013.0862creative commons licensePublished in Volume: 11 Issue S1: August 24, 2013PDF download

Bayesian Networks for Evaluation of Evidence from Forensic Entomology

In the aftermath of a CBRN incident, there is an urgent need to reconstruct events in order to bring the perpetrators to court and to take preventive actions for the future. The challenge is to discriminate, based on available information, between alternative scenarios. Forensic interpretation is used to evaluate to what extent results from the forensic investigation favor the prosecutors' or the defendants' arguments, using the framework of Bayesian hypothesis testing. Recently, several new scientific disciplines have been used in a forensic context. In the AniBioThreat project, the framework was applied to veterinary forensic pathology, tracing of pathogenic microorganisms, and forensic entomology. Forensic entomology is an important tool for estimating the postmortem interval in, for example, homicide investigations as a complement to more traditional methods. In this article we demonstrate the applicability of the Bayesian framework for evaluating entomological evidence in a forensic investigation through the analysis of a hypothetical scenario involving suspect movement of carcasses from a clandestine laboratory. Probabilities of different findings under the alternative hypotheses were estimated using a combination of statistical analysis of data, expert knowledge, and simulation, and entomological findings are used to update the beliefs about the prosecutors' and defendants' hypotheses and to calculate the value of evidence. The Bayesian framework proved useful for evaluating complex hypotheses using findings from several insect species, accounting for uncertainty about development rate, temperature, and precolonization. The applicability of the forensic statistic approach to evaluating forensic results from a CBRN incident is discussed.

How to Communicate with the Public About Chemical, Biological, Radiological, or Nuclear Terrorism: A Systematic Review of the Literature

A deliberate attack involving chemical, biological, radiological, or nuclear (CBRN) material has the potential to cause substantial fear among the public. This presents problems for communicators, who will need to provide information quickly after an attack while ensuring that their messages are easily understood and likely to be attended to by members of the public. Identifying in advance what people would want to know, where they would get information from, and how messages should be presented might allow communicators to ensure that their messages have the best chance of having their desired effect. In this review, we identified all peer-reviewed studies that have assessed communication strategies or information needs using hypothetical CBRN scenarios or in actual CBRN incidents. We identified 33 relevant studies. Their results support existing psychological models of why people engage in health protective behaviors, with information about the severity of the incident, the likelihood of being exposed, the efficacy and costs or risks of recommended behaviors, and the ability of individuals to perform recommended behaviors being sought by the public. Trust plays a crucial role in ensuring that people attend to messages. Finally, while a large variety of spokespeople and sources were identified as being turned to in the event of an incident, the use of multiple information sources was also common, affirming the importance of communicating a consistent message through multiple channels. Further research is required to extend these predominantly US-based findings to other countries and to confirm the findings of research using hypothetical scenarios.

Is preparedness for CBRN incidents important to general practitioners in East London?

General practitioners (GPs) have an important role in public health response to CBRN incidents, including disseminating information to worried patients and undertaking risk assessments of patients. The authors undertook the first known UK survey of GPs’ CBRN preparedness to assess knowledge and attitudes towards CBRN preparedness among GPs in East London, in the area of the Olympic Park. A questionnaire was developed, focusing on GPs’ self-preparedness for, and perceived roles in CBRN incidents, and GPs’ access to resources and policies for dealing with such incidents. Of 157 GPs, 56 responded, although some responded collectively for their practice. The majority of respondents recognised roles for themselves in CBRN incidents, including recognition of illness, supporting decontamination, and appropriate reporting. However, 79 per cent of GPs also felt unprepared for such incidents. The most popular topic for training to address this was clinical presentation of CBRN exposures. Most practices had no policy for dealing with suspect packages and white powder incidents. Since this survey, guidance and training has been made available to local GPs. As the UK will host more events like the 2012 Olympics, preparedness for GPs will continue to be an important consideration in the UK.

What is the optimal position of an intubator wearing CBRN-PPE when intubating on the floor: A manikin study

Introduction Prompt airway management following a CBRN incident is linked to improved patient survival. However, responding rescuers will have to wear CBRN-PPE and treat patients positioned on the floor which will adversely impact on intubation skill performance. Methods 48 final year paramedic students intubated manikin's positions in 4 different positions; on an ambulance trolley (60 cm of the floor), lying prone, kneeling and sitting. Each skill was performed twice once wearing CBRN-PPE and once in normal clothes. Intubating order was randomised. Results Intubation performance when wearing standard clothing was similar in all four positions but this was not the case when intubation was performed while wearing CBRN-PPE. CBRN-PPE had a negative impact on intubation performance regardless of the position of the intubator. Intubation on the trolley while wearing CBRN-PPE was completed in 100% of attempts within 60 s compared with 79.2% for kneeling, 75% for sitting and 43.8% for laying. After 120 s nearly 20% of intubation attempts using the kneeling and sitting position and nearly 40% of attempts with the intubator lying on the floor were still not completed. Intubation on an ambulance trolley, while wearing CBRN-PPE, was always successful compared with sitting (88.8%), kneeling (81.2%) and laying (62.5%). Conclusion This manikin-based study serves to reaffirm that CBRN-PPE has an adverse impact on intubation performance as well as identifying the negative impact of patient position on the performance of intubation within a CBRN environment. Elevating the patient off the floor, prior to intubation, could improve intubation success when wearing CBRN-PPE as well as potentially improving safety of the intubator. In the immediate phase of a CBRN incident, intubation attempts should be delayed until optimal intubating conditions are available or at least until the patient is removed from the floor. Use of and intermediate airway devices should be considered as a ‘stop gap’.

Does position of the patient adversely affect successful intubation whilst wearing CBRN-PPE?

Introduction Following a CBRN incident attending medical personnel will be required to instigate life saving airway interventions whilst wearing CBRN-PPE. CBRN-PPE is known to adversely affect fine motor skill but little is known about whether the position of the patient compounds this problem. Methods Seventy-five clinicians were recruited and performed intubation and insertion of a LMA in to a manikin whilst wearing CBRN-PPE. Both skills were completed twice with the manikin positioned on a bench and once on the floor. Following completion of the study 25 participants (a minimum of 2 participants from each professional group) were interviewed to ascertain their experiences. The recruitment of a non-homogenous group allowed for subgroup analysis with regards the potential impact of professional background on skill performance. Results 9.33% first attempts at intubation at waist height ended in failure but this reduced to 4% on the second attempt. This improvement was reversed with the manikin on the floor where the failure rate was 26.67%. Intubation on the floor took significantly longer to perform, being 45.9 s slower than the first attempt at intubation in the optimal position [95% CI (30.7 s, 61.1 s); p < 0.001] and 62.4 s longer than the second [95% CI (48.4 s, 76.3 s); p < 0.001]. LMA insertion was successful at all attempts, regardless of the manikins position. LMA placement on the floor was no slower than the second attempt at waist height ( p = 0.231) and faster than the first attempt at waist height (by 4.8 s [95% CI (3.4 s, 6.1 s); p < 0.001]). Anaesthetists were consistently the fastest at performing all airway skills regardless of the position of the manikin but previous exposure to wearing CBRN-PPE had no statistically significant impact on skill performance. All 25 clinicians interviewed had difficulty in viewing the larynx with the manikin positioned on the floor regardless of being an experienced ‘on floor’ intubator with the movement of the CBRN-PPE hood being the principle reason. This is in contrast to only three participants noting issues with vision whilst standing-up. Conclusion the position of the patient is likely to be an independent factor when choosing to either intubate or insert a LMA whilst wearing the current NHS CBRN-PPE.

Impact of Chemical, Biological, Radiation, and Nuclear Personal Protective Equipment on the performance of low- and high-dexterity airway and vascular access skills

Background Following CBRN incidents health care professionals will be required to care for critically ill patients within the warm zone, prior to decontamination, whilst wearing CBRN-PPE. The loss of fine-motor skills may adversely affect delivery of medical care. Methods 64 clinicians were recruited to perform, intubation, LMA placement, insertion of an IV cannula and IO needle whilst wearing CBRN-PPE. A fractional factorial design was employed, in which each of the 64 clinicians had two attempts at performing each skill whilst wearing CBRN-PPE and once unsuited according to a pre-specified sequence. Analysis The unsuited and suit data were analysed independently with the primary outcome being time taken to complete each skill whilst suited. Analysis was undertaken using STATA (V9.2). Results Mean times differ considerably by skill ( p < 0.001). Overall, times to completion on attempt 2 were shorter than attempt 1 ( p = 0.045), though the reduction in time differed significantly by skill ( p = 0.004). LMA placement was on average completed nearly 45 s faster than intubation, and IO cannulation was nearly 90 s faster than IV cannulation. Whilst suited, 8% of intubation and 12% of intra-venous cannulation attempts were unsuccessful. Previous familiarity with CBRN-PPE did not improve performance ( p = 0.23). Professional groups differed significantly ( p = 0.009) with anaesthetists performing all skills faster than the other clinicians. Conclusion This study supports the concept of instigating airway and vascular access skills whilst wearing CBRN-PPE but challenges the sole reliance on ‘high-dexterity skills’. Intubation is feasible but must be considered within the context of the incident as the LMA may offer a viable alternative. Intra-venous access prior to casualty decontamination is arguably a pointless skill and should be replaced with IO access.

DNA reviews: DNA identification following CBRN incidents

Chemical, biological, radioactive, or nuclear (CBRN) incidents can occur due to accident or deliberate action, and may result in substantial loss of life. Whatever the cause, the requirement for identification of the deceased may necessitate the removal of contaminated samples to a DNA laboratory for processing. This review looks at the potential types of CBRN that may result in the requirement for DNA identification of the deceased and investigates the potential risks and difficulties associated with processing samples of this type.

CBRN Attack Perpetrators: An Empirical Study

Based on zero-inflated negative binomial regressions applied to the Monterey weapons of mass destruction data, this article assesses the future risks from chemical, biological, radiological, and nuclear (CBRN) terrorism. Once the threshold for CBRN attacks is surpassed, further attacks arise: the expected number of CBRN incidents is over one and a half times higher than past events. Religious cults and groups with a transnational orientation pose the largest CBRN threat to society. Other things constant, nationalists/separatists and religious fundamentalists are not more apt to engage in CBRN terrorism than compared to “other groups.” Democratic and corrupt regimes are the likely venues for CBRN incidents. Based on past incidents, rich countries are especially vulnerable to CBRN terrorism. Thus, recent actions by the U.S. Department of Homeland Security to put more resources into guarding against CBRN attacks appear sound. This study indicates that nonfundamentalist terrorists also present CBRN risks to democracies. From a foreign policy viewpoint, CBRN terrorism is not a problem that rich democratic countries can confront alone, because the terrorists will move to where there is the least vigilance. Our study indicates the likely perpetrators and types of attacks that nations must cooperate to avoid.

CBRN Incidents: Political Regimes, Perpetrators, and Targets

This article investigates the relationship between regime characteristics and the likelihood of chemical, biological, radiological, and nuclear (CBRN) terrorist incidents. Odds ratios establish that democratic ideals—democratic rule, strong rule of law, and honest regimes—are associated with more CBRN incidents. Failed states may be where some terrorist groups form or take refuge, but these states have not been the venue of choice for CBRN incidents. Religious (cults and fundamentalists) and nationalist/separatist groups are not more likely than others to engage in CBRN attacks. To date, indiscriminate CBRN attacks are as likely as discriminate attacks to cause casualties. Transnational terrorist groups are less adept than others in concealing their acquisition of CBRN substances. For some regressions, democratic rule and strong rule of law are positive determinants of CBRN incidents.

Progress and challenges in the development of physically-based numerical models for prediction of flow and contaminant dispersion in the urban environment

The release of chemical, biological, radiological, or nuclear (CBRN) agents by terrorists or rogue states in a North American city (densely populated urban centre) and the subsequent exposure, deposition and contamination are emerging threats in an uncertain world. The modeling of the transport, dispersion, deposition and fate of a CBRN agent released in an urban environment is an extremely complex problem that encompasses potentially multiple space and time scales. The availability of high-fidelity, time-dependent models for the prediction of a CBRN agent's movement and fate in a complex urban environment can provide the strongest technical and scientific foundation for support of Canada's more broadly based effort at advancing counter-terrorism planning and operational capabilities.The objective of this paper is to report the progress of developing and validating an integrated, state-of-the-art, high-fidelity multi-scale, multi-physics modeling system for the accurate and efficient prediction of urban flow and dispersion of CBRN (and other toxic) materials discharged into these flows. Development of this proposed multi-scale modeling system will provide the real-time modeling and simulation tool required to predict injuries, casualties and contamination and to make relevant decisions (based on the strongest technical and scientific foundations) in order to minimize the consequences of a CBRN incident in a populated centre.

Policies in place throughout the world: action by the European Union

Policies in place throughout the world: action by the European Union