Cullen Case

Radiologic and nuclear events: contingency planning for hematologists/oncologists

Untoward events involving radioactive material, either accidental or intentional, are potentially devastating. Hematologists and oncologists are uniquely suited to help manage radiation victims, as myelosuppression is a frequent complication of radiation exposure. In the aftermath of a large event, such as a nuclear detonation, there may be a national call for surge capacity that involves hematologists/oncologists across the country in the disaster response. In preparation, the National Marrow Donor Program and American Society for Blood and Marrow Transplantation have established the Radiation Injury Treatment Network (RITN), a voluntary consortium of transplant centers, donor centers, and umbilical cord blood banks. RITN is partnered with the Office of the Assistant Secretary for Preparedness and Response in the United States Department of Health and Human Services to develop treatment guidelines, educate healthcare professionals, coordinate situation response, and provide comprehensive evaluation and care for radiation injury victims. We outline the current plans for event response and describe scenarios, including catastrophic events that would require extensive support from hematologists/oncologists across the country. In addition, we highlight important reference resources and discuss current efforts to develop medical countermeasures against radiation toxicity. Practitioners and institutions across the country are encouraged to become involved and participate in the planning.

Stem Cells, Multiorgan Failure in Radiation Emergency Medical Preparedness: A U.S./European Consultation Workshop

The concern of the public regarding terrorist actions involving nuclear emergencies resulted in the reopening of the discussion regarding the best ways to cope with the inevitable health impairments. Medical experts from the US and from Europe considered it of importance to harmonize at an international level the diagnostic and therapeutic approaches regarding the radiation‐induced health impairments. The present contribution is the result of the first U.S./European Consultation Workshop addressing approaches to radiation emergency preparedness and assistance, which was held recently at Ulm University, Ulm, Germany. Discussions dealt with the assessment of the extent of damage after total body exposure and, in particular, the quantity and quality of the damage to the hematopoietic stem cell pool. Secondly, the pathogenesis of the multiorgan failure was considered because of the organ‐to‐organ interactions. Thirdly, approaches were considered to harmonize the “triage‐methods” used on an international level using the “Response Category” approach as developed for the European Communities. These discussions lead to the conclusion that there is a strong need for continuing education of physicians, nurses, and support personnel to address the issues posed by the management of patients suffering from radiation syndromes. Finally, the discussions expressed the need for more international cooperation in research and development of more refined methods to treat patients with any type of radiation syndromes. Stem Cells 2009;27:1205–1211

Medical Planning and Response for a Nuclear Detonation: A Practical Guide

This article summarizes major points from a newly released guide published online by the Office of the Assistant Secretary for Preparedness and Response (ASPR). The article reviews basic principles about radiation and its measurement, short-term and long-term effects of radiation, and medical countermeasures as well as essential information about how to prepare for and respond to a nuclear detonation. A link is provided to the manual itself, which in turn is heavily referenced for readers who wish to have more detail.

Public health and medical preparedness for a nuclear detonation: the nuclear incident medical enterprise

AbstractResilience and the ability to mitigate the consequences of a nuclear incident are enhanced by (1) effective planning, preparation and training; (2) ongoing interaction, formal exercises, and evaluation among the sectors involved; (3) effective and timely response and communication; and (4) continuous improvements based on new science, technology, experience, and ideas. Public health and medical planning require a complex, multi-faceted systematic approach involving federal, state, local, tribal, and territorial governments; private sector organizations; academia; industry; international partners; and individual experts and volunteers. The approach developed by the U.S. Department of Health and Human Services Nuclear Incident Medical Enterprise (NIME) is the result of efforts from government and nongovernment experts. It is a “bottom-up” systematic approach built on the available and emerging science that considers physical infrastructure damage, the spectrum of injuries, a scarce resources setting, the need for decision making in the face of a rapidly evolving situation with limited information early on, timely communication, and the need for tools and just-in-time information for responders who will likely be unfamiliar with radiation medicine and uncertain and overwhelmed in the face of the large number of casualties and the presence of radioactivity. The components of NIME can be used to support planning for, response to, and recovery from the effects of a nuclear incident. Recognizing that it is a continuous work-in-progress, the current status of the public health and medical preparedness and response for a nuclear incident is provided.

Radiation Injury Treatment Network (RITN): Healthcare professionals preparing for a mass casualty radiological or nuclear incident

Purpose: To describe the history, composition, and activities of the Radiation Injury Treatment Network (RITN). The Radiation Injury Treatment Network® is a cooperative effort of the National Marrow Donor Program and the American Society for Blood and Marrow Transplantation. The goals of RITN are to educate hematologists, oncologists, and stem cell transplant practitioners about their potential involvement in the response to a radiation incident and provide treatment expertise. Injuries to the marrow system readily occur when a victim is exposed to ionising radiation. This focus therefore leverages the expertise of these specialists who are accustomed to providing the intensive supportive care required by patients with a suppressed marrow function. Following a radiological incident, RITN centres may be asked to: Accept patient transfers to their institutions; provide treatment expertise to practitioners caring for victims at other centres; travel to other centres to provide medical expertise; or provide data on victims treated at their centres. Moving forward, it is crucial that we develop a coordinated interdisciplinary approach in planning for and responding to radiological and nuclear incidents. The ongoing efforts of radiation biologists, radiation oncologists, and health physicists can and should complement the efforts of RITN and government agencies. Conclusion: RITN serves as a vital partner in preparedness and response efforts for potential radiological and nuclear incidents.

Assessing Surge Capacity for Radiation Victims with Marrow Toxicity

Hematologists/oncologists would provide essential care for victims of a catastrophic radiation incident, such as the detonation of an improvised nuclear device (IND). The US Radiation Injury Treatment Network (RITN) is a voluntary consortium of 37 academic medical centers, 8 blood donor centers, and 7 umbilical cord banks focused on preparedness for radiation incidents. The RITN conducted 2 tabletop exercises to evaluate response capability after a hypothetical IND detonation in a U.S. city. In the 2008 exercise, medical centers voluntarily accepted 1757 victims at their institutions, a small fraction of the number in need. In the 2009 exercise, each center was required to accept 300 victims. In response, the centers outlined multiple strategies to increase bed availability, extend staff and resources, and support family and friends accompanying transferred victims. The exercises highlighted shortcomings in current planning and future steps for improving surge capacity that are applicable to various mass casualty scenarios.

Medical management of radiation victims in the United States

Many governmental and non-governmental agencies are involved in the planning for radiation events in the U.S. We will focus on medical management after mass casualty events, specifically the involvement of the Radiation Injury Treatment Network (RITN), a voluntary consortium of medical centers across the continental U.S. RITN and its partners have established standardized approaches for the evaluation and treatment of radiation victims, which are now available online. Efforts are underway to streamline these processes, provide training to healthcare practitioners around the country, and harmonize with similar efforts around the world.

World Marrow Donor Association Crisis Response, Business Continuity, and Disaster Recovery Guidelines

Multiple institutions, such as donor registries, donor centers, transplantation centers, collection centers, and courier companies, are involved in the international exchange of hematopoietic stem cells. The ability to safely and efficiently ensure continued operation of a donor registry relies on an organizations resiliency in the face of an incident that could impede donor search, donor selection, stem cell collection, or transportation. The Quality Assurance Working Group of the World Marrow Donor Association has developed guidelines on how to establish an organizational resiliency program intended for donor registries initiating an emergency preparedness process. These guidelines cover the minimal requirements of preparedness in prevention and mitigation, crisis response, business continuity, and disaster recovery, and the need for continued maintenance and revision. Issues of international cooperation are addressed as well.

Radiation disasters: role of the BMT team.

Bone marrow transplant (BMT) teams do not generally consider themselves to be emergency responders. But the bone marrow is the most radiosensitive organ in the body, and early changes in peripheral blood counts remain the best indicator of major total-body radiation exposures. Following a mass casualty incident, such as that occasioned by a nuclear detonation, BMT teams should expect that they will be called upon for their expertise in managing severe myelosuppression. Numerous resources, including the Radiation Injury Treatment Network, are available to assist BMT teams in planning for such a role.

Planning and Response to Radiation Exposures

The March 11 earthquake and tsunami in Japan has caused the worst radiation disaster since Chernobyl. In the ensuing weeks, dozens of workers have been exposed to radiation while struggling to limit the release of radioactivity from damaged reactor containment vessels and compromised spent-fuel storage pools. Fortunately, no serious immediate injuries have been reported. Exposure monitoring for individual workers enables managers to limit radiation doses, and this relatively controlled situation should prevent, barring further calamity, any dangerous exposures. Nevertheless, some medical professionals including a group of experienced hematologists in Japan advising on safety measures for this catastrophic situation have proposed that, because the bone marrow is known to be the most radiosensitive organ in the body, hematopoietic progenitor and stem cells (HPC) should be collected prophylactically from some or all workers [1]. Then, if a subsequent uncontrolled radiation exposure occurred, a worker who received a marrow-ablative dose of radiation could be rescued with an infusion of his own (autologous) cells. Autologous HPC transplantation has been used therapeutically to treat various cancers for more than 30 years. The procedure makes it possible to deliver otherwise lethal doses of radiation and/or chemotherapy to the cancer and achieve higher tumor cell kill. It works, and works very well. Countless cancer survivors can attest to its effectiveness and safety. But this is a finely tuned delivery of cytotoxic therapy: too little and the autologous HPC are irrelevant; too much and the toxicities to other organs (gut, lung, blood vessels, brain) prove fatal [2]. It is estimated that exposures of whole-body irradiation 4 to 9 Gy (4000-9000 mSv) fall in this range where marrow suppression is the critical factor for survival, but partial-body irradiation, as might occur with workers partially shielded by walls or equipment, may spare some marrow tissue allowing spontaneous hematologic recovery [3-5]. For radiation casualties without radiation monitors, the ability to assign precise radiation dose to each organ is not possible today. Victims with even severe exposures can be medically supported for weeks to months if autologous recovery is possible, but transplantation of HPC for selected cases could accelerate recovery [6]. So, what is the likelihood that a worker in the Fukushima Daiichi nuclear plant will receive that precise dose of radiation that will render autologous HPC rescue a necessary and life-saving procedure? We do not know, but it is probably very low. 1262 Letters to the Editor