NCRP REPORT No.

165

Responding to a
Radiological or Nuclear
Terrorism Incident: A Guide
for Decision Makers

Recommendations of the
NATIONAL COUNCIL ON RADIATION
PROTECTION AND MEASUREMENTS

January 11, 2010

National Council on Radiation Protection and Measurements

7910 Woodmont Avenue, Suite 400 / Bethesda, MD 20814-3095
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Responding to radiological or nuclear terrorism incident : a guide for decision

makers.
p. cm. -- (NCRP report ; no. 165)
Includes bibliographical references and index.
ISBN 978-0-9823843-3-6
1. Terrorism. 2. Nuclear terrorism--United States. 3. Chemical terrorism--
United States. I. National Council on Radiation Protection and Measurements.
HV6432.R477 2010
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Copyright © National Council on Radiation

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Preface

A high priority for the U.S. Department of Homeland Security

(DHS) is the preparation of emergency responders and decision
makers for conducting rapid, efficient countermeasures to an act of
radiological or nuclear terrorism. Several publications by the
National Council on Radiation Protection and Measurements
(NCRP) have provided guidance on effective responses to terrorism
incidents, including Report No. 138 (2001), Management of Terror-
ist Events Involving Radioactive Material; Commentary No. 19
(2005), Key Elements of Preparing Emergency Responders for
Nuclear and Radiological Terrorism; Report No. 161 (2008), Man-
agement of Persons Contaminated with Radionuclides; and the pro-
ceedings of the 2004 NCRP Annual Meeting on Advances in
Consequence Management for Radiological Terrorism Events pub-
lished in Health Physics in 2005.
This Report on Responding to a Radiological or Nuclear Terror-
ism Incident: A Guide for Decision Makers provides a comprehensive
analysis of key decision points and information needed by decision
makers at the local, regional, state, tribal and federal levels in
responding to radiological or nuclear terrorism incidents. It provides
a framework for preparedness efforts by describing in depth the
information that should be acquired and communicated as a basis
for the decision-making process. This Report is written with consid-
eration of basic information that may be useful to planners develop-
ing local and regional response plans that in turn should be used to
support training and exercise programs to prepare for acts of radio-
logical or nuclear terrorism. The Report provides valuable supple-
mentary information in support of the U.S. National Response
Framework, the National Incident Management System, and other
federal and state guidance that has been issued in recent years.
This Report was prepared by Scientific Committee 2-2 on Pre-
paredness for Responding to the Aftermath of Radiological and
Nuclear Terrorism: A Guide for Decision Makers. Serving on Scien-
tific Committee 2-2 were:

John W. Poston, Sr., Chairman

Texas A&M University
College Station, Texas

iii
iv / PREFACE

Members
Brooke R. Buddemeier John J. Lanza
Lawrence Livermore National Florida Department of Health
Laboratory Pensacola, Florida
Livermore, California
Abel J. Gonzalez Edwin M. Leidholdt, Jr.
Nuclear Regulatory Authority of U.S. Department of Veterans
Argentina Affairs
Buenos Aires, Argentina Mare Island, California
Robert J. Ingram Debra McBaugh
Fire Department, City of New State of Washington,
York Department of Health
Center for Terrorism and Olympia, Washington
Disaster Preparedness
Bayside, New York
Cynthia G. Jones Stephen V. Musolino
U.S. Nuclear Regulatory Brookhaven National
Commission Laboratory
Washington, D.C. Upton, New York
Kathleen Kaufman Tammy P. Taylor
County of Los Angeles Los Alamos National Laboratory
Department of Public Health Los Alamos, New Mexico
Los Angeles, California

Consultant
Jerrold T. Bushberg
University of California, Davis
Sacramento, California

NCRP Secretariat
Kenneth L. Groves, Technical Staff Consultant
Bonnie G. Walker, Assistant Managing Editor
Cindy L. O’Brien, Managing Editor
David A. Schauer, Executive Director

The Council wishes to express its appreciation to the Committee

members for the time and effort devoted to the preparation of this
Report. NCRP is also grateful for the financial support provided by
the DHS Directorate of Science and Technology.

Thomas S. Tenforde
President
Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

1. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
2.1 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
2.2 Target Audiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
2.3 Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
2.4 Report Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
2.5 Quantities and Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
2.6 Types of Radiological or Nuclear Terrorism Incidents . . . .7
2.6.1 Radiological Terrorism Incidents . . . . . . . . . . . . . .7
2.6.1.1 Radiological Dispersal Device . . . . . . . 9
2.6.1.2 Radiation Exposure Device . . . . . . . . 11
2.6.1.3 Deliberate Contamination of Food,
Water or Consumables. . . . . . . . . . . . 12
2.6.1.4 Dispersal of Radioactive Material from
Fixed Radiological or Nuclear Facilities
or Materials in Transit . . . . . . . . . . . .12
2.6.2 Improvised Nuclear Device . . . . . . . . . . . . . . . . . .12

3. Key Radiation Protection Principles . . . . . . . . . . . . . . . . . .15

3.1 Establishment of Control Zones . . . . . . . . . . . . . . . . . . . . .15
3.1.1 Defining the Hot Zone . . . . . . . . . . . . . . . . . . . . . .16
3.1.2 Defining the Dangerous-Radiation Zone . . . . . . .17
3.2 Protecting People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
3.2.1 Recommendations for Members of the General
Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
3.2.2 Recommendations for Emergency Responders . .20
3.2.3 Recommendations for Public Health and Medical
System Personnel . . . . . . . . . . . . . . . . . . . . . . . . .23
3.2.4 Building Design and Construction . . . . . . . . . . . .23
3.2.5 Building Ventilation Systems . . . . . . . . . . . . . . . .24

4. Response-Plan Development and Implementation . . . . . .25

4.1 Federal Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
4.2 Roles and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . .27
4.3 Response-Plan Requirements . . . . . . . . . . . . . . . . . . . . . . .30

v
vi / CONTENTS

4.3.1 Hazard Evaluations . . . . . . . . . . . . . . . . . . . . . . . 32

4.3.2 Decontamination of Members of the General
Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.3.3 Control of Doses to Emergency Responders . . . . 34
4.3.4 Training and Exercises . . . . . . . . . . . . . . . . . . . . 34
4.4 Providing Information to Members of the General Public 36
4.4.1 Preincident Public Information Program . . . . . . 37
4.4.2 Preparing for Post-Incident Messages . . . . . . . . 38
4.5 Mutual-Aid Agreements . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.6 International Agreements . . . . . . . . . . . . . . . . . . . . . . . . . 40

5. Radiological Terrorism Incident . . . . . . . . . . . . . . . . . . . . . 43

5.1 Radiological Terrorism Incident Response Plan . . . . . . . . 43
5.2 Radiological Terrorism Incident Hazard Zones . . . . . . . . 45
5.3 Protective Actions for Emergency Responders and Members
of the General Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.3.1 Sheltering versus Evacuation in the Emergency
Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.3.2 Postemergency-Phase Protection of Members of the
General Public . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.3.3 Improvised Respiratory Protection . . . . . . . . . . . 47
5.3.4 Management of Concerned Citizens . . . . . . . . . . 47
5.3.5 Protection of Emergency Responders . . . . . . . . . 48
5.4 Triage for Inhaled Radionuclides . . . . . . . . . . . . . . . . . . . 49
5.5 Management of the Crime Scene . . . . . . . . . . . . . . . . . . . 50

6. Nuclear Terrorism Incident . . . . . . . . . . . . . . . . . . . . . . . . . . 51

6.1 Hazard Analysis and Zones . . . . . . . . . . . . . . . . . . . . . . . . 55
6.2 Response-Plan Considerations . . . . . . . . . . . . . . . . . . . . . 57
6.3 Public Information Program to Improve Response to a
Nuclear Terrorism Incident . . . . . . . . . . . . . . . . . . . . . . . . 61
6.3.1 Preincident Public Information Program . . . . . . 61
6.3.2 Preparing for Post-Incident Messages . . . . . . . . 62
6.4 Protective-Action Recommendations Specific to a Nuclear
Terrorism Incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
6.5 Planning for the Protection of Emergency Responders
After a Nuclear Terrorism Incident . . . . . . . . . . . . . . . . . 67
6.6 Nuclear Terrorism Incident Recommendations for
Emergency Responders . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
6.7 Considerations for Downwind Populations at Long
Distances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

7. Preparing the Public-Health and Medical System

Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
7.1 Public-Health and Medical Preparedness Overview . . . . 73
 CONTENTS / vii

7.2 Hospital Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

7.3 Reception Centers Other Than Hospitals . . . . . . . . . . . . .82
7.4 Triage Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87
7.5 Treatment Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
7.5.1 Medical Treatment of Victims . . . . . . . . . . . . . . . .90
7.5.2 Radiological Assessment of Patients . . . . . . . . . .92
7.5.3 Management of Individuals at Community
Reception Centers . . . . . . . . . . . . . . . . . . . . . . . . .93
7.5.4 Management of Individuals at Alternative Medical
Treatment Sites . . . . . . . . . . . . . . . . . . . . . . . . . . .94
7.5.5 Diagnosis of Early Health Effects and Assessment of
Internal Contamination . . . . . . . . . . . . . . . . . . . .94
7.5.6 Hospital Management of Radiation Casualties . .95
7.5.7 Use of Countermeasures . . . . . . . . . . . . . . . . . . . .95
7.5.8 Medical Follow-Up of Individuals Exposed to
Ionizing Radiation . . . . . . . . . . . . . . . . . . . . . . . . .96
7.6 Decontamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96
7.7 Bioassays for Internal Contamination and
Biodosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
7.7.1 Bioassays for Internal Contamination . . . . . . . .102
7.7.2 Biodosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
7.8 Population Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . .108
7.9 Handling Contaminated Waste . . . . . . . . . . . . . . . . . . . .110
7.10 Handling Contaminated Deceased Persons . . . . . . . . . . .112
7.11 Recruitment and Credentialing of Supplementary
Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115

Appendix A. Employer and Emergency Responder

Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119

Appendix B. Public Information Statements . . . . . . . . . . . . .124

B.1 In the Event of a Radiological Dispersal Device . . . . . . .124
B.2 In the Event of an Improvised Nuclear Device . . . . . . . .128

Appendix C. Key Decisions for Federal Decision Makers

(as they relate to international conventions and
agreements) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134
C.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134
C.2 Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135
C.2.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135
C.2.2 Key Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . .135
C.3 Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
C.3.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
C.3.2 Key Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
C.4 Radioactive-Waste Management . . . . . . . . . . . . . . . . . . .138
viii / CONTENTS

C.4.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

C.4.2 Key Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Appendix D. Controlling Consumer Products — Food, Water,

etc. (international implications) . . . . . . . . . . . . . . . . . . . . . 141
D.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
D.2 Radiation Protection Considerations . . . . . . . . . . . . . . . 142
D.3 International Intergovernmental Agreements . . . . . . . 143
D.3.1 Nonedible Consumer Products . . . . . . . . . . . . . 143
D.3.2 Edible Consumer Products (other than drinking
water) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
D.3.3 Drinking Water . . . . . . . . . . . . . . . . . . . . . . . . . . 145
D.4 Dealing with Consumer Products After Radiological or
Nuclear Terrorism Incidents . . . . . . . . . . . . . . . . . . . . . . 146
D.5 Handling Situations Involving “Hot Particles” . . . . . . . . 147

Appendix E. Resources of the U.S. Department of Energy . 149

E.1 Radiological Assistance Program . . . . . . . . . . . . . . . . . . 149
E.2 Consequence Management Home Team . . . . . . . . . . . . . 150
E.3 Consequence Management Response Team Phase I . . . 150
E.4 Consequence Management Response Team Phase II . . 151
E.5 Consequence Management Response Team-
Augmentation/ Federal Radiological Monitoring and
Assessment Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
E.6 Aerial Measuring System . . . . . . . . . . . . . . . . . . . . . . . . 152
E.7 National Atmospheric Release Advisory Center . . . . . . 152
E.8 Radiation Emergency Assistance Center/Training Site 152

Appendix F. Decontamination of People . . . . . . . . . . . . . . . . . 153

F.1 Instructions on How to Perform Decontamination at
Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
F.2 Instructions to Members of the General Public Waiting
for Decontamination at the Scene of an Incident . . . . . . 154

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

The NCRP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

NCRP Publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
1. Executive Summary

The guidance presented here for local, regional, state, tribal and
federal decision makers is intended to provide the most comprehen-
sive summary to date of recommendations and key decision points
for planners preparing responses to radiological or nuclear terror-
ism incidents. It is unique because it considers both forms of ter-
rorism within one publication while accounting for their funda-
mental differences. It is not uncommon for radiological or nuclear
terrorism incident planning preparations to be broadly addressed
together in a single radiation-specific hazard response publication.
The potential consequences of nuclear terrorism are radically dif-
ferent from those of radiological terrorism and therefore the plan-
ning and preparation must take into account these differences.
This Report accounts for those differences, yet draws from the char-
acteristics that are similar for the two basic incident scenarios.
The Report does not present a distillation of recommendations
and key decision points in an executive summary. This is deliber-
ate. NCRP strongly recommends that key decision makers use and
understand this planning guidance in its entirety to adequately
begin the planning process for response to radiological or nuclear
terrorism incidents or to assess existing plans. It is incumbent
upon key decision makers who use this guidance to understand the
recommendations and decision points in the proper context. This
can only be accomplished by studying the text and, for planners
with less familiarity with the topic, the references supporting the
Report.

1
2. Introduction

2.1 Purpose

Local and state emergency-response decision makers (e.g.,

elected and appointed officials, emergency management officials,
incident commanders) should be well prepared in the event of an
act of radiological or nuclear terrorism. Terrorism preparedness is
a high priority of the U.S. Department of Homeland Security (DHS).
Two National Council on Radiation Protection and Measure-
ments (NCRP) reports offer advice for the planning of responses to
radiological or nuclear terrorism incidents and discuss the critical
roles of adequate planning, preparation and funding for the sup-
port of emergency-response actions (NCRP, 2001; 2005). Soon after
the events of September 11, 2001, NCRP released Report No. 138,
Management of Terrorist Events Involving Radioactive Material
(NCRP, 2001). This report was followed by a more focused publica-
tion, NCRP Commentary No. 19, Key Elements of Preparing Emer-
gency Responders for Nuclear and Radiological Terrorism (NCRP,
2005). The current Report is intended to support preparedness
efforts by providing a framework of key recommendations and deci-
sion points needed by decision makers preparing for the response
to a radiological or nuclear terrorism incident.
The purpose of this NCRP Report is to provide this framework
by defining:

• preincident planning and preparation;

• essential policy recommendations;
• issues to be addressed and key decision points;
• actions to be taken to protect public health, safety and secu-
rity; and
• critical information needed by decision makers to initiate
appropriate actions during the early (emergency) response
to an act of radiological or nuclear terrorism.

The Report has two primary components:

• information needed by decision makers to protect the health

and safety of emergency responders and members of the
general public; and

2
 2.3 SCOPE / 3

• consolidated recommendations on key decision points; levels

of radiation doses; dose rates at which a response should be
initiated; and the nature, timing and extent of the response.

This Report is consistent with, and builds upon, existing U.S.

federal policy and guidance.

2.2 Target Audiences

This Report is intended for those organizations and individuals

responsible for planning and executing a response to a radiological
or nuclear terrorism incident. The intended audience of this Report
is decision makers at the local, regional, state, tribal and federal
levels who are responsible for decisions affecting public health,
safety and security. These decision makers include:

• elected and appointed officials;

• incident commanders;
• planners across disciplines that support emergency response;
• leaders of emergency-response departments;
• managers of public health departments;
• managers of healthcare organizations; and
• managers responsible for providing assets.

2.3 Scope

The response to a radiological or nuclear terrorism incident

is commonly divided into three phases (DHS, 2008; ICRP, 2005;
NCRP, 2001). In the United States, these are referred to as the
early, intermediate and late phases, although other organizations
such as the International Commission on Radiological Protection
(ICRP) give them more descriptive names: the rescue, recovery and
restoration phases. These phases cannot be represented by exact
time periods, and transitions from one phase to another are not
likely to be distinct. Nevertheless, they are useful in emergency-
response planning for radiological or nuclear terrorism incidents for
describing the hazards present, decisions that should be made, and
response actions necessary at various times following an incident.
The early phase (emergency phase) is the period at the beginning
of an incident when immediate decisions for effective protective
actions are required, and when actual field-measurement data
generally are not available. Exposure to the radioactive plume,
short-term exposure to deposited radionuclides, and inhalation of
radionuclides are generally taken into account when considering
4 / 2. INTRODUCTION

protective actions for the early phase. The response during the
early phase includes initial emergency-response actions to protect
public health and welfare in the short term, considering a time
period for protective action of hours to a few days. Priority should
be given to lifesaving and first-aid actions. During this early phase,
incident commanders and other decision makers must make deci-
sions and direct operations with only limited information. In gen-
eral, early-phase protective actions should be taken very quickly,
and the protective-action decisions can be modified later as more
information becomes available (DHS, 2008). The early phase fol-
lowing a radiological dispersal device (RDD) or improvised nuclear
device (IND) incident may last from hours to days, likely lasting
longer for an IND incident.
The intermediate phase may follow the early-phase response
within as little as a few hours or in days. The intermediate phase
of the response is usually assumed to begin after the incident
sources and releases have been brought under control and protec-
tive-action decisions can be made based on measurements of expo-
sure and radionuclides that have been deposited as a result of the
incident (DHS, 2008). The main sources of exposure to people in
this phase are irradiation by recently-deposited radionuclides,
inhalation of resuspended material, and ingestion of contaminated
food or water. Actions during the intermediate phase include
detailed surveys to characterize the deposition of radionuclides and
may include food interdiction and relocation of some members of
the general public. The intermediate phase may last from weeks
to many months, until protective actions can be terminated.
The late phase begins with the initiation of restoration and
cleanup actions to reduce radiation levels in the environment to
acceptable levels and ends when all the remediation actions have
been completed. These phases are described in more detail in the
references listed above (DHS, 2008; ICRP, 2005; NCRP, 2001).
This Report principally addresses recommendations associated
with planning and preparedness associated with the early phase
and the leading edge of the intermediate-phase response. It does not
explicitly provide recommendations for planning during the inter-
mediate-phase response, which will be managed with resources
defined in the National Response Framework (FEMA, 2008a), nor
does it address recommendations for the late-phase response which
will be addressed in a subsequent NCRP report.1

1NCRP Scientific Committee 5-1 on Approach to Optimizing Decision

Making for Late-Phase Recovery from a Radiological or Nuclear Terror-
ism Incident.
 2.5 QUANTITIES AND UNITS / 5

The Report draws on many publications, including previous

NCRP publications addressing these issues. It should be recognized
that there is a wealth of information available within the United
States and internationally. NCRP has considered much of this
information, both published and unpublished. Reports and guid-
ance on this subject will continue to be issued by federal and state
agencies, as well as some professional societies.
After a short summary of the types of terrorism-related inci-
dents involving radioactive and/or nuclear material(s) included in
this Report, Section 3 presents a discussion on the two main topics
of the Report:
• establishing control zones around the incident site, and
• protecting emergency responders and members of the gen-
eral public.

This is followed by a detailed discussion (Section 4) on response-

plan development and implementation. Consideration of radiologi-
cal or nuclear terrorism incidents is divided into two separate
sections (Sections 5 and 6, respectively) to allow more effective dis-
cussion of these topics. Finally, Section 7 is intended to assist in
planning and preparing the public health and medical response for
managing these incidents.

2.4 Report Goals

The primary goal of this Report is to provide recommendations

and decision points to be considered and implemented in the prepa-
ration of effective response plans well in advance of potential terror-
ism incidents involving radioactive or nuclear materials. This Report
provides NCRP recommendations that can be used by local, regional,
state and tribal planners to prepare response plans. Once response
plans are developed, NCRP strongly recommends that communities
periodically conduct tabletop and field exercises to ensure that
the response to radiological or nuclear acts of terrorism is effective
in meeting the challenges that such incidents may present.

2.5 Quantities and Units

This Report is focused almost exclusively on the early-phase

response to radiological or nuclear terrorism incidents. During this
early phase, the incident commander will attempt to manage the
radiation levels that emergency responders receive during the con-
duct of their duties by: (1) establishing radiation control zones
using observed exposure rates from external sources and surface
contamination levels, and (2) making decisions regarding the
6 / 2. INTRODUCTION

cumulative absorbed dose to individual emergency responders for

various emergency-response activities.
The primary radiation quantities and units used in this Report
to implement (1) and (2) are those in common use in the United
States for emergency response, and are listed below (also see the
Glossary). NCRP has adopted the International System (SI) of
radiation quantities and units for its reports (NCRP, 1985). There-
fore, in the text the corresponding SI quantity and unit is displayed
in parenthesis after the common quantity and unit.
For the radiation control zones (regarding exposure rate from
external sources):

• Common use: exposure rate in milliroentgens per hour

(mR h–1) or roentgens per hour (R h–1); and
• SI system: air-kerma rate in milligrays per hour (mGy h–1)
or grays per hour (Gy h–1).

The quantities and units for exposure rate (or air-kerma rate) refer
to photons only. For photon energies <300 keV, the actual air-kerma
rate is 0.087 mGy h–1 (for 10 mR h–1) [0.087 Gy h–1 (for 10 R h–1)]; the
numerical value (0.087) is slightly different for higher energies (e.g.,
0.088 for 60Co gamma rays). In this Report, the corresponding air-
kerma rate is given to one significant digit [e.g., 10 mR h–1 exposure
rate (~0.1 mGy h–1 air-kerma rate)]. Neutrons are not expected to be
present or will be a minimal contributor at the time emergency
responders are present. Significant neutron exposure is expected
only during the initial blast from an IND. The blast will be over
before emergency responders arrive.
For the radiation control zones (regarding surface contamina-
tion):

• Common use: activity in disintegrations per minute per unit

area (dpm cm–2); and
• SI system: activity in becquerels per unit area (Bq cm–2).

The quantities and units for surface contamination apply to alpha

particles, beta particles and gamma rays from radioactive contam-
ination.
For the control of cumulative absorbed dose to emergency
responders [the decision dose (Section 3.2.2)] from exposure to
external sources:

• Common use: cumulative absorbed dose in rads (rad); and

• SI system: cumulative absorbed dose in grays (Gy).
 2.6 TYPES OF RADIOLOGICAL INCIDENTS / 7

The quantities and units for cumulative absorbed dose to emer-

gency workers from exposure to external sources refer to photons
only, and the cumulative absorbed dose is treated as though it
were a whole-body absorbed dose. Neutrons are not expected to be
present or will be a minimal contributor at the time emergency
responders are present. Alpha and beta particles will not penetrate
the protective bunker gear of emergency responders, and the inha-
lation of radioactive material can be controlled by the respiratory
protection used by emergency responders.
Additional quantities and units referred to in this Report in the
context of other specific discussions are defined in the Glossary.

2.6 Types of Radiological or

Nuclear Terrorism Incidents

The purpose of this section is to describe the characteristics and

potential consequences of radiological or nuclear terrorism inci-
dents. Radiological terrorism involves the use of radioactive mate-
rial and nuclear terrorism involves the detonation of a nuclear
device. The types of radiological or nuclear terrorism incidents that
are considered in the context of this Report are:

• radiological dispersal devices (RDDs);

• radiation exposure devices (REDs);
• deliberate contamination of food, water, or other consum-
ables with radioactive material;
• dispersal of radioactive material from fixed radiological or
nuclear facilities or material in transit; and
• improvised nuclear devices (INDs).

These types of devices or uses of radioactive material will be dis-

cussed briefly below. Section 2.6.1 describes the first four and Sec-
tion 2.6.2 describes INDs. More detail can be found in NCRP Report
No. 138 (NCRP, 2001), NCRP Commentary No. 19 (NCRP, 2005),
and ICRP Publication 96 (ICRP, 2005). The International Atomic
Energy Agency (IAEA, 2004a) provides more information on spe-
cific radionuclides that could be used in radiological terrorism.

2.6.1 Radiological Terrorism Incidents

Radiological terrorism incidents can range from those involving

small and localized consequences to those involving a more wide-
spread impact to the environment with a footprint (i.e., area of con-
tamination) over large distances on the order of a few miles and
8 / 2. INTRODUCTION

greater (Harper et al., 2007). It is possible that a terrorist organi-

zation could devise a means of radiological attack other than those
described in this section. Therefore, preparedness measures should
always be flexible and scalable.
Protective actions and other decisions in the first few hours
after notification of a radiological terrorism incident will probably
have to be made with few field measurements or before data are
available. There will be little or no knowledge of the initial quantity
of radioactive material and the aerosolized fraction at the time the
incident is discovered. Deliberate contamination of food or water or
the use of an RED may be revealed by a set of medical conditions
from victims who report for medical treatment (e.g., nausea, vomit-
ing, skin injuries, and/or depressed white cell blood counts), which
will initiate the response to consider an RED; by detection of radio-
active material with radiation survey devices; or by announcement
by the terrorists themselves. If internal contamination is sus-
pected, one of the first priorities will be to identify the specific
radionuclides involved.
A radiological terrorism incident may expose a few people or
possibly several hundred to thousands of people to low-level con-
tamination. These people will ultimately require some type of
decontamination. Fear may cause many uninjured people to seek
hospital care, hindering the ability of hospitals to provide care for
those with severe injuries caused by the explosion and other nonra-
diological early health effects normally seen at the hospital emer-
gency departments (EDs). A very large number of people might
require screening for external contamination, bioassay for internal
contamination (Section 7.7.1), consideration of decorporation ther-
apy (administration of drugs to hasten the elimination of some
radionuclides, and consideration for long-term health monitoring.
An incident involving a small amount of radioactive material
likely will cause localized impacts on people and the environment.
A large source of radioactive material that is poorly dispersed might
also have minimal, localized consequences in terms of cleanup, such
as a small footprint or ballistic fragments with little or no aerosol.
This situation would be handled like the spill of any hazardous
material (HAZMAT) that would be remediated, and the infrastruc-
ture rapidly restored. Conversely, a large quantity of radioactive
material that is effectively dispersed could have wide-ranging
impacts. Experiments with potential RDD materials have demon-
strated that increasing the quantity of radioactive material in a
radiological device may or may not lead to widespread dispersal
because the environmental impacts are determined by the fraction
of the material that is aerosolized by the device. Large particles will
 2.6 TYPES OF RADIOLOGICAL INCIDENTS / 9

result in relatively-high local deposition, whereas small particles

will travel further from the release point (Harper et al., 2007).
The amount of material that is aerosolized and the resulting
plume that affects the area over which these materials will be dis-
persed depend on the method of dispersal, the design of the device,
atmospheric conditions, terrain, and the chemical and physical
form of the radionuclide (Harper et al., 2007). Few or none of these
parameters will be known at the time of discovery of the incident.
RDD aerosolization experiments have shown that, even if a very
large quantity of radioactive material is dispersed, the potential for
early health effects is bounded within an area of ~1,600 feet (500 m)
in radius from the release point (Harper et al., 2007). If it is known
that the source used in such an incident had an activity <10,000 Ci
(370 TBq) of any radionuclide, the initial radiation hazard zone
boundary can be established at ~800 feet (250 m) (Musolino and
Harper, 2006) from the point of the explosion. Based on experi-
ments for an outdoor explosion of an RDD, the plume is likely to
pass from the immediate area within ~10 to 15 min, which would
reduce the risk of acute inhalation of airborne activity to emergency
responders and members of the general public in this area (Harper
et al., 2007). Conversely, in a device that produces poor aerosoliza-
tion, the material could result in dangerous localized hot spots
and/or ballistic fragments that might create high external exposure
rates. The potential for ballistic fragments is independent of the
amount of radioactive material (Harper et al., 2007).

2.6.1.1 Radiological Dispersal Device. A device that spreads radio-

active material with malicious intent is called a radiological disper-
sal device (RDD). An RDD that uses explosives for dispersion of the
radioactive material is commonly referred to as a “dirty bomb.” An
RDD may or may not effectively disperse the radionuclide. An RDD
might fail to detonate or be discovered prior to being triggered. In
the latter case, the device could be rendered safe by bomb disposal
technicians with particular care exercised to not cause a release of
radioactive material.
In any terrorism incident, there could be an attempt to use an
improvised explosive device or other nonradiological secondary
device to harm emergency responders and members of the general
public. Therefore, response plans should consider this additional
threat to personnel (e.g., law enforcement, fire/rescue) and critical
infrastructure (e.g., medical facilities), both near the scene of the
incident and other locations. Furthermore, a secondary device in
conjunction with an RDD could significantly increase the number
of persons with traumatic injuries.
10 / 2. INTRODUCTION

In general, it is most likely that the consequences of an outdoor

explosion of an RDD will impact only a small area consisting of a
few city blocks, but, like a chemical spill, care is needed to limit the
spread of the material into other areas and prevent uncontami-
nated people from entering. It is expected that most exposures
would be too small to cause early health effects to people and, with
the exception of severe injuries from the conventional explosion, the
major consequence will be low-level external contamination and
possibly large-scale psychosocial effects.
A malfunctioning IND could result in consequences similar to
an RDD. In this Report, IND refers to any type of device designed
to cause a nuclear yield using conventional explosives to create a
supercritical mass of special nuclear material (e.g., enriched ura-
nium or 239Pu).2 A malfunctioning IND would occur if the conven-
tional explosive detonates, but no nuclear yield is achieved. Such an
incident might aerosolize and scatter a fraction of the special
nuclear material from the weapon, create an airborne plume, and
contaminate the environment. The effect of a nuclear device that
detonates with a large nuclear yield is discussed in Section 2.6.2.
For an outdoor explosion of an RDD, high radiation doses and
large intakes of radionuclides and their associated early health
effects are unlikely for devices that incorporate only 241Am, 252Cf,
192
Ir, or 226Ra because, typically, these radionuclides are not avail-
able in the range of kilocurie (~40 TBq) quantities, in contrast to
some other radionuclides commonly used in industry, research and
medicine (e.g., 60Co, 90Sr, and 137Cs). Because of the associated high
security and the lack of use in routine commerce and industry, the
availability of a large enough quantity of 238Pu or 239Pu to produce
an incident comparable to one with 10,000 Ci (370 TBq) or greater
of a beta and gamma emitter is considered improbable compared to
one using 60Co, 90Sr, or 137Cs (IAEA, 2004b; Musolino and Harper,
2006).
The number of people directly injured or killed by the force of an
RDD could range from none to a few, or perhaps hundreds. An RDD
using nonexplosive means of dispersal would likely not directly
cause any injuries or deaths from trauma. In the case of an RDD
using explosive means of dispersal, the number of deaths and
injured persons would depend upon the amount of explosive, the
design of the device, its placement, and the number of people in its
vicinity at the time of detonation. An RDD detonated when people
are not near would not directly cause any casualties from trauma.

2Nuclear
yield is the amount of energy that is released when a nuclear
weapon is detonated (see Glossary for more information).
 2.6 TYPES OF RADIOLOGICAL INCIDENTS / 11

An outdoor explosion of an RDD would not be likely to deliver suf-

ficient doses to people to cause early health effects, except perhaps
for a few people close to the explosion who inhale aerosols from the
concentrated plume (Musolino and Harper, 2006). However, an
RDD using a large amount of explosives and detonated near many
people, or causing a building to collapse similar to the truck bomb
that destroyed the Alfred P. Murrah Federal Building in Oklahoma
City in 1995 could kill more than a hundred people from the explo-
sive blast and cause traumatic injuries to additional hundreds
(COCDM, 1996). While it is true that the number of people directly
injured by the explosive force of an RDD would be small, if the inci-
dent is not handled promptly and correctly, the risk is a small
increased probability of cancer from the radiation exposure.

2.6.1.2 Radiation Exposure Device. A radiation exposure device

(RED) consists of a large quantity of radioactive material clandes-
tinely placed to expose people to ionizing radiation. This form of
terrorism would use an intact sealed source or radioactive material
enclosed in a container to expose unsuspecting people instead
of widespread dispersal of the material. An RED might go unde-
tected for a relatively long time, complicating the assessment of the
exposed population.
For substantial harm to occur, the exposed individuals would
have to be in close proximity to the source of radiation for extended
periods of time. The smaller the activity, the closer individuals
would have to be and the longer they would have to be in its vicinity
for significant effects to occur. Early clinically-significant radiation-
induced health effects are not likely unless individuals receive
doses exceeding 150 to 200 rad (1.5 to 2 Gy) to a substantial portion
of the body. Such effects may include ARS, with exposed individuals
exhibiting nausea, vomiting, fatigue, weakness, dizziness, disorien-
tation, fluid imbalance, impaired production of blood cells, and sup-
pression of the immune system, with increased risk of infection,
and, at very-high doses, possibly death. People who are very close
to the device for a significant time (e.g., hours) may also exhibit
local radiation injuries to the skin, such as redness and nonhealing
burns. Unless the deployment of an RED is announced by the ter-
rorists or the device is discovered by radiation detection instru-
ments, the only evidence of an RED may be people seeking medical
care for the signs and symptoms of ARS and perhaps radiation inju-
ries to the skin. Early symptoms of high radiation exposure may not
be recognized as an indication of radiation exposure unless medical
personnel are specifically trained to include that in their diagnostic
process. Vomiting is a sensitive prodromal (early) symptom of ARS
12 / 2. INTRODUCTION

and the time from exposure to the onset of vomiting has been
used successfully to estimate the seriousness of the radiation dose
[>100 rad (1 Gy)] received by individuals. However, vomiting can
also be caused by many more common conditions including severe
psychological stress. When the cause is a high radiation dose, indi-
vidual variability in time-to-vomiting is considerable and thus
it may serve only to provide upper and lower limits of the dose
actually received (Goans and Waselenko, 2005). Because of the pro-
tracted radiation exposure caused by an RED, ARS-associated vom-
iting may not occur as soon after exposure or at dose levels as
happens from prompt short-term exposures at similar dose levels.
Most dose estimates for radiation-induced vomiting are based on
the latter scenario (Goans and Waselenko, 2005). Beyond the early
health effects noted above, long-term health effects of an RED
include an increased risk of developing late radiation effects includ-
ing cancer.

2.6.1.3 Deliberate Contamination of Food, Water or Consumables.

The deliberate contamination of food, water, or other consumables
with radioactive material is another possibility for an attack. This
could range from contamination far from the point of consumption
that could potentially affect a large number of people, but with only
very small quantity of radioactive material being consumed by any
individual, or contamination close to the point of consumption,
which would likely affect fewer people, but with a larger quantity
of radioactive material being consumed by each individual.

2.6.1.4 Dispersal of Radioactive Material from Fixed Radiological

or Nuclear Facilities or Materials in Transit. For localities with
fixed radiological or nuclear facilities that already have emergency-
response plans in place for accident scenarios and unplanned
releases of radioactive material, the emergency response to an
attack or sabotage of such facilities is similar to the response neces-
sary for an RDD. The general response plan to transportation acci-
dents involving any HAZMAT would be adequate for the initial
response to sabotage of any quantity of radioactive material in rou-
tine transport. All such plans should consider that such incidents
could be a terrorism incident or an accident.

2.6.2 Improvised Nuclear Device

In the past, most civil defense scenarios from the Cold War
involved an exchange of large numbers of high-yield thermonuclear
weapons. Today, the most likely terrorism nuclear weapon scenario
 2.6 TYPES OF RADIOLOGICAL INCIDENTS / 13

involves the use of a single, probably low-yield fission device. A

nuclear weapon could be constructed from stolen nuclear weapon
components or fabricated de novo from fissile material (e.g., 239Pu
or uranium highly enriched in 235U). This type of device is referred
to as an improvised nuclear device (IND). Alternatively, a nuclear
weapon could be stolen, bought, or otherwise obtained from a state
with nuclear weapon capability. The effects of these devices are dis-
cussed in NCRP Report No. 138 (NCRP, 2001) and NCRP Commen-
tary No. 19 (NCRP, 2005). Glasstone and Dolan (1977) treat
nuclear weapons and their effects in detail.
A nuclear terrorism incident would result in large-scale conse-
quences to public health and safety. The effects in the immediate
area of the nuclear terrorism incident would be catastrophic and
the emergency-response support capability in the immediate area
would likely be destroyed or severely compromised. Response units
in areas of heavy fallout within 10 to 20 miles (~15 to 30 km) of
the detonation site may be sheltered for several hours to protect
themselves from potentially lethal levels of radiation. Unlike the
response to an RDD where the local response infrastructure is gen-
erally unaffected, emergency response to a nuclear terrorism inci-
dent would be from outside the region immediately impacted by the
detonation.
Blast effects from a nuclear terrorism incident would include
blown-in windows and doors; overturned vehicles; collapsed build-
ings; ruptured surface and subsurface utilities such as electric
power, gas and water mains; collapsed tunnels; and loss of major
communication facilities. Blast injuries to people would include lac-
erations and contusions from flying glass and other debris, crush
and other traumatic injuries, and broken bones.
Thermal effects are caused by the emission of ultraviolet, infra-
red, and visible electromagnetic radiation from the explosion and
would most likely lead to structural fires over a wide area. Thermal
effects to humans would include temporary and permanent blind-
ness, and skin burns.
Early health effects are caused by prompt x rays, gamma rays,
and neutrons emitted from the point of detonation and from resid-
ual beta and gamma radiation from the subsequent fallout after
the nuclear terrorism incident. These effects manifest themselves
in signs and symptoms determined by the radiation dose received
by each person. Effects from very-high radiation doses may include
some or all of the following: nausea, vomiting, fatigue, weakness,
dizziness, disorientation, fluid imbalance, impaired production of
blood cells, suppression of the immune system with increased risk
of infection, and, death. These observed symptoms depend on the
14 / 2. INTRODUCTION

total absorbed dose and the dose rate at which it is delivered. The
time to onset of these symptoms will be a function of the absorbed
dose as well as the health and ages of the individuals exposed.
Those people exposed to sublethal levels of radiation may have an
increased risk of developing cancer. A discussion of biodosimetry
can be found in Section 7.7.2.
Radioactive fallout will contaminate the environment and the
exteriors of buildings and unsheltered people, food and water. Exten-
sive radioactive fallout is produced by surface and near-surface
nuclear detonations. For air bursts at a sufficient altitude, the fis-
sion products and activated materials from the device may be so
widely dispersed and carried away by winds that there will be little
local fallout. Fallout contains many radionuclides with a wide range
of half-lives. Because of this, the intensity of the radiation from fall-
out is highest and most dangerous initially; the intensity of the radi-
ation decreases rapidly in the first minutes and hours after fallout
deposition and decreases more gradually as time progresses.
A nuclear detonation creates an electromagnetic pulse (EMP)
that may damage electrical and electronic equipment, and render
some of it unusable either temporarily or permanently. EMP effects
differ significantly as a function of the height of the nuclear deto-
nation above the ground and the effects are not easily predicted.
3. Key Radiation
Protection Principles

Radiation protection emergency-response plans must be in

place before an incident to effectively manage the aftermath of
radiological or nuclear terrorism. These include local and regional
policies for:

• establishment of control zones:

- hot zone; and
- dangerous-radiation zone.
• protecting people:
- recommendations for members of the general public;
- recommendations for emergency responders; and
- recommendations for public health and medical personnel.

These policies should be established, codified and promulgated

to all agencies that have roles in response to radiological or nuclear
terrorism incidents. Although national and state regulations exist
for routine (nonemergency) occupational exposures and control
zones, these regulations are not appropriate for emergency condi-
tions including radiological or nuclear terrorism incidents.
NCRP (2005) recommends an approach based on two actions:

• establishment of radiation control zones; and

• control of absorbed doses to individual emergency responders.

Radiation control zones divide the incident site into areas of differ-
ing levels of radiation risk where specific exposure controls can be
applied. The absorbed dose to each emergency responder governs
decisions regarding duration (stay time) for various emergency-
response activities.

3.1 Establishment of Control Zones

Establishing control zones is a quick way to delineate appropri-

ate protective actions for both the response community and mem-
bers of the general public before the incident is fully characterized.
For this reason, a key preincident preparedness action is to develop

15
16 / 3. KEY RADIATION PROTECTION PRINCIPLES

a process for defining control zones and to develop the protective

actions recommended within each control zone. Three zones are
defined:

• cold [outdoor exposure rate d10 mR h–1 (~0.1 mGy h–1 air-
kerma rate)];
• hot [!10 mR h–1 (~0.1 mGy h–1)]; and
• dangerous-radiation zone [t10 R h–1 (~0.1 Gy h–1)].

The last two are discussed more fully below.

3.1.1 Defining the Hot Zone

This Report adopts the control zone outer perimeter definition

described in NCRP Commentary No. 19 (NCRP, 2005), which is
consistent with the hot-line definition described in the ASTM Stan-
dard E 2601-08 (ASTM, 2008). NCRP also adopts the American
Society for Testing and Materials and National Fire Protection
Association terminology of the hot zone, which is defined as the
zone immediately surrounding a HAZMAT incident that extends
far enough to minimize deterministic effects and reduce the risk of
stochastic effects from the HAZMAT to personnel outside the zone
and is demarcated by the hot line. In addition, this Report provides
amplifying information on initial actions and implementation of
control zones and the recommended actions for emergency
responder and public safety within the control zones.

Recommendation: Establish the hot zone boundary if any of

the following exposure rate or surface contamination levels is
exceeded:

• 10 mR h–1 exposure rate (~0.1 mGy h–1 air-kerma rate);

• 60,000 dpm cm–2 (1,000 Bq cm–2) for beta and gamma
surface contamination; and
• 6,000 dpm cm–2 (100 Bq cm–2) for alpha surface contami-
nation.

It is important to recognize that boundaries are not to be deter-

mined precisely [e.g., a boundary approximating 10 mR h–1
(~0.1 mGy h–1) can be established for an instrument reading
between 5 mR h–1 (~0.05 mGy h–1) and 20 mR h–1 (~0.2 mGy h–1) as
these readings are essentially equivalent from the standpoint of
health risk and operational flexibility]. Where practical, the hot
 3.1 ESTABLISHMENT OF CONTROL ZONES / 17

zone boundary should be established to match physical boundaries

(e.g., streets and fences) that are close to the radiation levels iden-
tified above. There is a discussion on how to convert counts per
minute to disintegrations per minute in NCRP Commentary No. 19
(NCRP, 2005) that will be useful when discussing methodologies for
making measurements that will establish the boundary for the hot
zone.
In addition, it will be necessary to perform an all-hazards
assessment of the incident site and establish the control zones for
the worst hazard(s) identified. Examples of other possible hazards
include:

• unstable structures;
• fires;
• chemical, biological, and other toxic material hazards;
• damage to transportation infrastructure (e.g., roads, rails,
tunnels);
• damage to the electrical power system;
• natural gas releases from ruptured lines;
• water supply interruptions; and
• other terrorism actions (e.g., improvised explosive devices).

3.1.2 Defining the Dangerous-Radiation Zone

Within the hot zone, a dangerous-radiation zone should be

established where and if the exposure rate reaches 10 R h–1
(~0.1 Gy h–1 air-kerma rate). Exposure and activity levels within
the dangerous-radiation zone have the potential to cause early
health effects if doses to people are not controlled and thus actions
taken within this area should be restricted to time-sensitive, mis-
sion-critical activities such as lifesaving (NCRP, 2005). The use of
the term dangerous-radiation zone in the context of this Report,
based only on radiation levels, is not meant to preclude that other
significant nonradiological hazards might exist. Emergency
responders should always be vigilant as to the existence of all haz-
ards that could impact life safety. People may also be excluded from
an area because it has been designated as a crime scene.

Recommendation: Actions taken within the dangerous radi-

ation zone (i.e., exposure rate t10 R h–1 (~0.1 Gy h–1 air-kerma
rate) should be restricted to time-sensitive, mission-critical
activities such as lifesaving.
18 / 3. KEY RADIATION PROTECTION PRINCIPLES

Emergency responders who enter the hot zone should be

equipped with radiation monitoring equipment that provides unam-
biguous alarms, based on predefined levels, to facilitate decision
making. It is recommended that the instrument alarm when the
exposure rate reaches 10 R h–1 (~0.1 Gy h–1), corresponding to
the recommended value for the perimeter of the dangerous-radia-
tion zone, and when the cumulative absorbed dose reaches the deci-
sion dose of 50 rad (0.5 Gy) (NCRP, 2005). The term decision dose is
discussed in Section 3.2.2.

3.2 Protecting People

There is a national and international consensus on the basic

principles that should be followed when undertaking decisions on
the protection of people against radiation exposure in the after-
math of a radiological or nuclear terrorism incident (IAEA, 2005;
ICRP, 2005; NCRP, 2001). These principles, which apply to both
emergency responders and members of the general public, can be
summarized as follows:

• Undertaking protective actions should be justified to ensure

that they produce more good than harm; in the aftermath of
an incident, it is not always mandatory to intervene with
protective actions.
• If the intervention with protective actions is justified, these
actions should be optimized to select the best protective
options under the prevailing circumstances.
• Decisions on justification and optimization should also con-
sider individual doses so that these do not exceed levels
established before an incident occurs:
- emergency responders [i.e., firefighters, police, and emer-
gency medical services (EMS) personnel];
- medical and public health personnel;
- comforters (i.e., those citizens who provide support to
emergency responders after an incident), care givers, and
other volunteers; and
- members of the general public.

In addition to the international consensus on general principles,

NCRP also recognizes that during a radiological or nuclear emer-
gency, where conditions are extreme, routine exposure control con-
cepts are not directly applicable because of the potential for doses of
much greater magnitude than those that radiation workers or emer-
gency responders normally accrue. However, the general principle
 3.2 PROTECTING PEOPLE / 19

of optimization can be used during extreme emergency situations.

In these instances, applying the principle of optimization can be
viewed as making every reasonable and practical effort to both
maintain doses to radiation below the levels causing early health
effects, and to reduce the risk of stochastic effects, so as to maximize
lifesaving and protection of critical infrastructure (Musolino et al.,
2008).
The potential benefits from the actions emergency responders
take and the exposures they receive should be considered, judged
on a case-by-case basis, and take into account the risks that would
be incurred. During these types of emergencies, it may be allowable
to expose personnel to high doses of radiation, but then the primary
goal should be to ensure that early health effects are avoided and,
as a secondary goal, that the risk of stochastic effects is minimized.
Beyond keeping emergency responders below levels of dose that
will cause early health effects, the incident commander will apply
optimization principles.3 These principles apply equally as well
when used to control doses to personnel during emergencies as they
do in routine operations (Musolino et al., 2008).

3.2.1 Recommendations for Members of the General Public

Current federal public protection guidance is based on the con-

cept of dose avoided. For example, Table 8.5 of NCRP Report
No. 138 (NCRP, 2001) identifies actions that should be considered
based on averted exposures. In the initial minutes to hours of a
radiological or nuclear terrorism incident, it will be difficult to pre-
dict public exposure, identify appropriate actions to avoid expo-
sures, inform members of the general public, and execute the
protective actions.

3For example, the incident commander can optimize the dose to per-
sonnel by distributing the work among several individuals [i.e., 10 emer-
gency responders each receiving 10 rad (100 mGy)], instead of one person
receiving 100 rad (1 Gy), or by controlling the numbers of emergency
responders undertaking a given function to minimize the overall collec-
tive dose. When large areas are highly contaminated, the incident com-
mander can justify the authorization that emergency responders may
receive doses up to 50 rad (500 mGy) or greater to rescue injured victims,
but might not so authorize to protect property. DHS Protective Action
Guides (DHS, 2008), allows the incident commander to exercise judgment
on implementing the decision points (i.e., continue lifesaving, and/or pro-
tect property), if the decision dose must be exceeded to complete a task or
the overall mission (Musolino et al., 2008).
20 / 3. KEY RADIATION PROTECTION PRINCIPLES

Recommendation: NCRP recommends that the initial public

protective action for both radionuclide dispersion incidents and
nuclear detonations be early, adequate sheltering followed by
delayed, informed evacuation. Until the level and extent of con-
tamination can be determined, efforts should be made to avoid
being outdoors in potentially-contaminated areas.

3.2.2 Recommendations for Emergency Responders

Recommendation: NCRP does not recommend a dose limit

for emergency responders performing time-sensitive, mission-
critical activities such as lifesaving. Instead, decision points
should be established by the incident commander based upon
operational awareness and mission priorities.

The recommendation above is consistent with existing national

and international guidance reviewed which identifies the condi-
tions and activities in which higher levels of dose may be war-
ranted. In all cases, appropriate measures should always be taken
to keep doses to individual emergency responders as low as reason-
ably achievable (the ALARA principle), given the situation and
response objectives. This can be accomplished by minimizing the
time spent in hazardous areas, wearing appropriate personal pro-
tective equipment (PPE), staff rotation, and establishing dose and
dose-rate decision points.
As an example, let us suppose there is a nearby child daycare
facility with young children. After assessing the situation, it is
determined that there are injured people inside the facility, some
damage to the structure, and the dose rates outside the facility are
~10 rad h–1 (100 mGy h–1). In this case, emergency responders may
have to work for an extended time and could receive large doses in
rescuing and providing first aid to the victims while evacuating
uninjured children. Since there are many persons whose lives are
at risk in this situation, the incident commander would certainly
choose to protect these people’s lives despite the fact that the emer-
gency responders may receive absorbed doses greater than occupa-
tional limits. Provided that their absorbed doses are below the
threshold for ARS, the incident commander might use 5, 25, and
50 rad (50, 250, and 500 mGy) or more as decision points (not lim-
its) to control total dose (NCRP, 2001). With respect to protecting
 3.2 PROTECTING PEOPLE / 21

property, the incident commander sometimes may decide to con-

tinue fire suppression even though radiation levels are high. A case
in point might be a fire in a building that threatens an adjacent
critical facility, such as an electric power substation, the destruc-
tion of which could entail large-scale societal disruption from the
loss of electrical power (Musolino et al., 2008).
There are a number of resources available that can be used to
establish recommendations and criteria for managing emergency-
responder doses. The recently published Planning Guidance for
Protection and Recovery following RDD and IND Incidents (DHS,
2008) modifies previously issued guidance from the U.S. Environ-
mental Protection Agency (EPA, 1992) by providing a description of
justification for approaching or exceeding 50 rad (0.5 Gy) to a large
portion of the body in a short time (an early exposure). Both NCRP
(1993) and the Conference of Radiation Control Program Directors
(CRCPD, 2006) recommend a 50 rad (0.5 Gy) decision dose to eval-
uate whether or not to remove personnel from continuing lifesaving
operations. IAEA (2006) recommends 100 rem (1 Sv) personal dose
equivalent (at 10 mm) (see Glossary) for lifesaving efforts and
ICRP (2005) places no cap on lifesaving. In all cases, emergency
responders should be made fully aware of the risks of both early
and late (cancer) health effects from such large doses. The provi-
sion of this information to emergency responders is discussed later
in this section.

Decision point: NCRP recommends, when the cumulative

absorbed dose to an emergency responder reaches 50 rad
(0.5 Gy), a decision be made on whether or not to withdraw the
emergency responder from the hot zone. NCRP considers
the 50 rad (0.5 Gy) cumulative absorbed dose a decision dose,
not a dose limit.

NCRP identified the decision dose of 50 rad (0.5 Gy) with the
assumption that additional dose would be accumulated as the emer-
gency responder withdrew from the area (NCRP, 2005). If warranted
by the mission and circumstances, continuing the mission could be
a legitimate decision even after an emergency worker receives the
50 rad (0.5 Gy) decision dose. The 50 rad (0.5 Gy) decision dose was
developed in an effort to keep an emergency responder’s individual
dose from unintentionally surpassing 100 rad (1 Gy), below which
clinically-significant early health effects are not likely to occur.
Early health effects are not likely unless individuals receive doses
22 / 3. KEY RADIATION PROTECTION PRINCIPLES

exceeding 150 to 200 rad (1.5 to 2 Gy) to a substantial portion of the

body. Such effects may include ARS, with exposed individuals exhib-
iting nausea, vomiting, fatigue, weakness, dizziness, disorientation,
fluid imbalance, impaired production of blood cells, and suppression
of the immune system with increased risk of infection, and at very-
high doses, possibly death.
While exposing emergency responders to an additional dose at
a subsequent incident without regard for the elapsed time between
events is discouraged, in some instances it may not be possible. In
those instances where a response is required utilizing emergency
responders who had received a previous dose, the incident com-
mander may allow emergency responders to receive an additional
dose using the same criteria as for all other emergency responders.
When possible, taking into account their other duties, and par-
ticularly when first entering an area, emergency responders should
measure and report the exposure rates. This will help the emer-
gency responders and their incident commanders identify and
avoid areas of extremely high exposure rates and identify low expo-
sure rate locations that may be used as staging areas. This will also
assist the emergency responders and their incident commanders in
controlling emergency responder exposures, determining the rough
profile and extent of the radionuclide contamination, redefining the
radiological hazard zone boundaries, and characterizing the overall
incident.
Many federal agencies including EPA, the U.S. Nuclear Regu-
latory Commission (NRC), the Occupational Safety and Health
Administration, U.S. Department of Energy (DOE), and many other
expert advisory organizations recommend that emergency workers,
whose duties during a radiological or nuclear terrorism incident may
entail exceeding occupational dose limits (occupational dose limits
are not applicable by law or regulation to emergency situations), do
so as volunteers who have been provided information on the health
risks of such exposures to allow them to make informed decisions
(DHS, 2008; IAEA, 2006; ICRP, 2005; NCRP, 2001; 2005). However,
NCRP recommends that, to the extent practical, informed consent
of such emergency workers be obtained in advance of a radiolog-
ical or nuclear terrorism incident and not when such an incident
occurs. For individuals who are expected to perform as emergency
responders (e.g., firefighters, police, and EMS personnel), these
responsibilities should be identified in job descriptions, conditions of
employment, and other employment-related documents, as appro-
priate, and included in routine training and qualification. By doing
so, these emergency workers will be provided with information on
the potential health consequences of such exposures to allow them
 3.2 PROTECTING PEOPLE / 23

to make informed decisions before the radiological or nuclear terror-

ism incident. Details of both the responsibilities of the employer and
the emergency responder are discussed in Appendix A.

3.2.3 Recommendations for Public Health and Medical

System Personnel

Healthcare workers at hospitals and other medical facilities and

public health system personnel, who may encounter contaminated
victims of a radiological or nuclear terrorism incident for the
purpose of treatment or assessment, are sometimes referred to as
“first receivers” (Koenig, 2003; OSHA, 2005). NCRP considers such
workers to be a category of emergency responders (NCRP, 2005). As
is the case for other emergency responders, and because of their
important roles in the response to a radiological or nuclear terror-
ism incident, NCRP recommends that the doses to these workers
not be subject to dose limits. However, experience has shown that
medical workers providing care to the contaminated victims of a
radiological terrorism incident are unlikely to exceed the occupa-
tional dose limits for a radiation worker. Medical personnel near
the Chernobyl nuclear reactor accident who treated contaminated
workers accumulated doses <1 rad (10 mGy) (Mettler and Voelz,
2002).

3.2.4 Building Design and Construction

Building design and construction will play an important part in

ensuring occupant safety after a radiological or nuclear terrorism
incident. For example, a building designed for earthquake resis-
tance is far more likely to survive the shock of a nuclear terrorism
incident, and the higher standards for windows for hurricane pro-
tection in many coastal states may reduce injuries from broken
windows. Building ventilation systems can incorporate features,
such as filters, that protect occupants from outside HAZMAT.
When a new public building is designed in a major metropolitan
area or surrounding community, consideration should be given to
building codes or design elements that help reduce potential blast
effects and can help protect occupants from external hazards, par-
ticularly the radiation from fallout that might be deposited outside
and on the building after an IND detonation. This recommendation
applies particularly to buildings that will be directly involved in
emergency response, such as fire, police, and EMS stations; emer-
gency operations centers (EOCs); emergency dispatch centers; and
hospital EDs.
24 / 3. KEY RADIATION PROTECTION PRINCIPLES

3.2.5 Building Ventilation Systems

Recommendation: Methods to control ventilation systems in

office/large apartment buildings should be considered as this
action could reduce the inhalation dose to persons sheltering
inside.

Ideally, the prompt shutdown and isolation of the air intake to a

large urban building for 60 min post-release would reduce the inha-
lation of radionuclides by the occupants of the building. This action
would also reduce the contamination of the components of the ven-
tilation system. For this countermeasure to be effective, it would
require the operator of the building to promptly be aware or notified
that a radionuclide is associated with an explosion or have an auto-
matic system with a radiation sensor. If the building is not equipped
with a radiation detector, it is not likely that the management will
know there is airborne activity in less than 10 min. In addition,
most buildings do not have the ability to shut down an entire
ventilation system with the push of a button. Conversely, in some
circumstances, the efficiencies of the filters can be significant,
removing greater than 90 % of the radionuclide, depending on the
particle size, the condition of the filter, and its design (Musolino and
Harper, 2006). It is advisable to keep away from the contaminated
filters and not access their enclosures until health authorities per-
form a radiological assessment (Musolino and Harper, 2006).
Even if the building ventilation system can be promptly isolated,
atmospheric conditions still could result in unfiltered air flowing
into the structure from pathways that are normally secondary or
precluded when the ventilation system is in routine operation.
Therefore, for this countermeasure to be effective an engineering
analysis of the ventilation system should be performed.
4. Response-Plan
Development and
Implementation

Decision makers will encounter many challenges in a radiologi-

cal or nuclear terrorism incident. Many of these challenges will not
be specific to response to a radiological or nuclear terrorism inci-
dent, such as law enforcement, security, and potential other possi-
ble terrorist threats such as improvised explosive devices. This
Report will primarily address the key issues common to both radio-
logical and nuclear terrorism incidents and identify the key ele-
ments that must be considered and addressed in a response plan
for both types of incidents.
Emergency planners should review and augment existing plans
and related documents necessary for achieving preparedness for a
radiological or nuclear terrorism incident. Important elements of
a response plan include hazard analysis, notifications, establish-
ment of radiological control zones, emergency-responder decision
doses, recommendations for managing emergency-responder dose,
and a decontamination plan for members of the general public.
Communications should also be addressed. It is critical to be able
to communicate.
Methods and processes need to be developed to transfer informa-
tion from the incident scene to appropriate local and state agencies.
This includes determining what equipment (telephone, fax, email
and radio) is available at each location. Processes are then needed
for these agencies to coordinate their response activities and public
communications. Testing and practicing these processes and meth-
ods should be included in all drills and exercises. Other necessary
preparations include ensuring the availability of equipment such
as radiation detection and monitoring equipment, dosimeters, PPE
and replacement clothing; performing training; and conducting
exercises.
4.1 Federal Guidance
Following the September 11, 2001 attacks, more urgent efforts
were made to implement common incident management and
response principles for terrorism incidents. In the United States,

25
26 / 4. RESPONSE-PLAN DEVELOPMENT AND IMPLEMENTATION

the National Response Framework (NRF) describes how an all-haz-

ards response should be conducted. It is built upon scalable, flexi-
ble and adaptable coordinating structures to align key roles and
responsibilities across the nation (FEMA, 2008a). It describes spe-
cific authorities and best practices for managing incidents that
would include large-scale terrorist attacks and catastrophic natu-
ral disasters.
One of the key elements supporting NRF is the Nuclear/Radio-
logical Incident Annex (NRIA) (FEMA, 2008b) which describes the
policies, concepts of operations, and responsibilities of the federal
departments and agencies governing the immediate response and
short-term recovery activities for incidents involving release of
radioactive material from inadvertent or deliberate acts. NRIA
applies to two categories of radiological or nuclear terrorism
incidents:
• inadvertent or otherwise accidental releases; and
• releases caused by deliberate acts such as radiological or
nuclear terrorism incidents.

These incidents may include the release of radioactive material

that poses an actual or perceived hazard to public health, safety,
national security, and/or the environment.
The National Incident Management System (NIMS), which
complements NRF, provides standard command and management
structures that apply to response activities (FEMA, 2008c). NIMS
provides a consistent, nationwide template to enable federal,
tribal, state, regional and local governments, the private sector,
and nongovernmental organizations to work together to prepare
for, prevent, respond to, recover from, and mitigate the effects of
incidents regardless of cause, size, location or complexity.
Supplementing DHS guidance, the Executive Office of the Pres-
ident released Planning Guidance for Response to a Nuclear Deto-
nation (EOP, 2010). This interagency publication provides guidance
and recommendations for public and emergency responder actions
in the event of an urban nuclear detonation. The DHS/Federal
Emergency Management Agency (FEMA) Planning Guidance
adopted the use of EPA’s Early and Intermediate Phase Protective
Action Guides (PAGs) for RDDs and INDs, and provided an optimi-
zation process to develop cleanup goals in the late phase of an RDD
or IND response.
U.S. requirements for food and water restrictions differ from
international guidance discussed later in this Report. A contamina-
tion incident caused by the use of an RDD or an IND would direct
the emergency responders to current RDD and IND guidance
 4.2 ROLES AND RESPONSIBILITIES / 27

(DHS, 2008). This guidance refers to the 1998 FDA recommenda-

tions and EPA proposed drinking water PAG, both guidelines rec-
ommend no more than 0.5 rem (5 mSv) effective dose to members
of the general public during the first year after the incident. FDA
has regulatory authority when products enter into, or are intended
for interstate commerce. The regulation, which allows local, state
and tribal authorities to detain products, refers to “adulteration” by
some contaminant, but is not specific for radionuclides. In specific
cases, FDA uses policy guidance and has adopted EPA derived
intervention levels as a trigger (not a regulatory limit) for interdic-
tion. FDA also has authority, under the Public Health Service Act,
to interdict the movement of food as a precautionary measure when
a Public Health Emergency has been declared (FDA, 1998).
Under the Safe Drinking Water Act of 1974, EPA (1974) sets
national health-based standards for drinking water to protect
against both naturally-occurring and man-made contaminants
that may be found in drinking water. EPA, states, and water sys-
tems then work together to make sure that these standards are
met. After a radiological terrorism incident, the proposed drinking
water PAG may only apply for up to a 1 y time period during the
intermediate phase. The fact that PAGs for water are designed for
the intermediate phase, however, should not preclude reasonable
precautionary measures (e.g., closing water intakes and using
available stored water) during the early phase. The goal is to keep
the dose to members of the general public consistent with the
ALARA principle (EPA, 1974).

4.2 Roles and Responsibilities

It is important to understand the roles and responsibilities of
local, state, tribal and federal agencies. Response challenges result-
ing from radiological or nuclear terrorism incidents can quickly
overwhelm local, regional and state resources and requests for fed-
eral assistance should be anticipated.
Decision makers should recognize that, in the early phase of the
incident, state and federal resources will take time, perhaps days,
to arrive. Therefore, local organizations should be prepared to
assume all roles and responsibilities in the earliest phase of an inci-
dent, relying entirely upon local resources. The actions of local and
regional emergency responders within the first 2 h, particularly for
an RDD incident, will define the success of a response, and will sig-
nificantly influence the public’s confidence in their government’s
ability to provide an adequate response. In some incidents, local
organizations retain ultimate authority when state and federal
personnel arrive and should be prepared to direct and effectively
28 / 4. RESPONSE-PLAN DEVELOPMENT AND IMPLEMENTATION

utilize these resources, whereas in other situations command may

be transferred to incoming state and federal resources.
It is important to understand the relationships among existing
local, regional, state, tribal and federal response plans. Federal
agencies can and will begin to provide assistance remotely via
assets such as those listed in Table 4.1. NRIA (FEMA, 2008b) pro-
vided more information on federal assets that could be used
remotely or that could be en route to the incident within hours of
the incident to support local, state, and tribal authorities. Local
and regional planning authorities should determine the roles and
responsibilities of each organization that participates in response
to radiological or nuclear terrorism incidents (Resources for nuclear
and radiation disaster response (Maiello and Groves, 2006).
All potentially-affected organizations should jointly develop a
regional, multi-agency response plan to ensure the issues that each
organization will confront are addressed. Individual organizations
may have existing plans that address radiological or nuclear terror-
ism incidents (FEMA, 2008b). The individual plans should be com-
pared to remove conflicts and specify how the organizations will
share responsibilities. The plans should specify which organization
is in charge of each activity so that response will proceed efficiently.
These plans should be consistent with the Incident Command Sys-
tem model and NIMS (FEMA, 2008c).
The state radiation control program can be contacted for assis-
tance in developing a response plan. The most effective response
will occur if local agencies jointly prepare their plans. In addition,
once the plan is in place, agencies should conduct tabletop and field
exercises, critique the exercises, and revise their plans, through les-
sons learned, in advance of an incident.
Each agency and organization whose staff is likely to become
contaminated during a radiological or nuclear terrorism incident
should establish procedures for surveys and decontamination of
staff. This not only includes response organizations, such as fire,
police and EMS, but also hospitals and organizations whose per-
sonnel may perform surveys of members of the general public for
contamination.
Each organization should also establish procedures to limit the
spread of radionuclide contamination within its facilities, such as
fire stations, hospitals, buildings used for decontamination, commu-
nity reception centers (CRCs), and alternative medical treatment
sites (AMTSs). The procedures should recognize that contamination
control will likely not be possible during the early (emergency)
phase of an incident and that minor contamination of an area
should not prevent its use. However, reasonable attempts should be
TABLE 4.1—Partial list of federal assets available for a response to a radiological or nuclear terrorism incident
in the early phase.a
Asset Activation Process Services

RAP teams, FRMAC and other DOE • Call DOE Watch Office at • RAP provides initial radiological
assets (202) 586-8100. assessment and support to the inci-
• Requests for RAP teams may also be dent commander.
directed to the appropriate DOE • FRMAC coordinates all environmen-
Regional Coordinating Office. tal radiological monitoring, sampling,

4.2 ROLES AND RESPONSIBILITIES

and assessment activities for the
response.

IMAAC Call IMAAC directly at (925) 424-6465 Produces and disseminates the federal
or DHS National Operation Center consequence predictions for an
Watch at (202) 282-8101. airborne HAZMAT release.

Advisory Team for Environment, Food, Call the CDC Emergency Operations Develops coordinated advice on
and Health Center at (770) 488-7100. environmental, food, health, and
animal health matters.
aSee
Appendix E for a more complete list of DOE assets.

/ 29
30 / 4. RESPONSE-PLAN DEVELOPMENT AND IMPLEMENTATION

made to limit the spread of contamination. If an area, such as a

room in a hospital ED designated for the reception of contaminated
injured patients, becomes heavily contaminated, performing limited
decontamination of the area will reduce the doses received by people
working in the area and the spread of contamination to other areas.
Organizations with emergency-response vehicles, particularly
ambulances, should establish procedures regarding the decontam-
ination of vehicle interiors. The procedures should recognize that
complete contamination control will likely not be possible during
the early (emergency) phase of an incident and that minor contam-
ination of a vehicle's interior should not prevent or delay its use to
respond to emergencies. However, reasonable attempts should be
made to limit the contamination inside a vehicle. Methods for min-
imizing contamination of the interior of an ambulance include:

• removing the outer clothing of a contaminated patient

before loading the patient into an ambulance;
• placing two sheets on the gurney before placing a contami-
nated patient on the gurney; and
• folding the edges of the sheets over the patient.

Furthermore, reasonable attempts should be made to reduce the

amount of radionuclide contamination inside a vehicle after a task,
such as transportation of a contaminated injured patient to a hospi-
tal. These measures will reduce the doses received by people work-
ing in the vehicle.
In general, the removal of radionuclide contamination from out-
door areas is not an early (emergency) phase activity following a
radiological or nuclear terrorism incident. However, there may be
instances in which high dose rates from contamination deposited
by a plume of radioactive material will impede or prevent the use
of essential infrastructure, such as a fire station or a hospital ED.
In such cases, washing the roof, other horizontal surfaces, and
nearby paved areas with water may reduce the dose rate suffi-
ciently to permit use of the facility. This may require assistance
from the fire department and planning in advance of an incident.
Similarly, emergency vehicles with heavily contaminated exteriors
may be rendered usable by rinsing their exteriors with water. Dur-
ing lifesaving operations, do not waste valuable resources to con-
tain contaminated wash water.
 4.3 RESPONSE-PLAN REQUIREMENTS / 31

4.3 Response-Plan Requirements

Municipalities have been required by the Occupational Safety

and Health Administration (OSHA, 2006) to develop and maintain
emergency-response plans that address response to and manage-
ment of incidents involving HAZMAT releases. In the past, these
plans focused upon radioactive material released from transporta-
tion accidents and nuclear facilities rather than terrorism or other
malevolent incidents.
The emergencies described above usually are highly localized
releases with health risks to small numbers of people. Radiological
terrorism incidents can be expected to produce a much wider disper-
sion of radioactive material and pose potential health risks to larger
populations. This distribution of radioactive material over a greater
area and the possibility that explosives may be used to disperse the
material creates challenges that are very different from an acciden-
tal or nonmalevolent highly localized release.
As discussed in the next several sections, emergency planners
should determine the specific requirements and elements for a
response plan. The high level coordinated actions that should be
addressed in the plan include the following:

• identifying key agency roles and responsibilities in respond-

ing to a radiological or nuclear terrorism incident;
• developing a “continuity of operations plan” and alternate
emergency operations sites with a predetermined command
succession, communications links and staffing including
supplemental staffing as addressed in Section 7.11;
• describing how state and federal resources will be integrated
into the local/regional emergency management system;
• identifying redundant communication systems for public
messages immediately after a radiological or nuclear terror-
ism incident to provide clear, factual and timely guidance to
members of the general public;
• establishing a notification process to request state and fed-
eral resources;
• establishing a community plan that addresses the needs of
vulnerable populations (e.g., hospitals, child daycare centers,
prisons/jails, assisted living facilities, children at or en route
to school);
• making timely damage assessments and providing for resto-
ration of critical services, resources and infrastructure; and
• developing a recovery and restoration section of the plan to
manage long-term health and environmental issues and the
32 / 4. RESPONSE-PLAN DEVELOPMENT AND IMPLEMENTATION

local and state agencies that should be responsible for this

mission, including possible relocation of people and busi-
nesses.

Before an incident occurs, communication should be established

with the organizations listed in Table 4.1. This will be an important
planning step to ensure the coordination needed during the actual
incident response. The regional DOE Radiological Assistance Pro-
gram (RAP) teams, DOE Federal Radiological Monitoring and
Assessment Center (FRMAC), DHS Interagency Modeling and Atmo-
spheric Assessment Center (IMAAC), and EPA National Response
Team can assist in the development of response plans as well as sup-
port following a radiological or nuclear terrorism incident.

Recommendation: Designate regional situational assessment

centers [these may be established emergency operations centers
(EOCs)] that will collect and assess information from observa-
tions, instrument readings, weather, and computer modeling.

Communities should develop a complete list of entities to notify

following recognition that an incident may involve radiological or
nuclear terrorism. The contact lists should include subject matter
experts with radiation expertise. Discussions should be held in
advance with these subject matter experts to determine how best
their expertise could be used in the event of a terrorism incident
involving radioactive or nuclear material. State radiation control
program personnel and DHS advisors and relevant federal agen-
cies (e.g., DHS, DOE, NRC, and EPA) should be included as well.
Planners should assess the community’s requirements for radi-
ation detection and monitoring equipment, dosimeters, and spe-
cialized PPE. Instruments should be calibrated and maintained in
accordance with applicable standards, including recommended
maintenance schedules of both the manufacturers and professional
societies. FEMA (2002), NCRP (2005), and the American National
Standards Institute (ANSI, 2006a; 2006b) provide guidance on this
subject.

4.3.1 Hazard Evaluations

An evaluation of the hazards present in a work environment is

the basis for the safe completion of tasks in that environment. This
is true for planned special exposures that could result from inci-
 4.3 RESPONSE-PLAN REQUIREMENTS / 33

dents such as cleanup operations at a hazardous waste site (NRC,

1992). While all the hazards are not always known in advance,
a hazard evaluation should also be performed during an emergency
response to accidental and intentional release of HAZMAT.
While this Report focuses on radiation issues, planners should
consider all hazards. Standard procedures for assessing the scene
for all hazards should be used until the incident hazards are deter-
mined. In a terrorism incident, a secondary or follow-on attack is a
possibility and response plans should address this. Emergency
responders will follow their standard procedures for dealing with
an explosion, recognizing the possibility of other terrorist threats
such as improvised explosive devices during their response. Many
HAZMAT training programs for both private and public organiza-
tions develop and use a process to conduct this hazard evaluation.
One such example is “A-P-I-E” (analyze, plan, implement and eval-
uate) used by the International Association of Fire Fighters in their
HAZMAT training programs (NFPA, 2005). Whether this specific
one or another is used, it is the use of a process that is important.
This evaluation is an ongoing process of collecting information
that begins before the incident occurs, continues during the
response as new information is obtained, and stops after success-
ful response to the incident and a final after-action review has been
conducted. The information collected always begins with life haz-
ards to victims and emergency responders, the hazards and mate-
rials involved, and resources available and needed.
As an example, in a transportation accident involving radioac-
tive material in shipment, emergency responders not only collect
information on any trapped or injured victims and the identity of
the material and strength of the source, but they take an all-haz-
ards approach. This includes the stability of the vehicle, other
materials included in the load, fuel that may be leaking, downed
utility wires, uneven terrain, wind conditions and weather, to give
some examples. Emergency responders use this information to
determine the actions necessary to control the release, best PPE
to wear, and safest approach.
In a terrorism incident such as an RDD or IND, the same all-haz-
ards evaluation should be performed. Life safety is a primary con-
sideration with a large number of potential victims as well as the
risk posed by the release of radioactive material or a nuclear deto-
nation and fallout. There likely will be many other hazards present
and information should be collected quickly to conduct a hazard
evaluation. These may include: the modality of radiation exposure
(RED) or release of radioactive material (RDD, IND); blast damage,
building integrity, ruptured gas lines, broken glass, downed utili-
34 / 4. RESPONSE-PLAN DEVELOPMENT AND IMPLEMENTATION

ties; and damage to infrastructure including water systems and

roads, fires, motor vehicle accidents, general debris, radioactive
dust particles, hot spots, and fallout. The identity of the radionu-
clides present will be a critical piece of information to be collected to
make the best decisions on how to protect emergency responders
from the hazards of the radiation and will help the incident com-
mander in determining the appropriate response. This is an exam-
ple where preincident planning assistance provided by subject
matter experts will improve the local/regional early response. In
a radiological terrorism incident (RED, RDD), the radiation and
radioactive material may not be the most significant hazard to
emergency responders, whereas, after an IND detonation, the
radioactive fallout will likely be the most significant hazard impact-
ing large areas.

4.3.2 Decontamination of Members of the General Public

Regional plans should have a common strategy for personal

decontamination methods and priorities. This is especially impor-
tant for the injured, where inconsistent definitions and expecta-
tions among the emergency responders at the scene, ambulance
companies, and the hospital could delay critical medical care.
Detailed planning guidance for personal decontamination is
addressed in Sections 5.1, 6.6, and 7.6. The key point for radiologi-
cal terrorism is that external contamination of people is not likely
to pose an immediate danger to most contaminated individuals or
the emergency responders providing assistance. This reduces the
immediacy of the need for decontamination unless it is readily
available and allows the emergency-response community greater
flexibility in treating medical emergencies as well as selecting
decontamination options (NCRP, 2005). Response plans should
identify decision criteria and options for personal decontamination
for a variety of potential situations.

4.3.3 Control of Doses to Emergency Responders

There will be a variety of organizations involved in response to

radiological or nuclear terrorism incidents. All response agencies in
each locality or region should adopt similar radiation exposure pol-
icies (e.g., dose recommendations and decision doses) to ensure that
critical missions can be accomplished with personnel who have the
appropriate training and equipment. Section 3.2.2 provides recom-
mendations regarding policies and procedures for controlling doses
to emergency responders.
 4.3 RESPONSE-PLAN REQUIREMENTS / 35

4.3.4 Training and Exercises

Lifesaving is one of the primary responsibilities following an

RDD or IND terrorism incident. Training should emphasize the
fact that with proper preparation, effective lifesaving actions can be
taken after a radiological or nuclear terrorism incident, although in
the case of a nuclear terrorism incident, radiation levels will likely
preclude these efforts in large areas and not all emergency respond-
ers will be able to respond. Appropriate training and exercises can
describe the hazards that would endanger the lives of emergency
responders and members of the general public, and can minimize
risks to emergency responders while they are performing those
important lifesaving actions. Detailed training and exercise recom-
mendations can be found in NCRP Commentary No. 19 (NCRP,
2005).
All emergency responders should be trained initially at a level
corresponding to the duties and functions they would be expected
to perform. In addition to the emergency-responder community,
resource providers may be identified who should receive training
and participate in exercises. Programs should be developed that
include training for the staff as well as those outside the agency on
whom they depend for support including physicians and those
trained in radiation safety.
Training programs should include drills, exercises (including
table-top exercises), and a system to identify lessons learned
(FEMA, 2005). Refresher training should be given periodically and
at least every 2 y. It may be useful to have just-in-time training
modules available to be used at the time of an incident. For, exam-
ple, one of the most important “just-in-time” training modules is on
how to use radiation detection equipment. If emergency responders
do not use these instruments frequently, they may forget important
actions and how to use the different scales. Information relayed to
EOC could be in error by a factor of 10 or 100 if an emergency
responder does not adjust for the difference in scale, thereby mis-
leading the decision makers.
Training programs should incorporate the use of radiation
detection instruments and dosimeters to collect radiation data,
establish protective-action zones, and identify risk-benefit decision
points for incident commanders. Training programs would benefit
from the expertise provided by technical authorities for the purpose
of better understanding health and environmental recommenda-
tions (Brodsky et al., 2004). Using visual training tools, those con-
ducting training should define the zones based on damage and
36 / 4. RESPONSE-PLAN DEVELOPMENT AND IMPLEMENTATION

radiation levels defined in Sections 3 and 6. The following is a list

of the topics to be covered in this training:

• local incident command system policies;

• basic principles of radiation, radiation safety, and effects on
human health;
• protective-action guidance for emergency responders and
members of the general public;
• operation of specific types of radiation monitoring instru-
ments available to local emergency responders;
• analysis and integration of radiation monitoring instrument
data into basic incident command system or NIMS concepts;
• dose guidance;
• the hot zone and dangerous-radiation zone, and how to
establish operational working times based on radiation lev-
els encountered;
• for a nuclear terrorism incident, the methods and criteria
used to identify the light-, moderate- and severe-damage
zones (these are defined in Section 6);
• crime scene and evidence management;
• treatment and decontamination strategies and priorities;
and
• management of psychosocial issues.

4.4 Providing Information to

Members of the General Public

In a radiological or nuclear terrorism incident, a major chal-

lenge that could face response authorities is public fear and confu-
sion stemming, in part, from lack of understanding of radiation
hazards and a lack of awareness of appropriate protective actions.
The degree of success of a radiological or nuclear terrorism incident
response will depend in part upon the public’s awareness, prior to
an incident, of protective actions it can take. Public awareness and
use of protective measures such as sheltering will improve public
safety, reduce the demand for emergency-response resources, and
reduce response hindrances such as traffic congestion. These issues
should be addressed in a preincident public information program.
Effective preparedness before an incident also requires the
development of effective communication plans, including message
templates prepared before an incident for use during the incident,
and means to deliver the messages to those in the affected areas.
There is a considerable body of information dealing with effective
communication prior to or during a radiological emergency. For
 4.4 PROVIDING INFORMATION / 37

additional information on this subject the Centers for Disease Con-

trol and Prevention and NRC should be consulted (Becker, 2001;
2004; 2005; CDC, 2007b; EPA, 2007). Enough people should be
trained to communicate to members of the general public to meet
the predicted needs after an incident. A primary goal of radiological
terrorism would be to elicit fear in members of the general public.
A primary goal of a nuclear terrorism incident would be to kill and
injure many thousands of people, as well as elicit fear. There are
three main actions that will reduce the success of such a terrorism
incident:

• a prompt and effective response to an incident by local/

regional emergency responders in the first hours;
• provision of information to members of the general public
before an incident, so that they understand the likely risks
from such an incident, and the protective actions they
should take; and
• prompt and effective provision of information to members
of the general public after the occurrence of an incident
regarding the nature of the incident, the consequences to
members of the general public, and protective actions they
should take.

For an IND detonation in particular, an effective preincident

education program for members of the general public and prompt
and effective provision of messages soon after the incident would
likely save thousands of lives and reduce injuries of many more
people.

4.4.1 Preincident Public Information Program

Recommendation: In advance of an incident, planning officials

should work with local community leaders and the media to
inform members of the general public about preparedness plans
and protective actions members of the general public should
take following a radiological or nuclear terrorism incident.

Such a program should address, at a minimum, the following

topics:

• basic principles of radiation and its effects on health;

38 / 4. RESPONSE-PLAN DEVELOPMENT AND IMPLEMENTATION

• likelihood of this type of incident compared to other haz-

ards;
• similarities in preparedness actions for all-hazards planning;
• protective actions to be taken by members of the general
public if informed of a radiological terrorism incident;
• protective actions to be taken by members of the general
public if informed of a nuclear terrorism incident;
• planning and protective-action guidance for school and
workplace locations;
• media outlets that will carry accurate and timely official
incident information;
• guidance as to which local radio and television stations to
monitor; and
• community-specific topics such as location of shelters.

The public information campaign should occur at multiple lev-

els (e.g., teaching in schools, providing take-home messages to stu-
dents and employees, a local internet website, print distribution
such as in the local newspaper and telephone directory, and radio
and television public-service announcements). It will be helpful for
local public affairs specialists to partner with representatives from
the media in the development of the information to be distributed
because they have extensive experience in effective communication
for local populations. Furthermore, education of the media regard-
ing radiation, health effects of radiation, radiological or nuclear
terrorism incidents, and protective actions will help prepare the
media to provide members of the general public with accurate
information.

4.4.2 Preparing for Post-Incident Messages

Recommendation: Before an incident occurs, emergency

planners should prepare message templates to be provided to
members of the general public during the early (emergency
phase) of the incident.

Message templates should be prepared in anticipation of radio-

logical or nuclear terrorism incidents. This will greatly expedite
providing important information to members of the general public
and may help to reduce fear and inappropriate actions. The mes-
sages should answer the questions most likely to arise, such as:
 4.4 PROVIDING INFORMATION / 39

• Am I safe where I am?

• Is my family safe where they are?
• Is it safe to get my children from their school?
• If I think I’ve been contaminated with radioactive material,
what should I do?
• Is it safe for me to drink tap water?
• Is it safe for me to eat the food in my house or workplace?
• Is it safe for me to leave my house or workplace?
• How can I ensure the safety of my pet?
• Should I shelter or evacuate?
• Where should I shelter and for how long?
• Do I need to take further precautions because I have small
children, or because I am pregnant?
• What was the location of the incident?

Examples of post-incident messages for both radiological and

nuclear terrorism incidents are included in Appendix B (LA County,
2009). If a significant fraction of the population does not under-
stand English, the messages should be translated into the lan-
guages spoken. DHS Office of Health Affairs provides sample
messages that contain critical information for members of the gen-
eral public in the first hour and additional message templates are
available from the Centers for Disease Control and Prevention
(CDC, 2007b) and EPA (2007).

Recommendation: Plans should provide for establishing a

joint information center (JIC) and determining who will be the
primary spokesperson before and after a JIC is established.
These activities should be practiced in drills and exercises to
ensure they operate as designed.

Providing prompt, accurate and concise information to members

of the general public will be important during the response to an
incident. Initially, information will most likely come from a local
government official or designated public information officer. As the
incident response progresses past the first hours or days, and state
and federal resources arrive on-scene, a transition should occur
from the local public information officer to a JIC. Establishing a
JIC helps to avoid multiple spokespersons giving conflicting infor-
mation and guidance to the media and members of the general pub-
lic. It will be imperative to have at least one trusted official
spokesperson and avoid conflicting information from multiple offi-
40 / 4. RESPONSE-PLAN DEVELOPMENT AND IMPLEMENTATION

cial sources which may lead to confusion. Bringing many agencies

together to establish a JIC will be a challenge because most agen-
cies do not routinely work together on public information matters.
This challenge can be overcome through training and tabletop exer-
cises that bring the agencies together prior to an actual incident.
Local emergency management organizations should include the
use of the media in the public information program planning prior
to an incident. Multiple delivery methods, all providing the same
guidance, should be used. Reporters and media spokespersons
should be trained in common radiation terminology and know
where they can contact local authorities for accurate and timely
updates.

4.5 Mutual-Aid Agreements

Recommendation: It is strongly recommended that local,

regional, state and tribal governments and organizations
involved in response to a radiological or nuclear terrorism inci-
dent establish written mutual-aid agreements with each other
prior to such an incident.

For a large-scale radiological or nuclear terrorism incident, par-

ticularly an IND detonation, assistance from surrounding commu-
nities and perhaps even nearby states will be essential because
local resources will be insufficient. Mutual-aid agreements can be
effective tools to assist in sharing information, supplies, equipment
and personnel for the purpose of protecting public health. Local,
regional, state and tribal governments and private nonprofit orga-
nizations enter into mutual-aid agreements to provide assistance
to each other in the event of disasters and other emergencies. These
agreements usually are written, but occasionally are arranged
orally after a disaster or emergency occurs. Among other issues,
these agreements usually address liability and reimbursement.
States commonly have mutual-aid agreements with other
states. The Emergency Management Assistance Compact is a con-
gressionally-ratified organization that provides form and structure
to interstate mutual aid (NEMA, 2009). Through the Emergency
Management Assistance Compact, a disaster impacted state can
request and receive assistance from other member states quickly
and efficiently. NIMS maintains that states should participate in
mutual-aid agreements and establish intrastate agreements that
encompass all local jurisdictions (FEMA, 2008c; 2009).
 4.6 INTERNATIONAL AGREEMENTS / 41

4.6 International Agreements

A number of international agreements exist that could, in prin-

ciple, be applicable in the aftermath of terrorism incidents involving
exposure to ionizing radiation. Some of these international agree-
ments have been agreed upon by the U.S. government and may be
considered to be legally binding. Others have received the consent of
U.S. representatives and embody an international de facto commit-
ment. However, many only represent international scientific con-
sensuses on particular issues. Federal decision makers should plan
in advance whether and how to comply with these instruments.
International agreements could be applicable to consequences
arising from terrorist attacks that occur in locations under the
jurisdiction of the U.S. government, especially if the attack may pro-
duce consequences on places under jurisdiction of other national
governments. They could also be applicable in cases where a terror-
ist attack occurs outside the jurisdiction of the U.S. government, but
which may affect the U.S. territories.
The more important international agreements are the two Emer-
gency Conventions that have been ratified by the United States: the
Notification and the Assistance Convention (see below and Appen-
dix C). The Emergency Conventions assign specific response func-
tions and responsibilities to IAEA and the Parties, which include, in
addition to a number of countries, the World Health Organization
(WHO), World Meteorological Organization, and the Food and Agri-
culture Organization (FAO) of the United Nations. However various
international organizations have (by virtue of their statutory func-
tions or of related legal instruments) general functions and respon-
sibilities that encompass aspects of preparedness and response (i.e.,
WHO). WHO international health regulations requires interna-
tional notification of radiation emergencies [e.g., Member Countries
must notify WHO in a timely way of any threat that qualifies as a
public health emergency of international concern (whether infec-
tious, chemical, biological or radiological)]. In the United States,
CDC determines whether an emergency is a public health emer-
gency of international concern and the U.S. Department of Health
and Human Services (DHHS) notifies WHO (CDC, 2007a).
Pursuant to the obligations placed on it by the Emergency Con-
ventions, IAEA regularly convenes the Inter-Agency Committee on
the Response to Nuclear and Radiological Accidents, whose pur-
pose is to coordinate the arrangements of the relevant interna-
tional intergovernmental organizations for preparing for and
responding to nuclear and radiological emergencies. Currently its
members are representatives from the European Commission,
42 / 4. RESPONSE-PLAN DEVELOPMENT AND IMPLEMENTATION

European Police Office, FAO, IAEA, the International Civil Avia-

tion Organization, the International Maritime Organization, the
United Nations Scientific Committee on the Effects of Atomic Radi-
ation, the International Criminal Police Organization, the Nuclear
Energy Agency of the Organization for Economic Cooperation and
Development, the Pan American Health Organization, the United
Nations Environment Programme, the United Nations Office for
the Coordination of Humanitarian Affairs, the United Nations
Office for Outer Space Affairs, WHO, and the World Meteorological
Organization. It is chaired by IAEA and meets periodically. The
United States is a Member State of all these organizations except
the European Commission and the European Police Office.
The relevant international agreements can be classified as:

• legally-binding international obligations (i.e., de jure com-

mitments, which are usually expressed in “international
conventions”);
• international de facto commitments, which are usually
described in “basic safety standards;” and
• international scientific consensuses, which are explained in
publications such as “international estimates” or “interna-
tional recommendations.”

Appendix C describes in more detail the relevant interna-

tional instruments and the obligations that can arise from their
application.
The purpose of these agreements is to arrange for notification of
other countries when an incident occurs. Decision makers at the
local and state level likely will not be involved, since the U.S.
Department of State has responsibility for making formal notifica-
tions. However, some states that border on Mexico or Canada may
develop relationships with their counterparts, which can come into
play in an incident. This is particularly important if a nuclear ter-
rorism incident occurs whose effects will almost certainly extend
beyond the borders of the country.
Appendix D describes and addresses issues that arise from con-
sumer products being transported between countries after a radio-
logical or nuclear terrorism incident.
5. Radiological Terrorism
Incident

5.1 Radiological Terrorism Incident Response Plan

As discussed in Section 2.6.1, some forms of radiological terror-

ism may not be known at the time of occurrence whereas other inci-
dents, such as an explosive dispersal of radioactive material, may be
obvious shortly after the explosion and may result in a variety of
injuries that require emergency medical care. Preincident planning,
therefore, should consider situations where the knowledge that
there are victims unfolds slowly as well as those caused by an explo-
sive dispersal. When there are victims who require urgent medical
care, the first priority of the emergency responders is rescue and
lifesaving medical treatment, taking precautions to protect them-
selves from other hazards, particularly secondary terrorist attacks.

Recommendation: Medical emergencies and lifesaving take

priority over radiological monitoring and the concern for the
presence of radionuclide contamination. Radiation monitoring
equipment, although desirable, is not required to begin lifesav-
ing operations.

The planning should clearly recognize that the radiation levels

are unlikely to be immediately life threatening to emergency
responders, unlike those expected from a nuclear terrorism inci-
dent. Monitoring of radiation levels should be initiated as soon as
possible.

Recommendation: The geographic deposition of the radionu-

clide on the ground should be estimated initially from field
measurements with instrumentation and displayed on a map;
additional measurements should be made as soon as possible to
improve the data quality of this map. Data collection and man-
agement should be a coordinated joint task by all agencies who

43
44 / 5. RADIOLOGICAL TERRORISM INCIDENT

will respond with monitoring equipment: DOE Radiological

Assistance Program (RAP), Federal Radiological Monitoring
and Assessment Center (FRMAC), EPA on-scene coordinators,
EPA special teams, and other local, regional, state and federal
resources.

The radiological terrorism incident response plan should set the

second highest priority after lifesaving actions as beginning to map
the footprint of the dispersal using radiation monitoring equip-
ment. The plan should provide for coordination between all agen-
cies that will respond with monitoring equipment to jointly develop
plans before an incident to obtain, collect and map this information.
This map will identify “hot spots” and “protective zones” and help
the emergency responders reduce doses to themselves and others.
Furthermore, mapping of the area will assist in defining the mag-
nitude of the incident and developing evacuation plans. Field data
can be converted to a dose assessment of the affected populations if
these data can be rapidly collected and provided to local subject
matter experts, if available, and early responding outside resources
such as National Guard civil support teams, RAP regional teams
and Consequence Management Home Team (CMHT), and IMAAC.
The response plan should coordinate all the various local/
regional agencies with radiation monitoring capability (e.g., fire,
HAZMAT, police, and EMS) to report data to a regional assessment
center for consolidation and analysis. From this regional assess-
ment center, these data should be shared within the Unified Com-
mand if established and to the extent possible with the state EOC,
DOE CMHT, and the regional RAP team. CMHT can respond
within 1 h during normal business hours and 2 h after close of busi-
ness. When activated, the coordinator establishes a telephone
bridge and can invite local, regional, state, tribal and federal agen-
cies to participate in the call. Additionally, an assessment scientist,
geographic information system scientist, and web administrator
may join the call and prepare for requests for assistance.
In addition to the state EOC, DOE Consequence Management
Response Team (CMRT), and RAP assets can jointly provide remote
health-physics support and dose assessments in real-time to the
local health officials making protective-action decisions for emer-
gency responders and members of the general public. Planning in
advance for the use of these and other capabilities will greatly
enhance the effectiveness of the local response in the first few crit-
ical hours. See Appendix E for more information on the DOE radio-
logical emergency-response assets.
 5.2 RADIOLOGICAL TERRORISM INCIDENT HAZARD ZONES / 45

Recommendation: DOE regional coordinating office should

be involved in the development of plans, tabletop exercises, and
field exercises for the early (emergency) phase to ensure Radio-
logical Assistance Program (RAP) and Consequence Manage-
ment Home Team (CMHT) support during the first critical
hours of the incident.

5.2 Radiological Terrorism Incident Hazard Zones

Section 3 provides NCRP recommendations for defining the hot

zone and dangerous-radiation zone based on radiation measure-
ments at the scene. However, an RDD incident is not likely to pro-
duce a large dangerous-radiation zone in terms of the exposure rate.
While a large source of radioactive material that is poorly dispersed
may cause exposure rates >10 R h–1 (~0.1 Gy h–1 air-kerma rate) in
a limited area, this would be treated like any large spill of HAZMAT.
As such, the area is generally manageable by the emergency
responders as opposed to a dangerous-radiation zone from a nuclear
terrorism incident, which will be a much larger area. The initial hot
zones can be established with only qualitative measurements from
instruments (i.e., a simple association of an explosion with a radia-
tion signature from personal radiation detectors). Emphasis should
be put on the concept of dose avoidance by measuring the radiation
levels and establishing operational working times based on the
radiation levels that exist within the incident scene.

Recommendation: For an RDD, an initial hot zone boundary

should be established ~1,600 feet (500 m) in all directions from
the point of dispersion until measurements are made. If it is
known that the source used in the incident had an activity
<10,000 Ci (370 TBq), then the initial hot zone boundary can be
established at a radius of ~800 feet (250 m). Decisions should
not be based on the perceived wind direction, especially in an
urban setting in which the wind field can be very complex. Pro-
jections with environmental models will not provide accurate
predictions of consequences on a distance scale of ~1,600 feet
(500 m). Adjust the location of the hot zone boundary as radia-
tion measurements become available. This boundary definition
is appropriate for both alpha and beta and gamma emitting
radionuclides (Musolino and Harper, 2006).
46 / 5. RADIOLOGICAL TERRORISM INCIDENT

5.3 Protective Actions for Emergency

Responders and Members of the General Public

5.3.1 Sheltering versus Evacuation in the Emergency Phase

In Section 3, NCRP recommended immediate sheltering followed

by delayed, informed evacuation. People who are outdoors in the
immediate area should enter adequate shelter, and people indoors
should remain indoors until the plume of airborne radioactive mate-
rial has passed. Informing members of the general public of this pro-
tective action before an incident occurs will reduce exposure.
Sheltering during the passage of the plume of airborne radioac-
tive material will lower exposure, but sheltering beyond that time
could result in an additional exposure if radioactive air concentra-
tions inside the buildings become higher than the outdoor concen-
trations. This scenario could occur due to the intake of material
from the passing plume by the ventilation system of an urban
building so that, afterwards, when the outdoor concentrations have
significantly decreased, higher levels of particulates may remain
inside the building. Although a wide range of variability is
expected, estimates suggest that the concentrations inhaled inside
the building could be ~5 % of those in the outside environment.
Evacuation should be delayed until after the plume passes. The
optimal time for evacuation subsequent to this depends upon build-
ing protection factors (PFs), routes of exit from the hot zone, and
other factors. Authorities will inform members of the general pub-
lic regarding when to evacuate (Musolino and Harper, 2006).
Based on the actual experience after the attacks on the World
Trade Center, the plan for managing evacuees should presume
an orderly mass self-evacuation. With that assumption, having
advance community planning efforts in place that direct self-evac-
uees to avoid crossing the hot zone are important. At the appropri-
ate time initial emergency responders should be prepared to guide
evacuees along designated evacuation routes which have estab-
lished egress locations far away from the immediate area where the
source was dispersed (Musolino and Harper, 2006).

5.3.2 Postemergency-Phase Protection of Members of the

General Public

Planning and communication with members of the general public

should assume that the EOC or the unified command will likely
redefine the size of the evacuation area after ground deposition of
radioactive material are more accurately mapped with additional
measurements, likely within a 12 to 36 h period after the incident.
 5.3 PROTECTIVE ACTIONS / 47

Although there are some local regions that have plans to quickly
map the ground deposition, detailed surveys and mapping will prob-
ably occur after the outside emergency-response personnel and
resources arrive, likely in 12 to 24 h in accordance with NRF (FEMA,
2008a). For the intermediate phase, the existing EPA relocation
PAGs of 2 rem (20 mSv) effective dose in the first year and 0.5 rem
(5 mSv) effective dose in any subsequent year are considered
appropriate for RDD and IND incidents (DHS, 2008). The evacua-
tion area may extend several miles from the point of release in some
cases, but, regardless, it is likely to occur at some distance beyond
the hot zone established in the early (emergency) phase (Musolino
and Harper, 2006).

5.3.3 Improvised Respiratory Protection

Recommendation: Using improvised respiratory protection by

breathing through a dry cloth reduces the exposure from inha-
lation of airborne activity in the passing plume and from resus-
pension.

Improvised respiratory protection as a countermeasure is possi-

ble only if a member of the general public is informed before an inci-
dent occurs or before individuals are exposed to a passing plume.
This issue is a topic for discussion with members of the general pub-
lic in the planning stage rather than an emergency recommenda-
tion to be issued by the local health authorities after an incident
occurs. This countermeasure can be used to reduce internal dose
from inhalation of particles during the ~10 to 15 min of the plume
passage. For improvised respiratory protection, the mouth and nose
should be covered with a dry cloth or handkerchief. A wet cloth,
although it would tend to absorb water-soluble particles such as
cesium chloride and keep them out of the respiratory tract, would
increase difficulty breathing and might induce the person not to use
any respiratory protection. Discontinue use of the temporary respi-
ratory protection 30 min after the nuclear terrorism incident
(Musolino and Harper, 2006).

5.3.4 Management of Concerned Citizens

Recommendation: Following a radiological terrorism inci-

dent, hospitals should plan for large numbers of uninjured
48 / 5. RADIOLOGICAL TERRORISM INCIDENT

people (“concerned citizens,” previously known as “worried

well”) seeking medical evaluation and/or decontamination.
Management of these persons outside the hospital emergency
department (ED) or diversion to community reception centers
(CRCs) for monitoring and decontamination should be
addressed in the planning process.

The large numbers of people who self-evacuate may put them-

selves in danger and will impede the efficient movement of emer-
gency responders. Although radionuclide contamination on the
ground is not a significant health risk in most cases, many uninjured
people will not believe that is the case and will seek medical atten-
tion. Because of this, hospitals may be overwhelmed by people who do
not need medical treatment or decontamination and by people who
need only decontamination. Consequently, hospitals may have diffi-
culty providing care for patients who require urgent medical treat-
ment. The term that has been used extensively in the past for these
individuals is worried well; CDC and other federal agencies prefer to
use the term concerned citizens. In order to be consistent with current
terminology, this Report will use the term concerned citizens.

5.3.5 Protection of Emergency Responders

At the scene of an RDD incident, standard protective clothing
(e.g., firefighting/bunker gear) and respiratory protection devices
are sufficient to protect emergency responders from contamination
by radioactive material (NCRP, 2005). The wearing of PPE should
be based on the hazards of the mission assigned (e.g., by detection
with radiation survey devices or as a consequence of intelligence
information). Firefighting hazards require full firefighting PPE.
Because the initial plume will likely pass beyond the hot zone
within 10 to 15 min, most emergency responders will not be
exposed to high airborne concentrations of radioactive particulates
because they will arrive after the plume has passed or first encoun-
ter the plume downstream when concentrations have become
diluted. Therefore, the remaining levels of airborne activity, along
with any contribution from resuspension, are expected to be rela-
tively low, but should be confirmed with equipment for measuring
airborne radioactive material as soon as available from a follow-up
response organization if not available from the initial emergency
responders. Air-purifying respirators are sufficient to protect
emergency responders from resuspension outdoors (Musolino and
Harper, 2006).
 5.4 TRIAGE FOR INHALED RADIONUCLIDES / 49

Recommendation: Assess the inventory of radiation detection

and measuring instruments to ensure that a sufficient number
of instruments of each capability are available. Radiation mon-
itoring instruments should be available to alert emergency
responders [i.e., firefighters, police, and emergency medical ser-
vices (EMS) personnel] to the presence of radiation and possible
exposure.

Instruments should be set to alert the emergency responders

when the exposure rate reaches 10 mR h–1 (~0.1 mGy h–1 air-kerma
rate), corresponding to the recommended value for establishing the
hot zone boundary.
If emergency responders are issued integrating personal dosim-
eters such as thermoluminescent, optically-stimulated lumines-
cent, or other passive dosimeters, they should be worn during the
response. Emergency responders who are assigned electronic
dosimeters for monitoring doses received should have them turned
on at all times.
Emergency responders should promptly measure and record
exposure rates to determine and map the rough profile of the con-
tamination and mark hot spots and control zone boundaries. The
former is important information that the local EOC will need to
begin to assess the scope of the incident; the latter will assist emer-
gency responders in controlling their own doses in the first critical
hours (Musolino and Harper, 2006).

5.4 Triage for Inhaled Radionuclides

Recommendation: Identify persons who were outdoors and

potentially in the path of the passing plume during the first
15 min after an explosion involving an RDD. These persons
should be screened to determine the need for medical treat-
ment for inhaled activity as a medical priority.

The planning process should develop procedures to identify peo-

ple who need medical evaluation for internal contamination. A per-
son is not likely to have received a significant dose from inhalation
without presenting gross external contamination at triage. People
with upper-body contamination, particularly of the shoulder, head
and hair, should be identified as possibly having significant inter-
nal contamination. Assume that individuals with contamination
50 / 5. RADIOLOGICAL TERRORISM INCIDENT

only on the lower portions of their bodies were not likely exposed to
the passing plume and did not inhale large quantity of airborne
radioactive material. People with significant upper-body contami-
nation may require evaluation for follow-up medical treatment
because they may have inhaled radioactive material. Countermea-
sures, such as decontamination or decorporation should be consid-
ered if indicated, but are not a highly urgent action. Serious medical
conditions (e.g., traumatic injuries, heart attacks, or strokes) have
precedence over all contamination-related issues (Musolino and
Harper, 2006). Evaluations for external and internal contamination
are discussed in detail in Section 7.

5.5 Management of the Crime Scene

When an incident is caused by a terrorist action, the site will

also become a crime scene and so the emergency response plan
should incorporate law-enforcement responsibilities and response
actions. The Federal Bureau of Investigation manages, leads and
coordinates all law-enforcement and investigative activities with
regard to the response to terrorist acts or threats, including tactical
operations, crime-scene investigation, crisis negotiation, and intel-
ligence gathering and dissemination (FEMA, 2008b). Public health
and security will still be the primary responsibility and focus of the
local authorities but they must accommodate evidence collection
and other law-enforcement activities. The local/regional emergency
responders must keep the scene as intact as possible while per-
forming their duties (FBI/CDC, 2009).
6. Nuclear Terrorism
Incident

Decision makers and others will face many challenges in a

nuclear terrorism incident. This section amplifies the policies of
Section 3 and the planning guidance of Section 4 to discuss chal-
lenges and provide recommendations specific to a nuclear terror-
ism incident. A key difference between an IND and an RDD is that
an IND results in a nuclear yield whereas an RDD does not (Ansari,
2009). Nuclear yield is measured in kilotons. A kiloton (kT) is the
explosive energy equivalent of a thousand tons of TNT. Nuclear
detonations are capable of producing impacts far surpassing that of
any conventional explosive.
The descriptions and planning factors provided in this Report
are based on the National Planning Guidance for Response to a
Nuclear Detonation (EOP, 2010), which describes a nuclear device
yield of 10 kT detonated at ground level in an urban environment
and suggested response actions. The effects of a nuclear explosion
<10 kT would be less. However, this yield is the current planning
basis for the federal government and this Report (IOM, 2009b).
A significant effect of a nuclear explosion is the blast that it gen-
erates. The blast originates from the rapidly expanding fireball of
the explosion, which generates a pressure wave moving rapidly
away from the point of detonation. Initially, near the point of deto-
nation (also referred to as ground zero) for a surface nuclear burst,
the overpressure is extremely high. With increasing distance from
ground zero, the overpressure and speed of the blast wave dissipate
to a point at which they cease to be destructive. A 10 kT nuclear ter-
rorism incident could destroy most of the buildings in several city
blocks and would severely damage infrastructure within 0.5 miles
(~0.8 km) or more of the explosion (Glasstone and Dolan, 1977).
Glass breakage is an important factor in assessing blast dam-
age, but different kinds of glass break at widely varying overpres-
sures. The glass dimensions, hardening, thickness, and many other
factors influence glass breakage although most windows within a
few miles of ground zero will be broken by a 10 kT nuclear terror-
ism incident.
The cold war civil defense concept of “duck and cover” can pro-
vide protection from flying debris, particularly glass. There will be

51
52 / 6. NUCLEAR TERRORISM INCIDENT

a bright flash that can be seen for very long distances (tens to hun-
dreds of miles) which can alert members of the general public to
take protective action. At 1 mile (~1.6 km), a 10 kT device has the
brightness of 1,000 mid-day suns (Glasstone and Dolan, 1977). Win-
dows were broken at a radius of 10 miles (~15 km) from Hiroshima,
Japan (BMA, 1983). The air-blast shock wave takes several seconds
to travel to areas a few miles away, thus providing people an oppor-
tunity to move away from windows and protect themselves from fly-
ing glass by “ducking” (i.e., crouching or lying down) and “covering”
(i.e., ducking under tables, moving into doorways, or covering vul-
nerable areas like the neck and face with the hands and arms).
The thermal pulse from the nuclear terrorism incident can
cause skin burns to those within a few miles of the nuclear terror-
ism incident who have a line-of-sight view of the fireball. The
potential for fire ignition in modern cities from thermal effects is
poorly understood but remains a major concern. Fires may be
started by the initial thermal burst igniting flammable materials
in buildings, or by the ignition of gas from broken gas lines and rup-
tured fuel tanks.
Secondary fires are expected to be prevalent following a nuclear
terrorism incident. Secondary fires will result in medically-routine
burns, but the health threat will be compounded by other injury
mechanisms associated with a nuclear terrorism incident. Fires
destroy infrastructure, pose a direct threat to survivors and emer-
gency responders, and may threaten people taking shelter or
attempting to evacuate. If fires are able to grow and coalesce, a fire-
storm4 could develop that would be beyond the abilities of firefight-
ers to control.
Another significant effect from a nuclear explosion is ionizing
radiation. Intense radiation is produced by the nuclear fission pro-
cess that creates the explosion and from the decay of radioactive
fission products (radionuclides resulting from nuclear fission). Dur-
ing a nuclear explosion, fission products are created that attach to
particles and debris to form fallout; these particles are the main
source of radionuclide contamination produced by a nuclear explo-
sion. Fission products emit primarily gamma and beta radiation.
The various fission products have widely differing radioactive
half-lives. Some have very short half-lives (e.g., fractions of a sec-
ond), whereas others emit radiation for months or years. Radiation
from a nuclear explosion is categorized as prompt radiation, which

4A firestorm is a conflagration, which attains such intensity that it

creates and sustains its own wind system that draws oxygen into the
inferno to continue fueling the fires.
 6. NUCLEAR TERRORISM INCIDENT / 53

occurs within the first minute, and latent radiation, which occurs
after the first minute and is mostly emitted by radioactive fallout
(NATO, 1996). Both can deliver lethal doses. Moderate to large
doses that are not large enough to be lethal are known to increase
long-term cancer risk.
For low-yield detonations, prompt radiation can be an impor-
tant contributor to casualties. The prompt radiation, however, is of
short duration and its intensity decreases with increasing distance
from ground zero. This decrease is a result of the radial distribution
of radiation as it travels away from the point of detonation, and the
absorption and scattering of radiation by the atmosphere and
buildings. Buildings help to block the direct path of prompt radia-
tion. However, even if an individual is shielded behind buildings,
scattered radiation from the atmosphere can still make people sick
or prove fatal.
Nearly all the activity in fallout comes from fission products
produced during a nuclear terrorism incident (e.g., uranium or plu-
tonium nuclei split apart in the fission reaction). A smaller contrib-
utor is the induced activity (activation) of local materials by
neutron capture. In the fireball, the fission products and neutron
activation products are incorporated into or condensed onto the
particles generated from the explosion, which then descend as fall-
out. In a fallout zone, exposure to external sources of gamma radi-
ation is the dominant health concern, but beta radiation will cause
severe tissue damage if the material remains in contact with
unprotected skin, resulting in “beta burns.”
As a rule, fallout particles that are the most hazardous are read-
ily visible as salt or sand-sized grains (Crocker et al., 1966), but a
lack of visible fallout should not be misinterpreted to mean activity
is not present. Therefore, appropriate radiation monitoring should
always be performed (Glasstone and Dolan, 1977). Fallout that is
immediately hazardous to emergency responders and members of
the general public will descend to the ground within the first few
hours. The most significant hazard area will extend 10 to 20 miles
(~16 to 32 km) from ground zero, but this area will decrease in size
over a few days as the fallout decays (Buddemeier and Dillon,
2009). Figure 6.1 shows a hypothetical pattern of nuclear terrorism
incident damage and fallout deposition. Fallout may contaminate
only a part of the blast damage area.
Contamination from fallout will hinder response operations in
the local fallout areas and may preclude some and will delay many
actions before sufficient radioactive decay has occurred. Monitor-
ing radiation levels is imperative for the response community.
Combining the measured radiation levels with predictive plume
54 / 6. NUCLEAR TERRORISM INCIDENT

Fig. 6.1. Nuclear terrorism incident damage and fallout pattern.

Significant differences in fallout patterns can result from varying wind
directions and speeds at varying altitudes (Buddemeier and Dillon, 2009).

models and possibly measurements from aircraft can be valuable in

determining response courses of action and making protective-
action decisions (Buddemeier and Dillon, 2009; Yoshimura and
Brandt, 2009).
A phenomenon caused by a nuclear terrorism incident called the
electromagnetic pulse (EMP) poses no direct health threat, but can
be very damaging to electronic equipment. EMP is a transient elec-
tromagnetic field generated by the nuclear terrorism incident that
produces a high-voltage surge in conductors. This voltage surge can
damage electronic components that it reaches. EMP phenomenon is
a major effect for bursts at very-high altitude, but it is not well
understood how it radiates outward from a surface level nuclear
terrorism incident and to what degree it will damage the electronic
systems that permeate modern society. Although experts have not
achieved agreement on expected effects, there is general agreement
that the most severe consequences of EMP would not occur beyond
 6.1 HAZARD ANALYSIS AND ZONES / 55

2 miles (~3 km) from a surface level 10 kT nuclear terrorism inci-

dent (EOP, 2010). Stalling of vehicles and disruptions in communi-
cations, computer equipment, control systems, and other electronic
devices could result. Because the extent of EMP effect is expected
to occur relatively close to ground zero, other effects of the explosion
(e.g., blast destruction) are expected to dominate EMP effect.
Equipment brought in from unaffected areas should function prop-
erly. It is not possible to make accurate recommendations on protec-
tion strategies for EMP damage to infrastructure or equipment
needed for or affecting emergency response, such as two-way radios,
telecommunications systems, and vehicles. Where possible, plan-
ners should incorporate EMP resistant equipment and consider
redundancy with dissimilar means of communication.

6.1 Hazard Analysis and Zones

Situational awareness, achieved by quickly obtaining and dis-

seminating information, will be critical for effective initial response
and life safety. Planning activities should focus on identifying meth-
ods and organizations which will collect, analyze and disseminate
the large amount of information, much of it incomplete in the early
phase, that will be arriving from a variety of sources in the initial,
critical hours of an incident.
A key regional planning aspect is ensuring that the various
agencies responding to a radiological or nuclear terrorism incident
have consistent definitions of hazard zones. Section 3 provides
NCRP recommendations for defining the hot and dangerous-radia-
tion zones based upon radiation levels. However, there are three
additional “hazard zones” for a nuclear terrorism incident based on
damage severity.
Blast damage extends outward from the nuclear terrorism inci-
dent in all directions, perhaps for several miles. This Report defines
damage zones that are consistent with those used in the National
Planning Guidance for Response to a Nuclear Detonation (EOP,
2010). Closest to the nuclear terrorism incident site will be the
severe-damage zone where buildings are destroyed. Hazards and
the unlikelihood of viable survivors make entry into the area
unwarranted. Slightly further away would be the moderate-dam-
age zone, where there will be significant building damage and rub-
ble. However, there will also be a large number of persons with
severe injuries who may survive if given prompt medical treat-
ment. The light-damage zone, represented by the area that has bro-
ken windows as a primary effect, can extend for miles from the
nuclear terrorism incident location (Figure 6.2).
56 / 6. NUCLEAR TERRORISM INCIDENT

Fig. 6.2. Nuclear terrorism incident hazards zones. Terrain and other
factors may cause these zones not to be circular. The grey cloud represents
the dangerous radioactive fallout zone in the downwind direction (figure
courtesy of the Brookhaven National Laboratory, Upton, New York).

Recommendation: After a nuclear terrorism incident, dam-

age zones should be established. NCRP recommends the follow-
ing: the light-damage zone is where windows are broken, the
moderate-damage zone is the area of significant building dam-
age, and the severe-damage zone is the area in which most
buildings are destroyed.
 6.2 RESPONSE-PLAN CONSIDERATIONS / 57

There will be many hazards after a nuclear terrorism incident,

including widespread fires and the presence of toxic materials, but
one of the most significant, if it was a ground level or near ground
level nuclear terrorism incident, will be the residual radiation from
radioactive fallout and neutron activation of materials. Although
the radiation levels are by far most hazardous in the first few
hours, some areas within a few miles downwind may still be haz-
ardous days after the nuclear terrorism incident. Rapid identifica-
tion of these fallout areas for implementation of protective
measures is one of the highest priorities of emergency management
and public health authorities.
Identifying the dangerous-radiation zone [exposure rate t10 R h–1
(a0.1 Gy h–1 air-kerma rate)], as defined in Section 3, will have crit-
ical implications on response activities in or near fallout areas. The
dangerous-radiation zone is an area where large doses could be
delivered to emergency responders in a short period of time. After a
ground level nuclear terrorism incident, the dangerous-radiation
zone will be created by fallout that is deposited in the first few
hours and have boundaries that may extend for 20 miles (~32 km),
depending upon the yield and weather, but this dangerous-radia-
tion zone will rapidly shrink as the fallout decays and may only be
a mile or two long after a few days. As an example, an emergency
responder working in an area with an initial 10 R h–1 exposure rate
(~0.1 Gy h–1 air-kerma rate) 4 h after the nuclear terrorism incident
will receive ~25 R (~0.25 Gy air kerma) in a 4 h work period.
The dangerous-radiation zone changes too rapidly in the first
day to warrant physical marking of the perimeter. However, efforts
should be made to secure a safe perimeter and dissuade people from
entering. It is recommended that those working near dangerous-
radiation zones have instruments that monitor the exposure rate.
As depicted in Figures 6.1 and 6.2, much of the moderate- and
light-damage zones will not be in the dangerous-radiation zone
and operations in the light and moderate-damage zones can safely
proceed once the perimeter of the dangerous-radiation zone has
been identified. The t10 mR h–1 (a0.1 mGy h–1 air-kerma rate)
hot-line definition is useful for ensuring the staging areas and
reception centers are outside of the hot zone, which will extend
much further downwind but will also shrink in size over time as the
radioactive fallout decays.

6.2 Response-Plan Considerations

Because the response to a nuclear terrorism incident will
require extensive coordination of a large number of organizations,
regional planning is essential to success. The following delineates
58 / 6. NUCLEAR TERRORISM INCIDENT

consideration of roles and responsibilities, and essential elements

of response planning. The establishment of mutual-aid agree-
ments, essential for nuclear terrorism incident preparedness, was
discussed in Section 4.
Specific challenges that should be addressed in developing a
response plan for nuclear terrorism incidents include (Buddemeier
and Dillon, 2009; EOP, 2010):
• Many local response personnel will be unable to respond due
to their proximity to the blast site and they will need to shel-
ter-in-place for at least the first hour, after which radiation
levels should be measured and evacuation routes determined.
• The blast and possibly an EMP will create infrastructure fail-
ures in electricity, communications, and gas and water distri-
bution systems. The extent of this EMP effect is uncertain.
• Fires, caused by the thermal pulse and blast damage, may
be a hazard for sheltered or trapped individuals.
• Rubble piles in urban canyons may hinder evacuation and
response efforts.
• Flash blindness may cause car accidents that block road-
ways within ~6 miles (~10 km) of the incident.
• Secondary hazards (e.g., chemical releases, flooding, hazard-
ous gases and dust from building collapses) will also be
present.
• There may not be a visible mushroom-shaped cloud. Low
yield, ground detonations in an urban environment may
generate a nonuniform, and chaotic debris cloud. Night or
overcast skies can obscure the view of the cloud produced.
• It will be difficult to predict or avoid unsafe fallout areas.
The tremendous heat of the fireball causes a buoyant rise
that will push the fallout several miles high where upper
atmospheric winds, which often travel at high speeds
[>50 mph (>80 km h–1)], carry the fallout and it would be
difficult to avoid exposure for those within its path. Even if
the cloud is visible, fallout particles may fall in nearby areas
due to lower atmospheric wind directions.
• Varying wind directions at different altitudes may result in
fallout deposition in locations which are not in the direction
of the surface wind.
• The extensive debris cloud caused by the blast may obscure
visibility within a few miles of the nuclear terrorism incident.
• The primary hazard is the radiation from the fallout parti-
cles on the ground and other horizontal surfaces; inhalation
is a minor concern (Glasstone and Dolan, 1977; Levanon
and Permick, 2008).
 6.2 RESPONSE-PLAN CONSIDERATIONS / 59

In preparing to respond to a nuclear terrorism incident, decision

makers may encounter terms and concepts with which they are not
familiar. Lists of concepts useful to decision makers who are not radi-
ation experts include the following:

• nuclear terrorism incident terms such as yield, prompt

effects, and fallout;
• ionizing radiation and the types of ionizing radiation;
• exposure or dose to a person versus contamination with
radioactive material;
• external and internal contamination of a person;
• quantities and units for describing radiation;
• dose limits versus decision doses; and
• radiation health effects and the ranges of exposures that
cause them.

Preparedness actions that should be addressed in the plan

include:
• developing a “Continuity of Operations Plan” and alternate
emergency operations sites with a predetermined command
succession, communications links and staffing;
• determining radiation PFs for buildings that may be used as
public shelters;
• identifying alternative communication systems for public
messaging immediately after a nuclear terrorism incident to
provide clear, factual and timely guidance to members of the
general public;
• making timely damage assessments and providing for resto-
ration of critical services, resources and infrastructure;
• identifying key agency roles and responsibilities in respond-
ing to a nuclear terrorism incident;
• developing a patient referral plan for immediate and long-
term treatment as a result of critical injuries and severe
radiation doses; and
• developing a recovery and restoration plan to manage long-
term health and environmental issues and the local, state,
tribal and federal agencies that will be responsible for this
mission, including possible relocation of people and busi-
nesses.

Regional plans should also include common understanding of

personal decontamination methods and priorities for managing fall-
out contaminated populations after a nuclear terrorism incident. It
is expected that the fallout particles will be easy to brush off or be
60 / 6. NUCLEAR TERRORISM INCIDENT

removed by changing shoes and outer clothing. People who were

outside when the fallout arrived may also consider washing their
hair and exposed skin surfaces. Since fallout contamination decays
rapidly, it is most hazardous in the first few minutes and hours after
a person becomes contaminated. Given this time frame, the large
number of potential victims, and resources necessary for a formal
decontamination process, simple self-decontamination techniques
should be provided for a nuclear terrorism incident as people leave
the dangerous-radiation zone or enter shelters (Appendix F).
A key planning consideration for decontamination is the logistics
of providing replacement clothing and shoes, especially if tempera-
tures are cool and hypothermia is a consideration. See Section 7.6
for detailed planning guidance for personal decontamination.
For a large explosion whose cause is unknown, an emergency
alert system message should be broadcast stating that people
should shelter indoors. If a nuclear terrorism incident is suspected,
provide specific information on protection from fallout. The detona-
tion of a very large amount of explosive in a city may not be
promptly distinguishable from a very low yield nuclear terrorism
incident in a parking garage underground that would suppress the
flash. This topic is discussed further in Section 6.3.

Recommendation: Establish communication with emergency

responders in the affected area. Provide safety instructions
to the emergency responders and collect information on the
type of blast damage and the radiation level where the emer-
gency responders are sheltering and, if it is safe to measure it,
the radiation levels outdoors. Determine the exposure rates
[cold (outdoor exposure rate d10 mR h–1 (~0.1 mGy h–1 air-
kerma rate)], hot [!10 mR h–1 (~0.1 mGy h–1)], or dangerous-
radiation zone [t10 R h–1 (~0.1 Gy h–1)] at their locations.

Establish communication with emergency responders in the

affected area. Radios outside of the major building damage area
should still function, although communication repeaters may be
inoperative. Use alternate communication methods if needed.

Recommendation: Use a regional situational assessment cen-

ter to collect information from observations, instrument read-
ings, weather, and computer modeling to produce integrated
 6.3 PUBLIC INFORMATION PROGRAM / 61

situational awareness products (maps and displays). Products

and information should be disseminated to all regional emer-
gency operations centers (EOCs).

Designate a regional situational assessment center that will col-

lect information from observations, instrument readings, weather,
and computer modeling. Identification of areas with hazardous fall-
out is a priority. Even before a disaster is declared, establishing
lines of communication with the appropriate organizations will be
important. RAP, National Guard civil support teams, EPA on-scene
coordinators and special teams, FRMAC, and IMAAC can provide
valuable information collection, coordination and dissemination
support.

6.3 Public Information Program to Improve

Response to a Nuclear Terrorism Incident

Section 4 identifies the key components of a public informa-

tion program. Below is guidance specific to preparing members of
the general public for issues they may face in a nuclear terrorism
incident.

6.3.1 Preincident Public Information Program

Recommendation: Injuries from flying glass and other mis-

siles can be prevented by recognizing the immediate signs of a
large explosion (i.e., the flash) and moving away from windows
and using the “duck and cover” technique. The preincident pub-
lic information should describe this protective action.

The amount of time between the “flash” and the “bang” (sound
of the detonation) is sufficient to “duck and cover” which may pro-
tect people inside buildings, especially their eyes.

Recommendation: The most effective way to save lives is to

reduce exposure from fallout. The preincident public informa-
tion should emphasize the initial public protective action of early
adequate sheltering followed by delayed, informed evacuation.
62 / 6. NUCLEAR TERRORISM INCIDENT

As discussed in Section 4, the success of the response to a

nuclear terrorism incident will depend largely upon public aware-
ness, prior to an incident, of protective actions it can take. Public
awareness and use of protective measures such as sheltering will
improve public safety, reduce the demand for limited emergency-
response resources, and reduce response hindrances such as traffic
congestion. In a nuclear terrorism incident, it is anticipated that
the greatest challenge to response authorities will be public fear
and confusion resulting, in part, from the lack of understanding of
radiation hazards, particularly from the fallout created by the
nuclear terrorism incident. This issue should be addressed in a pre-
incident public information campaign.
The program should provide general information such as the
types of radiation, sources of radiation, common terminology for
describing radiation, health effects of radiation, and, specifically
for a nuclear terrorism incident, information on radioactive fallout
including how it travels and how people can protect themselves.
Information should be made available on how to determine the PFs
for the common types of shelters such as homes, places of employ-
ment, and schools.
With support from FEMA, local authorities should identify pub-
lic shelters for people outside buildings in the event a nuclear ter-
rorism incident occurs. Signs similar to the Civil Defense shelter
signs should be posted and visible for civilians with information on
the level of protection provided in terms of the length of safe shel-
tering time.

6.3.2 Preparing for Post-Incident Messages

Templates for messages providing protective-action guidance
for members of the general public should be prepared in anticipa-
tion of a nuclear terrorism incident and plans should provide for
the prompt release of such messages. See Appendix B for examples
of message templates for an IND. This will expedite providing
important information to members of the general public and may
help to reduce fear and inappropriate actions.

Recommendation: Protective-action guidance should be

issued to members of the general public as soon as possible
after any large explosion, even before confirmation that the
detonation was nuclear.

Initial information should be provided to members of the gen-

eral public within 10 to 15 min after a nuclear terrorism incident
 6.4 PROTECTIVE-ACTION RECOMMENDATIONS / 63

and released even before it has been confirmed that a nuclear ter-
rorism incident occurred. People outdoors or in severely damaged
buildings should be advised to immediately seek suitable shelter
and remain there for at least the first few hours or until guidance
is received from emergency-response personnel or other authori-
ties. Multiple delivery methods, all providing the same guidance,
should be used.
Local emergency-management organizations should include the
media in the public information program planning prior to an inci-
dent. Reporters and media spokespersons should be trained in com-
mon radiation terminology and know where they can contact local
authorities for accurate and timely updates.

6.4 Protective-Action Recommendations

Specific to a Nuclear Terrorism Incident

Recommendation: NCRP recommends that the initial public

protective action be early, adequate shelter followed by delayed,
informed evacuation. Until the level and extent of contamina-
tion can be determined, efforts should be made to avoid being
outdoors in potentially-contaminated areas.

Recommendation: The goal of response to a nuclear terrorism

incident is to save lives while minimizing risks to emergency-
response workers. Unless there is an impact on life-safety,
no resources should be initially expended for the protection of
property.

It is important to be in an adequate shelter when the fallout

arrives (Ansari, 2009). Fallout arrival times vary with nuclear yield
and weather, but people outside of the building collapse area
(severe-damage zone) should have at least 10 min before fallout
arrives. People who are outside or in cars should seek the nearest
adequate shelter. People who are already in an adequate shelter
should remain in the shelter.
Although some high-energy gamma rays from the fallout con-
tamination will penetrate the walls of buildings, protective actions,
including the use of shielding provided by thick walls, and increas-
ing the distance from outdoor fallout, can reduce exposures to peo-
ple by a factor of 10 or more (DOD, 1967).
64 / 6. NUCLEAR TERRORISM INCIDENT

The protection factor (PF) describes the amount of protection

from fallout radiation provided by being in a specified area of a
building or other structure. Similar to the sun protection factor
(SPF) values for sunscreen, the higher PF, the lower the radiation
exposure that a sheltered person would receive compared to an
unsheltered person in the same area. To obtain the sheltered expo-
sure, divide the outdoor radiation level by PF. Figure 6.3 shows pre-
sumed PFs for a variety of buildings and locations within the
building. For example, a person on the top floor or at the periphery
of the ground level of the office/large apartment building shown
would have a PF of 10 and would receive only one-tenth (10 %) of
the exposure that someone outside would receive. Someone in the
core of the building, halfway up, would have a PF of 100 and receive
only one one-hundredth (or 1 %) of the outdoor exposure. In fallout
areas, sheltering in locations with adequate PFs could prevent
lethal exposures. Section 7.2 discusses a hospital’s response to pos-
sible fallout radiation.
An adequate shelter is a location that places dense material
(e.g., earth), building materials, or distance between the occupants
and horizontal surfaces that will accumulate fallout. Using the PF
nomenclature described above (Figure 6.3), a PF of 10 or more is
considered an adequate shelter.

Fig. 6.3. Examples of PFs for a variety of building types and locations
(Buddemeier and Dillon, 2009).
 6.4 PROTECTIVE-ACTION RECOMMENDATIONS / 65

Examples of adequate shelters include:

• basements, particularly against a basement wall;

• multistory brick or concrete structures;
• office buildings (central core or underground sections);
• multistory shopping malls (away from the roof or periphery);
and
• tunnels, subways, and other underground areas.

Examples of inadequate shelters include:

• outdoor areas;
• cars, buses, and above-ground rail systems;
• light residential structures such as mobile homes and single-
story wood frame houses without basements; and
• single-story commercial structures without basements such
as strip malls, retail stores, and light industrial buildings.

Buildings do not have to be “air tight;” broken windows do not

greatly reduce the protection offered.

Recommendation: After the blast wave has passed, the most

critical lifesaving action for emergency responders and mem-
bers of the general public is to seek adequate shelter [with a pro-
tection factor (PF) of 10 or more] for at least the first hour, and
then use radiation measuring instruments (if available), public
messages, and shelter PFs to determine when to evacuate.

For a nuclear terrorism incident, survivors of the blast should

seek shelter that can provide a fallout PF of 10 or more within
10 min of a nuclear terrorism incident. A major challenge for plan-
ners and emergency responders is communicate with those in the
shelters and convince them to remain there until it is safe to leave.
The instinct to reduce one’s exposure to radiation by fleeing the
area or to reunite with family members must be recognized and
overcome for safety. A strong public education and communication
effort can help educate members of the general public and reduce
this problem. But, it must be recognized that some people will evac-
uate, despite announcements to shelter in place.
Informed evacuation, after sheltering for at least the first hour,
can begin in a phased process. Evacuation routes that take victims
out of the fallout area as quickly as possible, using vehicular tun-
nels, subway tunnels, or other protected routes if available, should
66 / 6. NUCLEAR TERRORISM INCIDENT

be identified. When traveling in contaminated urban areas, people

should stay out of the middle of roadways. The lowest outdoor expo-
sure areas are near the sides of large buildings. If roadways are
clear, ambulatory victims can be directed to local collection points
(always use adequate shelters for these) and picked up by desig-
nated transportation. Driving can be considered if the roads have
been cleared and the number of evacuees can be accommodated.
Higher exposures can occur if people leave their shelters too
early. Optimum shelter time depends on several key parameters:

• quality of the shelter;

• outside dose rate at that location;
• evacuation travel time through contaminated areas; and
• dose rates in the areas through which travel is required.

Recommendation: The dangerous-radiation zone should be

identified within the first hour(s) to permit response planning
and development of an informed, delayed evacuation strategy.

In the aftermath of the nuclear terrorism incident there are sev-

eral populations that are early-phase priorities (e.g., first few hours
after a nuclear terrorism incident) those:

• experiencing medical emergencies;

• threatened by fire or toxic materials (not fallout);
• in danger from building collapse; and
• in inadequate shelters.

Except for those in good shelters (PF = 100+), those near the edge of
the fallout area where travel times are short (<10 min) should con-
sider evacuation when an informed evacuation route is available.
Populations that should be considered the next priority (e.g., the
first day after a nuclear terrorism incident) include those:

• threatened by fire or toxic materials (not fallout);

• in moderate shelters, such as two to three story buildings
without basements;
• in danger from hot or cold weather;
• not in fallout areas, provided their evacuation does not ham-
per emergency-response operations or take them through
fallout areas; and
• needing medication (e.g., insulin).
 6.5 PROTECTION OF EMERGENCY RESPONDERS / 67

Those that should be considered a late-phase priority (days after

a nuclear terrorism incident) are those:

• in good shelters (large buildings or underground); and

• requiring evacuation assistance (e.g., nonambulatory, elderly,
hospital patients).

6.5 Planning for the Protection of Emergency

Responders After a Nuclear Terrorism Incident

NCRP emergency responder protection policies discussed in

Section 2 apply to a nuclear terrorism incident.

Recommendation: Radiation monitoring equipment is neces-

sary for emergency responder dose control and safety while
they are in their facilities and on emergency calls.

Recommendation: Radiation monitoring instruments should

be available to measure exposure rates up to at least 10 R h–1
(~0.1 Gy h–1 air-kerma rate), corresponding to the recom-
mended alert level for the dangerous-radiation zone. Addi-
tional instruments, in limited quantity, should be available to
measure exposure rates up to 1,000 R h–1 (~10 Gy h–1).

Fallout from a nuclear terrorism incident can generate very-

high levels of radiation. As recommended in NCRP Commentary
No. 19 (NCRP, 2005), radiation instruments should be avail-
able that can measure exposure rates up to 10 R h–1 (~0.1 Gy h–1
air-kerma rate). It may be necessary to support measuring expo-
sure rates as high as 1,000 R h–1 (~10 Gy h–1) for some emergency
operations.

Recommendation: Emergency service facilities (e.g., police

stations, fire stations, EOCs) should be evaluated to determine
the level of protection they provide against radiation from fall-
out. If a facility does not provide sufficient protection, an alter-
nate shelter strategy should be developed.
68 / 6. NUCLEAR TERRORISM INCIDENT

Emergency service facilities will require evaluation to deter-

mine the level of protection they provide against the hazards of
radioactive fallout. This is critical information that will be needed
for determining the initial actions and length of shelter time for
personnel in each facility. Water and food should be stored in facil-
ities that provide high levels of shelter protection where it may be
beneficial to stay for 24 to 48 h.

Recommendation: Prepare for backup communication that

will survive the loss of communication repeaters and electrical
power.

Communications systems in these facilities should be redun-

dant, tested regularly, and maintained appropriately. Immediately
after an IND incident, it will be critical to establish communica-
tions between each facility having emergency-response capabilities
and the agency emergency managers to obtain information on the
status within and outside the emergency-response facility shelter
for transmittal to the local EOC.

6.6 Nuclear Terrorism Incident

Recommendations for Emergency Responders

Recommendation: Emergency responders with radiation

detection instruments should initially shelter using the instru-
ments to monitor shelter conditions and not exit the shelter if it
requires entering a dangerous-radiation zone [t10 R h–1 expo-
sure rate (~0.1 Gy h–1 air-kerma rate)]. Emergency responders
without radiation monitoring equipment should shelter until
informed that they are not in the dangerous-radiation zone.

The blast and fallout of a nuclear terrorism incident may affect

large areas which contain a substantial portion of the community’s
response force. Emergency responders without radiation detection
instruments should follow the public protection strategy. Emer-
gency responders with radiation detection instruments should ini-
tially shelter using radiation detection instruments to monitor
shelter conditions and not exit the shelter if it requires entering
a dangerous-radiation zone [t10 R h–1 exposure rate (~0.1 Gy h–1
air-kerma rate)]. If exposure rates permit, emergency responders
 6.6 RECOMMENDATIONS FOR EMERGENCY RESPONDERS / 69

should assess the immediate area for hazards, staying close to shel-
ter locations and closely monitoring radiation levels, as it is impor-
tant to immediately shelter if radiation levels increase rapidly.
Once emergency responder safety is ensured, performing a
regional situational assessment is critical. Telephones and cellular
systems may not be working or may be overloaded in the broken
window blast area. However, two-way radio systems should work,
although they may only function in point-to-point mode if commu-
nication repeaters have been damaged. If electronic equipment is
not functioning, turning it off and then on may restore function. It
is a high priority for emergency responders to establish communi-
cation with other response elements.

Recommendation: Emergency responders should record and

report information on major hazards in their area and the loca-
tion of cold [outdoor exposure rate d10 mR h–1 (~0.1 mGy h–1
air-kerma rate)], hot [!10 mR h–1 (~0.1 mGy h–1)], or dangerous-
radiation zones [t10 R h–1 (~0.1 Gy h–1)].

After establishing communication, emergency responders

should report radiation levels at their location. Radiation readings
will change rapidly with time. As a consideration for local and
regional response plans, it may be more effective to report the zone
that the emergency responder is in, such as cold [outdoor exposure
rate d10 mR h–1 (~0.1 mGy h–1 air-kerma rate)], hot [!10 mR h–1
(~0.1 mGy h–1)], or dangerous-radiation zones [t10 R h–1
(~0.1 Gy h–1)]. Local and regional emergency responders should
record and report radiation levels at regular intervals. Identifica-
tion of dangerous-radiation zones is a priority, but also important
is reporting cold zone areas for the determination of safe evacua-
tion routes and response staging areas.
The response needs from a nuclear terrorism incident can
greatly exceed available response resources in the first few critical
hours. Response will require the effective use of citizen volunteers
to help manage and transport the injured and assist in evacuation.
Such citizen volunteers are briefly discussed in Section 7.1.
In summary, priority actions for emergency responders within
the blast damage area are:

• Shelter: The response force within the blast area should shel-
ter until their radiation detection equipment can confirm
70 / 6. NUCLEAR TERRORISM INCIDENT

that the exposure rates outside are <10 R h–1 (~0.1 Gy h–1
air-kerma rate).
• Use radiation detection equipment: Turn on survey and dose-
rate instruments. If dosimeters are available, they should be
prepared for use and distributed. Ensure detection equip-
ment is operational; if a zero reading occurs in a known radi-
ation area, there may be an EMP-induced malfunction.
• Establish communication: Emergency responder radio sys-
tems should work, although they may only function in point-
to-point mode, if repeaters have been damaged. Point-to-
point cellular phones may also function in this capacity. If
radios appear to be nonfunctional turning them off and on
again may restore the function.
• Perform reconnaissance of the immediate area: If outside
exposure rates are <10 R h–1 (~0.1 Gy h–1 air-kerma rate),
team(s) of two should proceed several blocks in each direc-
tion. Each team should be equipped with an exposure-rate
meter and should turn back if it encounters exposure rates
t10 R h–1 (~0.1 Gy h–1). The team should record the locations
of measured exposure rates.
• Establish the approximate nuclear terrorism incident loca-
tion: Although this sounds simple, limited visibility, the
effects of the positive and negative pressure blast wave, and
blast wave reflection may create a confusing environment
where areas of potential higher hazards may not be readily
apparent to those within a few miles of the incident. This
may be a good use for airborne assets, if available, to assess.
• Identify and record the locations of fires: Their extent and
expected growth rate.
• Identify and record the locations of other hazards: (i.e.,
chemical leaks, downed live electrical power lines, natural
gas leaks, etc.).
• Compile and report status and reconnaissance information:
If communication is limited, consider sending a volunteer to
the nearest base of operations station in a direction away
from the nuclear terrorism incident location. Potential dose
to the volunteer should be considered.
• Prepare for mass-casualty triage and extended operations:
Identify nearby locations that are safe to stage victims and
evacuees.
• Use citizen volunteers: Since the magnitude of the incident
will overwhelm all response resources. Life-safety will
depend on citizen-run triage sites, litter bearers, and evacu-
ation route clearing.
 6.6 RECOMMENDATIONS FOR EMERGENCY RESPONDERS / 71

Recommendation: Lifesaving priority should be focused in

the moderate-damage zone that is not in the fallout area.

Recommendation: Emergency responders should focus med-

ical attention in the light-damage zone only on life-threatening
injuries and life-threatening medical conditions.

The light-damage zone is where windows are broken, moder-

ate-damage zone is the area of significant building damage, and
severe-damage zone is the area in which most buildings are
destroyed. A challenge for emergency responders will be to get to
the lifesaving priority area (moderate-damage zone). This may
require the emergency responders to bypass victims in the light-
damage zone with minor, but compelling injuries. Expenditure of
significant response resources and time in the light-damage zone
could exhaust supplies desperately needed in the moderate-dam-
age zone.
Once the general areas and magnitude of fallout have been
determined, emergency responders who are not in danger should
be assigned time-sensitive, high-priority missions. After the light-,
moderate-, and severe-damage zones have been established, an ini-
tial priority is lifesaving in the moderate-damage zone that is not
in the dangerous-radiation zone.

Recommendation: Emergency responder actions within the

dangerous-radiation and severe-damage zones are not recom-
mended within 24 h after a nuclear terrorism incident unless
necessary for the life safety of large populations.

Although there will be injured individuals within the severe-

damage and dangerous-radiation zones, the limited response
resources of the first day should focus efforts on areas outside of
the severe-damage and dangerous-radiation zones because these
operations are less resource intensive to support. Missions into the
severe-damage and dangerous-radiation zones should only be con-
sidered if they are necessary to support the life safety of a large
number of people.
72 / 6. NUCLEAR TERRORISM INCIDENT

Recommendation: Decontamination plans should focus on

self-decontamination performed as people exit the severe-dam-
age and dangerous-radiation zones or enter shelters. The large
number of potentially-contaminated citizens and the resources
necessary for full decontamination will likely exceed the avail-
able response capabilities.

6.7 Considerations for Downwind

Populations at Long Distances

Evacuation should only be attempted if the population can be

out of the area before the fallout arrives; otherwise, sheltering is
the best countermeasure for at least the first 2 h until the actual
fallout hazard areas can be identified. Similar to hurricane impact
area predictive models, the actual incident consequences can vary
widely from the prediction. Protective actions should also be ini-
tially implemented in areas adjacent to the predicted fallout path.
Even a well-behaved fallout cloud will spread out as it travels and
deposit the fallout over a larger area (wider path), implying that:

• a large population likely will be impacted;

• longer travel times and distance will be needed to avoid the
fallout; and
• later fallout arrival times are expected.

Although exposures will be much lower and early health effects

(i.e., radiation sickness) are not expected beyond 10 or 20 miles
(~16 to 32 km) (nominally for a 10 kT explosion, though lower
yields will produce shorter ranges), the protective action recom-
mendations in Planning Guidance for Protection and Recovery
Following Radiological Dispersal Device (RDD) and Improvised
Nuclear Device (IND) Incidents (DHS, 2008) should be followed and
shelter should still be considered to reduce the potential dose to
outdoor populations in areas that may exceed 1 rem (0.01 Sv) total
effective dose (sum of effective doses from external and internal
radiation sources) which could include communities hundreds of
miles downwind.
7. Preparing the Public-
Health and Medical
System Response

7.1 Public-Health and Medical

Preparedness Overview

Recommendation: Review existing public-health and medi-

cal-response plans to ensure that radiological or nuclear terror-
ism incidents of any type and scope are addressed.

These preparations should address hospital preparedness, tri-

age and treatment challenges, decontamination, population moni-
toring, radioactive waste, contaminated deceased persons, and
recruitment and credentialing of supplemental staff.

Recommendation: The appropriate authority should develop

a public-health and medical concept of operations scenario sim-
ilar to that shown in Figure 7.1.

A radiological or nuclear terrorism incident will produce varying

numbers of victims requiring a coordinated public-health and med-
ical system response. The public-health and medical system
response after such an incident is complex and would involve a vari-
ety of emergency responders who are defined in NCRP Commen-
tary No. 19 (NCRP, 2005). Figure 7.1 shows a possible flow chart for
public-health and medical operations after a radiological or nuclear
terrorism incident. This section addresses many of the aspects
(facilities, referral patterns, etc.) found in this figure. The concept
of operations scenario presented in this Figure 7.1 should be scal-
able depending on the specific incident. For example, several hospi-
tals may be involved during an incident, each with its own
reception and triage center external to the ED. In addition, tempo-
rary decontamination centers (TDCs), community reception centers
(CRCs), and alternative medical treatment sites (AMTSs) could be

73
 74 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE
Fig. 7.1. Concept of operations for a public health and medical emergency-response system.
 7.1 PUBLIC-HEALTH AND MEDICAL PREPAREDNESS OVERVIEW / 75

opened depending on the characteristics of the incident and partic-

ularly the number of individuals affected. In particular, a nuclear
terrorism incident in a major metropolitan area would produce a
catastrophic number of victims, quickly overwhelming the local
public-health and medical system, and requiring regional, state,
national, and perhaps international assistance. All regional hospi-
tals not incapacitated by the nuclear terrorism incident would be
involved in response activities. All of the various types of reception
and decontamination centers and AMTSs should be opened in the
region to handle the very large number of victims expected after a
nuclear terrorism incident.
In addition to the components shown in Figure 7.1, casualty col-
lection points will spontaneously open, staffed by citizen volunteers
in relatively safe locations until sufficient numbers of emergency
responders are available to begin triage, treatment and transport
operations (EOP, 2010; Hrdina et al., 2009). These citizen volun-
teers will be people in the area, including medical personnel, who
choose to care for casualties, and, if available, members of commu-
nity emergency-response teams.
Severely injured, but nonfatal victims would be transported by
EMS or other means directly to a hospital ED triage site in the
region for definitive care. As soon as possible after notification of a
significant radiological or nuclear terrorism incident, each hospital
should activate an onsite hospital reception and decontamination
center (HRDC). The function of HRDC is to receive people who have
arrived at the hospital but do not require ED care. These people
may have minor injuries and radionuclide contamination and may
be worried about radiation exposure. The function of an HRDC is
described in more detail in Section 7.2.
AMTSs and CRCs (Figure 7.1) should be established as soon as
possible after an incident. The primary function of an AMTS is to
provide surge capacity for medical care outside of the hospital set-
ting for noncritical patients, those triaged as having minor injuries,
patients who are psychologically affected by the incident with no
other injuries, and the concerned citizens who self-refer to medical
facilities.5 The primary function of a CRC is to provide population
monitoring and decontamination services to large numbers of the
affected population. AMTSs and CRCs are described in more detail
in Section 7.3. A TDC(s) may or may not be established during an
incident. If these centers are established, they would decontami-
nate some or all people without severe injuries (Section 7.6).

5“Concerned
citizens” (see Glossary).
76 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

7.2 Hospital Preparedness

Recommendation: Every hospital should have plans to main-

tain operations during a radiological or nuclear terrorism inci-
dent of any type and scope, and to provide care for the victims
of such an incident.

The EOC or other local or regional emergency-response organi-

zations should maintain emergency contact information for all hos-
pitals and other healthcare facilities in the local and regional
healthcare system and should notify all these entities that a radio-
logical or nuclear terrorism incident has occurred as soon as possi-
ble after the incident is suspected or recognized. Redundant and
robust communications systems should be maintained between the
local, regional, state and tribal authority, and between the local or
regional authority and the local healthcare system (CDC, 2003).
Unless a hospital has sustained critical building structural and
infrastructure damage, it should be prepared to remain functional
to handle disaster victims. The victims may range from the criti-
cally injured and contaminated to the uncontaminated, concerned
citizens.

Recommendation: Each hospital in or near a major metropol-

itan area should prepare for the contingency that it could be in
the hot zone [outdoor exposure rate !10 mR h–1 (~0.1 mGy h–1
air-kerma rate)] from radioactive fallout after an improvised
nuclear device (IND) detonation and possibly with a radiologi-
cal dispersal device (RDD) detonated nearby.

Prior to an incident, each hospital should assess its buildings, as

described in Section 6.4, to determine what portions of these build-
ings constitute adequate shelters from fallout radiation. Each such
hospital should have at least one radiation survey meter, as
described in Section 6.5, that can measure exposure rates up to at
least 10 R h–1 (~0.1 Gy h–1 air-kerma rate). The hospital’s emer-
gency plan should include provisions, if radiation measurements or
other information indicates that the hospital is in the hot zone, to
perform radiation surveys of occupied areas within the hospital
to determine if temporary relocation of patients and staff to other
areas of the hospital is necessary. Performing these surveys and
 7.2 HOSPITAL PREPAREDNESS / 77

moving staff and patients out of areas with dangerously-high

exposure rates becomes a matter of urgency if the hospital is in
the dangerous-radiation zone [outdoor exposure rate t10 R h–1
(~0.1 Gy h–1 air-kerma rate)]. The emergency plan should take into
account that the upper floor or floors may have to be temporarily
evacuated because of radiation from fallout on the roof, unless the
roof is decontaminated, as described in Section 4.2.
Each hospital’s emergency operations plan should include pro-
visions for responding to a radiological or nuclear terrorism inci-
dent, including handling victims presenting after such an incident.
Each hospital should operate under the Hospital Incident Com-
mand System (EMSA, 2009). Hospital staff should receive training
regularly on the hospital’s radiological or nuclear emergency plan
and drills and exercises should be conducted periodically.
The hospital plan should be integrated into the local or regional
emergency operations plan under Emergency Support Function
No. 8 (FEMA, 2008a). After an incident occurs, requests from the
hospital for supplemental personnel, equipment and supplies are all
made through the local or regional EOCs to state and federal part-
ners. The hospital planning process should ensure the availability
of adequate equipment including radiation survey meters, supplies,
and supplemental staffing. Hospitals with nuclear-medicine and/or
radiation-oncology departments, and larger hospitals with radia-
tion safety organizations, will have radiation survey meters and
staff trained in their use. Existing nuclear-medicine instruments
may be useful in assessing internal radionuclide contamination, but
this will require establishing protocols in advance of an incident and
may include obtaining specialized software. Large medical centers
with nuclear-medicine clinics should have instrumentation with the
capability to identify the radionuclides from an RDD. These radio-
nuclides are listed in Musolino and Harper (2006).
Planners should ensure that there is adequate hospital surge
capability in case of a radiological or nuclear terrorism incident.
Any incident will have at least a regional impact, so planners
should ensure that there is more than a single hospital prepared to
deal with persons injured from the incident, in case a specific hos-
pital is incapacitated or overwhelmed by victims. Hospitals should
not be the primary receivers of uninjured individuals after a signif-
icant radiological or nuclear terrorism incident. Therefore, regional
plans should include measures to discourage people not needing
urgent medical care from going to hospitals and direct them to
CRCs for monitoring and decontamination.
The role of a hospital in a radiological or nuclear terrorism inci-
dent is to provide medical treatment for persons with significant
78 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

injuries from the incident, medically-significant internal contami-

nation, life-threatening radiation doses, or a combination of these.
Furthermore, the hospital still has responsibilities to care for those
not involved in the incident. It is not the role of hospitals to decon-
taminate uninjured persons with external radionuclide contamina-
tion, except as noted below.
The hospital plan should include security precautions to protect
the ED and other critical hospital locations from being over-
whelmed by concerned citizens not requiring emergency medical
care, as well as to deter terror activities directed at the hospital.
Security personnel should be provided at all triage and reception
locations, both in the ED and elsewhere, to maintain order.
Specific preparations must be made to handle the inevitable
self-referrals of uninjured concerned citizens or slightly-injured
people, who may or may not be contaminated. A method for dealing
with such people would be to explain to them that, although they
will ultimately be surveyed and decontaminated, if necessary,
there will be considerable delays. Empower them by providing
written instructions for self-decontamination (Appendix F), and
encourage them to go home, or refer them to other locations, as
determined by emergency management staff.
Each hospital’s radiological or nuclear emergency plan should
provide for the establishment of an HRDC separate from the ED
that would be operational within 1 to 2 h after the hospital is noti-
fied of the incident. HRDC should be located away from the ED on
or adjacent to the hospital campus to minimize the numbers of peo-
ple and traffic in and around the ED. The triage function would
continue screening persons for injuries or medical conditions
requiring ED care, and will be the primary means of such emergent
triage, and should not be concerned with handling the uninjured or
those who are only contaminated.
The purpose of the HRDC is to receive persons who do not
require care by the ED, but who may have minor injuries or medical
conditions needing minimal treatment and who may be contami-
nated. Until CRCs are opened, this center would also receive per-
sons who are concerned about contamination or radiation exposure.
A major purpose of the HRDC is to protect the ED from being over-
whelmed by people not requiring ED care, who if not redirected
would limit or terminate its urgent care capability. The functions of
HRDCs are to:

• provide triage for those persons not transported to the hos-

pital by EMS but who may be injured or otherwise need
medical evaluation;
 7.2 HOSPITAL PREPAREDNESS / 79

• provide, or refer to another hospital location for, minor med-

ical care to people not requiring care by the ED until the
AMTS(s) is or are opened;
• survey and decontaminate people with external radionu-
clide contamination;
• provide radiological triage by performing an initial screen-
ing of people who may have internal contamination due to
inhalation or ingestion of radionuclides; and
• provide information regarding the risks of radiation expo-
sure.

Those not contaminated should be provided information stating

so (including a wrist band, written documentation, or other means
verifying that they are not contaminated) and given an opportunity
for further follow-up, if necessary. Other services that might be pro-
vided by HRDC:

• crisis psychological counseling; and

• collection of samples from or referral to the appropriate
locations of those persons needing bioassays for suspected
internal contamination.

As part of the decontamination process, HRDCs should be able

to provide replacements for contaminated clothing. In addition, the
hospital should plan with local emergency management officials to
provide transportation, if needed, for members of the general pub-
lic to CRCs, AMTSs, or other locations.

Recommendation: Essential medical facilities, vehicles such

as ambulances, and equipment such as radiation detection
instruments should not be taken out of service because of low-
level radionuclide contamination.

The threat posed by this contamination can be easily managed,

does not pose a significant safety hazard and any radionuclide con-
tamination risk is greatly outweighed by the need to have these
critical medical assets available (Section 4.2).
Public announcements after an incident has occurred should
provide guidance on self-decontamination and on the availability
of TDCs, CRCs, AMTSs, and general and special-needs shelters,
when they are ready for operation. However, public announce-
ments should not mention the availability of HRDCs at hospitals to
avoid overwhelming them with concerned citizens.
80 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

NCRP Commentary No. 19 (NCRP, 2005) defines all hospital

staff as emergency responders who, as such, are subject to the occu-
pational dose limits. In most circumstances, especially with an
RDD, hospital staff doses should remain below the occupational
dose limits. However, Smith et al. (2005) raised issues of dealing
with the severely injured and those contaminated with radioactive
debris including shrapnel. Since the shrapnel may be considered
crime-scene evidence, consider the presence of law-enforcement
and/or forensic evidence recovery personnel during the surgical
removal. Their study showed that there are plausible situations in
which special precautions for first receivers are necessary while
handling the life-threatening injuries due to an RDD. More infor-
mation on this subject is available in Smith et al. (2005). Of special
concern is the potential failure to perform adequate radiation sur-
veys of patients and miss a victim with embedded high-activity
shrapnel. In this case the danger to staff from the high exposure
rate may go unrecognized. In addition, if high-activity shrapnel is
identified, the limited high exposure rate and spatial localization
capabilities of current survey meters may limit the ability to locate
and remove it in a timely manner. Section 3.2.3 provides recom-
mendations on doses to hospital staff during a radiological or
nuclear terrorism incident.
Plans for staffing the hospital during an incident should take
into account the possibility that a fraction of the staff may not
arrive or may leave because of concern for personal risk or the wel-
fare of their families. The hospital plan should include an activa-
tion scheme for obtaining supplemental staff, equipment and
supplies in case of an incident. The plan should also include facili-
ties and supplies for feeding and housing hospital staff (and per-
haps their family members, if the hospital is used as a staff shelter)
who are unable to return home during an incident. Medical
Reserve Corps (MRC) or other volunteers may be needed to supple-
ment hospital staff until National Disaster Medical System or
other replacements are available. Plans for supplemental staff
should include obtaining people capable of using radiation survey
equipment, interpreting the readings, and providing guidance
regarding decontamination.
Syndromic surveillance systems are designed to capture and
analyze health-indicator data to identify abnormal or unusual
health conditions or clusters to enable early detection of disease
outbreaks. An example of such a system is the CDC Electronic
Surveillance System for the Early Notification of Community-
Based Epidemics (Lombardo et al., 2004). The implementation of
a syndromic surveillance system in the ED, with participation by
 7.2 HOSPITAL PREPAREDNESS / 81

primary care and specialty physicians, would assist in the early

detection of the signs and symptoms of ARS such as fever, nausea,
vomiting and skin redness (erythema), especially in incidents
involving REDs. The possibility of an RED should be considered if
a number of individuals report to several different medical facili-
ties with prodromal symptoms absent any obvious alternative med-
ical diagnosis. Local public-health epidemiology staff could assist
in implementing such a system at the hospital and would also be
the recipients of this surveillance information.
Hospitals may quickly deplete their medical supplies and, thus,
must maintain close contact with local and regional emergency
management organizations so that the resources of CDC Strategic
National Stockpile (SNS) 12-Hour Push Packages and Vendor
Managed Inventory (VMI) can be made available. VMI contains
countermeasures for large radiation doses and internal contamina-
tion by some radionuclides, addressed in Section 7.5.7, that could
be used for some incidents.
The hospital plan should include operational training of the staff
of the ED, the persons who will staff the onsite HRDC, and any other
supplemental staff. The training should include information regard-
ing management of contaminated patients; facility preparation and
decontamination; the risks of radiation exposure and radionuclide
contamination as well as methods for coping with the psychological
stress of such incidents. The hospital plan should include periodic
drills to test and reinforce training and to identify weaknesses in
the plan. The staff of the nuclear-medicine department, the medical
physics staff of the radiation-oncology department, and the staff of
the radiation safety organization are trained in the use of radiation
survey meters and should be used to assist the ED, and to assist
in staffing HRDCs. The hospital plan should also include the provi-
sion of just-in-time training when an incident occurs.
Local and state public-health organizations and local and state
chapters of professional organizations with expertise in radiation
(e.g., Health Physics Society, American Association of Physicists in
Medicine, and Society of Nuclear Medicine) should assist hospitals
in training the hospital staff, including those in the ED. Several ref-
erences are available to assist in developing ED response plans and
training aids (Bushberg et al., 2007; HPS, 2008; Mettler and Voelz,
2002). Clinicians should be aware of the signs and symptoms of
ARS and know where they could receive just-in-time training after
an incident, such as at the Radiation Event Medical Management
website (DHHS, 2010) and the 17 min video prepared by CDC enti-
tled, Radiological Terrorism: Just in Time Training for Hospital
Clinicians (CDC, 2007b).
82 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

7.3 Reception Centers Other Than Hospitals

Recommendation: Each community should establish com-

munity reception centers (CRCs) and alternative medical treat-
ment sites (AMTSs) and should be prepared to handle large
numbers of potentially-contaminated people, most of whom
may have no injuries or noncritical injuries if the incident is not
a nuclear explosion.

After an incident of radiological or nuclear terrorism, members

of the general public will likely flee from the impacted area and
seek assistance and/or shelter (Figure 7.1). Section 3 discusses the
recommended actions for emergency responders and members of
the general public following such an incident. Depending upon the
severity of the incident, many members of the general public will
go, or try to go, home and await further guidance from media
sources. Others will attempt to go to a hospital to have their medical
conditions assessed, whether or not they have actual injuries. Vary-
ing numbers of people without significant traumatic injuries may
require surveys for radionuclide contamination, decontamination,
radiological triage, crisis psychological services, and registration for
long-term health monitoring.
CDC has developed the concept of a CRC that would be estab-
lished to assess affected members of the general public for radia-
tion exposure, perform decontamination, and enroll the victims in
a registry for long-term health monitoring (CDC, 2007c). Local
authorities should arrange, before an incident, to activate CRCs
following an incident. These centers could be located near hospitals
and in other community-wide locations. The reception centers
should be organized along the lines of the incident command sys-
tem. (This should not be interpreted as meaning that all compo-
nents of the incident command system must be staffed).
Public-health and emergency management staff at CRCs will
assess people for radiation exposure, survey them for radionuclide
contamination, screen them for medical conditions requiring trans-
fer to an AMTS or to a hospital, and enroll them in a community
registry. The specific functions of CRCs include:

• provide initial registration of the victims of the radiological

or nuclear terrorism incident;
• perform monitoring for external radionuclide contamina-
tion, using portal monitors if available;
 7.3 RECEPTION CENTERS OTHER THAN HOSPITALS / 83

• perform follow-up surveys of individuals found to be con-

taminated using hand-held survey instruments;
• provide external decontamination for those found to have
radionuclide contamination;
• provide definitive registration for individuals found to
have external and/or internal radionuclide contamination;
• provide initial psychosocial evaluations for victims includ-
ing concerned citizens;
• answer questions and address the immediate concerns of
the population;
• provide information and give instructions as to next steps;
• coordinate referrals to AMTSs or hospitals, depending on
acuity of medical need;
• screen people for internal contamination due to inhalation
or ingestion of radionuclides [may include initial collections
of bioassay samples, such as urine (CDC, 2008a)]; and
• provide documentation indicating that a contamination
screening has occurred and, if negative, or if the person has
been decontaminated, stating so using a wrist band, a hand
stamp, or written form.

While not their primary function, CRCs must be prepared to

perform medical triage and identify persons who need urgent care,
and to coordinate referrals of individuals to AMTSs or to hospitals.
More specific details of the operation of a CRC can be found in
Population Monitoring in Radiation Emergencies: A Guide for
State and Local Public Health Planners (CDC, 2007c). In addition,
NCRP Report No. 161 (NCRP, 2008) contains information for use
by local authorities to develop plans to screen populations for inter-
nal contamination.
As soon as feasible, but within 6 to 12 h after a radiological or
nuclear terrorism incident, CRCs should be opened in the affected
community at safe distances away from the incident site (i.e., for
a nuclear terrorism incident, outside of the light-damage zone and
not in areas of fallout) (CDC, 2007a; EOP, 2010). However, TDCs,
discussed in Section 7.6, could be established in a smaller-scope
incident to provide decontamination prior to CRC availability.
Before an incident, planners should identify suitable facilities
for CRCs. Facility requirements for CRCs have been described by
CDC (2007c). These characteristics include size, location, restroom
facilities, shower facilities, accommodations for persons with dis-
abilities, environmental controls against excessive heat or cold, ade-
quate access and egress control (in case of emergency evacuation),
security, and parking. Planners should obtain prior permission for
84 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

use of the facilities in case of an emergency and arrange for access

and use in an emergency, both during and outside normal working
hours.
Arrangements should be made for multiple CRC sites, as is
required for points of dispensing, separated by a distance and
located so that an incident is not likely to incapacitate multiple cen-
ters. Locating reception centers at or near likely major relocation
centers, or shelters is desirable, to facilitate the transport of per-
sons between the relocation centers and reception centers.
CRCs could be co-located with the currently existing emergency
preparedness points of dispensing for biological incidents. CRCs
would be staffed by public-health personnel and trained volunteers
such as members of the local community MRCs. Volunteer mem-
bers with MRCs who are health or medical physicists or otherwise
qualified would be essential to conduct the radiation monitoring
and decontamination services provided at CRCs and other loca-
tions. CRCs may be needed to provide continuous services for sev-
eral days after an incident, depending on the magnitude of the
situation. In addition, AMTSs could also be conjoined or located
close to CRCs to provide a specified level of medical care to the vic-
tims to keep them out of hospitals.
Because of the need to keep members of the general public away
from hospitals, unless they are in need of urgent medical care, CRCs
could be co-located with AMTSs. The co-location would be for conve-
nience purposes, less transportation, better security, etc. AMTSs
are designated to provide surge capacity for medical care outside of
the hospital setting. The primary mission of AMTSs is to handle
noncritical patients, those triaged with minor injuries, patients that
are psychologically affected by the incident with no other injuries,
and the concerned citizens who self-refer to medical facilities.
AMTSs would keep those without serious illnesses or injuries from
overwhelming hospital capabilities (Schenk, 2006). Well-prepared
communities should be able to open AMTSs within 12 to 24 h after
an incident. AMTSs would be staffed by federal National Disaster
Medical System staff including disaster medical-assistance teams,
other federal response teams, state medical-response teams or sim-
ilar teams, medical and nursing members of MRCs, hospital staff,
public health, home health agencies, and others. AMTSs may need
to maintain operations for a week or more, depending on the signif-
icance of the incident. AMTSs could be replaced by federal medical
stations or similar facilities when the federal assets are available
(FMS, 2008).
Psychosocial issues will be a significant problem for the affected
population and the reception centers should provide counseling
 7.3 RECEPTION CENTERS OTHER THAN HOSPITALS / 85

and referrals services for large numbers of individuals. Reception

center or AMTS staff should be supplemented by behavioral health
experts from the local area or more probably from outside the
affected area to address (Ansari, 2009; CDC, 2007a):

• post-traumatic stress;
• concern about exposure to radiation;
• stigmatization of those who received radiation exposure;
• anxiety about potential exposure; and
• depression and despair.

AMTSs will most likely be the location for providing more defin-
itive radiological assessments of the victims of the incident includ-
ing dosimetry for external as well as internal doses, and triage of
the subgroup of exposed persons who need decorporation/blocking
therapy. Those people are a medical priority but not a medical
emergency. Bioassays may be performed by direct measurement
such as whole- or partial-body counting; thyroid counting for radio-
active iodine; lung counting for inhaled insoluble radionuclides; or
by measurement of radionuclides in excreta, most commonly urine.
This bioassay capability may be limited to those radionuclides most
likely to be used for radiological terrorism. Section 7.7 and NCRP
Report No. 161 (NCRP, 2008) provide guidance on such bioassays.
Blood studies may also be useful in estimating the radiation doses
of the victims. These are briefly described in Section 7.5.5.
Registry medical records would be kept on all AMTS patients
that would later be transferred to the public-health department as
part of the long-term population monitoring. AMTSs would provide
definitive medical care unless hospitalization was required due to
the level of radiation dose or for other reasons.
Planners should arrange for portal monitors, radiation survey
instruments that can measure alpha and beta and gamma radia-
tion, other equipment, and supplies for the reception centers in
order to have the capability to monitor and evaluate contaminated
people. This is a locale specific issue to resolve depending on the
local capabilities and resources, and the size of the local population
that might need to be monitored and evaluated. The supplies
should include replacements for contaminated clothing and con-
tainers for radioactive waste such as exchanged clothing and dis-
carded PPE worn by the staff. These instruments, equipment and
supplies may be stored in stockpiles ready for use; may be obtained
from other sources when an incident occurs; or may include limited
stockpiles, with provisions for obtaining additional equipment
and supplies. If radiation survey instruments are stockpiled, they
86 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

should receive periodic calibrations, function checks, and replace-

ment batteries.
SNS could be a source of supplemental medical supplies for
AMTSs including VMI as a resource for radiological countermea-
sures. SNS Push Packages should be available anywhere in the
United States within 12 h of an incident with VMI available after
24 to 36 h. Detailed plans on AMTS staffing as well as required
equipment and supplies have been developed (Schenk, 2006).
Plans for staffing CRCs and AMTSs after an incident should
take into account the possibility that a fraction of the staff may not
arrive or may leave because of concerns of personal risk or concerns
about the welfare of their families or relatives. To minimize this
problem, training of staff should include information about the
risks of radiation exposure and radionuclide contamination and of
methods for preparing their families to cope with such incidents in
their absence.
Planners should prepare in advance the text of messages to
be released to the media and posted on the internet requesting
that specific groups of people affected by an incident go to CRCs
first and before being referred to AMTSs, or other appropriate
facilities.
Planners should establish activation and deactivation schemes
for CRCs and AMTSs. The activation scheme should include the
notification of persons who are to staff these locations. Deactivation
should include debriefing of the staff. After CRCs and AMTSs have
closed, local public-health organizations with the assistance of
CDC will continue the process of populating the registry and imple-
menting the long-term health monitoring program (Section 7.7).
After most disaster situations, there are individuals who cannot
or will not return to their homes. This may be due to infrastructure
issues (e.g., power outages), because their homes are damaged or
destroyed, because of transportation issues, or other reasons. Most
members of the general public could be accommodated in general
shelters. However, certain members of the general public may have
medical or other disabilities requiring them to seek assistance in
special-needs shelters. Local and regional emergency managers
must develop plans to open multiple general and special-needs
shelters in the community. The American Red Cross and other
organizations historically have staffed these shelters, commonly
with the assistance of local and regional public-health organiza-
tions. In addition, family-assistance centers should be established
by local and regional emergency management organizations
to ensure family members of emergency responders have access to
care and security.
 7.4 TRIAGE CHALLENGES / 87

7.4 Triage Challenges

Recommendation: Preincident planning is necessary to

ensure appropriate triage of the victims of a radiological or
nuclear terrorism incident despite possible hindrances such as
large numbers of patients with traumatic injuries; medical
facilities being overwhelmed by uninjured patients concerned
about possible radiation exposure and radionuclide contamina-
tion; and medical staff ’s lack of experience in triage of, and pos-
sibly fear of, such patients.

While a radiological terrorism incident may not produce num-

bers of casualties beyond the range of trauma casualties incurred
from the Oklahoma City incident, a nuclear terrorism incident in
an urban area will produce mass casualties on the scale of tens of
thousands, particularly blast, burn and radiation casualties. An
outdoor explosion of an RDD is more likely to produce traumatic
injuries, whereas REDs would produce only radiation injuries.
The guiding principle of medical and radiological triage is that
treatment of life-threatening injuries is paramount over concerns
for radionuclide contamination or radiation exposure (Smith et al.,
2005). In the case of an RDD, triage activities will begin at or
near the scene of the incident, although many people will likely
evacuate the highly contaminated area and those with injuries will
require triage elsewhere. For an RED, on-scene triage would prob-
ably not take place because of the likelihood that individuals
exposed would seek medical care at a variety of venues over an
extended period of time. For an IND incident, initial triage should
occur outside of the dangerous-radiation zone in the moderate-
damage zone. The light-damage zone will have primarily injuries
requiring self- or out-patient care (EOP, 2010).
For radiological or nuclear terrorism incidents, victims will
likely consist of members of the general public as well as emer-
gency responders. Medical and radiological triage will occur,
depending on the situation, on-scene or nearby, and at TDCs,
HRDCs, CRCs, and AMTSs. Treatment of life-threatening injuries
should take precedence over efforts to assess radionuclide contam-
ination or exposure.
In a mass-casualty situation, there is a paradigm shift in care
philosophy from “do the greatest good for each individual” to “do the
greatest good for the greatest number.” Injuries of moderate sever-
ity rather than greatest severity should have priority, and victims
88 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

are prioritized based on survivability. Until recently, this had been

referred to as altered standards of care where the philosophy of
standard of care is replaced by sufficiency of care (AHRQ, 2005;
Schenk, 2008). However, a recent Institute of Medicine letter report
(IOM, 2009a) describes crisis standards of care in which there is
substantive change from normal healthcare practices due to a per-
vasive or catastrophic disaster.
The U.S. military has four categories for field triage of patients:

• Immediate: A slightly-injured person who can be handled

with simple management.
• Urgent: The person is at risk for poor outcome if treatment
or transportation is delayed.
• Delayed: There is no risk to life or limb if specific care is not
immediately given.
• Expectant: The person is expected not to survive to reach
higher medical support without adversely affecting the
treatment of higher-priority patients. Palliative care should
be provided if feasible. When adequate resources are avail-
able, the expectant category does not exist (IOM, 2009a;
U.S. Army, 2008).

Four categories of patients for medical and radiological triage

will present to emergency responders and decisions will need to be
made as to their disposition:

• Exposed, contaminated, and injured: Require medical and

radiological evaluation, transportation to a medical facility
and decontamination;.
• Exposed and contaminated, but not injured: Require decon-
tamination and radiological and medical evaluation.
• Not contaminated, but injured: Require medical evaluation
and transportation to a medical facility.
• Not contaminated and not injured (concerned citizens): May
require transport to a reception center and, at least, will
need instructions on next steps.

All victims and emergency responders may require psychosocial

evaluations at appropriate venues such as CRCs, AMTSs, private
physician offices, or public-health facilities, so behavioral health
professionals should be made available.
On-scene triage consists of stabilizing injuries and significant
medical conditions and transporting the most seriously affected
individuals to prepared medical facilities. Ideally, in situations
where there are limited numbers of victims, an individual familiar
 7.4 TRIAGE CHALLENGES / 89

with radiation protection principles should communicate with the

receiving medical responders or if possible accompany the injured
to provide radiological assistance to the receiving medical respond-
ers. The presence of radionuclide contamination may be deter-
mined at the scene, en route to the receiving medical facility, or at
the medical facility depending on protocols (NCRP, 2001). If possi-
ble, decontamination should be performed at the scene of the inci-
dent (this may be possible in a small-scale incident), if it does not
significantly impede medical care.
A significant proportion of members of the general public at or
near the incident location will self-evacuate. They may have minor
injuries and may or may not be contaminated. Many will go to their
homes, but others will likely go to the nearest hospital, perhaps
before the injured arrive via the emergency medical system (Smith
et al., 2005). TDCs (Figure 7.1) may be able to assist these individ-
uals in a small-scale incident (Section 7.6). Hospital triage outside
of the ED should be implemented as soon as possible after the hos-
pital is alerted by the local or regional EOC that an incident with
mass casualties has occurred. This is especially true in incidents
where contamination concerns need to be addressed so that hospi-
tals can prepare the ED to receive contaminated people.
NCRP Report No. 161 (NCRP, 2008) shows a modified Radiation
Emergency Assistance Center/Training Site (REAC/TS) radionu-
clide exposure decision chart. This decision tree should be the basis
of initial radiological and medical triage of victims of any radiolog-
ical terrorism incident. A new triage model for responding to
large-scale radiological or nuclear terrorism incident mass casual-
ties has been developed and is called the Real-Time Monitoring
Response Medical Response System (Hrdina et al., 2009). This sys-
tem is a scalable approach to be used to characterize, organize, and
efficiently deploy personnel, equipment and supplies as physically
close to victims as is safely possible.
Medical and radiological triage may be performed multiple times
after an incident at or near the scene, at the designated, prepared
and secured area outside a hospital ED (HRDC), inside the hospital
ED, at CRCs, at AMTSs, or other facilities set up by emergency-
management organizations. The triage hierarchy is as follows:

• Primary triage: First triage done at the scene or prehospital

setting based on acuity levels of injury, illness or disease.
• Secondary triage: Reevaluation of a patient’s condition after
initial medical assistance at the scene. This may be done at
HRDC, in the hospital ED, or at CRCs, AMTSs, or other
locations.
90 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

• Tertiary triage: Reevaluation of a patient’s situation after

care is given and is ongoing at the hospital, AMTS, or other
location.

Copies of all publications prepared by EMS, radiation health

responders, or others at the scene of a radiological or nuclear ter-
rorism incident should accompany any transported patients to the
hospital, CRC, AMTS, or other locations.

7.5 Treatment Challenges

Recommendation: The local and regional public-health and

medical systems should prepare to provide medical treatment
to the victims of a radiological or nuclear terrorism incident
despite possible hindrances such as inadequate resources for
the number of patients, medical facilities being overwhelmed
by uninjured patients concerned about possible radiation expo-
sure and radionuclide contamination, and medical staff ’s lack
of experience in and possibly fear of treating such patients.
“Crisis standards of care,” should be implemented if resources
are insufficient to maintain normal standards of care.

7.5.1 Medical Treatment of Victims

The ability of a community to medically respond to radiological
or nuclear terrorism incidents will depend on the number of casu-
alties and the preparation of a community’s public-health and med-
ical-response infrastructure. Preincident planning and exercises
with participation of all community partners and agencies are of
paramount importance. Public-health and medical-response sys-
tem planners should prepare for a medical surge; these prepara-
tions should address staffing, equipment and supplies.
The management of radiation and combined (radiation and
traumatic) injuries can be divided into three stages:

• initial on-scene triage;

• emergency care; and
• definitive care (AFRRI, 2003).

Medical management of victims of an incident begins at the scene.

Management of radiation issues is almost always secondary to any
medical concerns. Medical triage is always the first phase of the
care of any causality.
 7.5 TREATMENT CHALLENGES / 91

Emergency care includes medical evaluation and any surgical

care required during the first 12 to 24 h after the incident. This
emergency care, for an injured individual, begins at the scene, con-
tinues during transport, and resumes at the medical facility, most
likely a hospital, but possibly an AMTS, depending on the severity
of the injury.
Definitive care is usually provided in a hospital where short-
and long-term treatment can be provided or the patient is stable
enough to be transferred to another facility. Long-term care of radi-
ation injuries would probably occur at specialty facilities designed
to provide intensive care, such as cancer centers, burn centers, and
trauma centers (Hrdina et al., 2009).
The number of victims that a hospital could expect depends on
the specifics of the radiological or nuclear terrorism incident. An
RED is likely to produce a variable number of radiation injuries
and adequate care of the injured can likely be provided in a well-
prepared hospital emergency system, assuming that it takes pre-
cautions against being overwhelmed by the uninjured concerned
citizens. Depending on the amount of explosives and the type and
amount of radioactive material used, an RDD incident could pro-
duce no or minimal traumatic and radiation injuries. However, a
large-scale RDD incident, especially if there are secondary explo-
sive devices, could produce dozens or even hundreds of traumatic
casualties, and perhaps a few radiation injuries that would stress
even a well-prepared hospital emergency system. An IND could
produce tens of thousands of casualties consisting of blast, burn
and radiation injuries.
For mass-casualty situations, crisis standards of care come into
play due to the inherent limitations in resources that will occur
(IOM, 2009a). In this situation, transfer, after stabilization, to
another outlying medical facility will be required. As the number of
traumatic injuries increases, the priority of treatment for internal
radionuclide contamination decreases.
The number of people requiring medical care and/or radiological
evaluations perhaps can be divided into the following categories:

• If less than 10 individuals are involved:

- transport and evaluate/treat everyone at nearest hospi-
tal facility.
• If more than 10, but less than 100 individuals are involved:
- initially transport those most significantly injured to the
nearest hospital(s) or other facilities, transport those
with no or minor injuries to outlying facilities or other
locations;
92 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

-evaluate and treat children and pregnant women at high

risk as a priority; and
- obtain demographics and histories on all in this category.
• If 100 or more individuals are involved (including the tens of
thousands of casualties following an IND):
- transport the most significantly injured but nonfatal to
available healthcare facilities especially with priority for
children and pregnant women;
- transport or direct those with no or only minor injuries
to HRDCs, CRCs, AMTSs, or other locations; and
- obtain demographics and history on others.

7.5.2 Radiological Assessment of Patients

During the initial interventions by emergency responders after

an incident, radiological assessments of patients should be per-
formed. Preferably, these would be performed by individuals with
radiological health training. Table 4.2 of NCRP Report No. 138
(NCRP, 2001) provides useful information on these matters.
An on-scene radiological assessment of casualties from a small
to medium-scale radiological terrorism incident would follow
medical triage, and would be the initial evaluation for radiation
exposure and contamination. In radiological triage, an indicator of
potential internal contamination is upper-body and/or facial con-
tamination before or after decontamination. However, if the person
has been decontaminated or has washed since the incident, absence
of external contamination should not lead to the conclusion that the
person was not contaminated by the incident. The recent history
of when and where the person traveled is another indicator of the
probability of internal contamination as some information about
the contamination footprint should be known by the time the recep-
tion center begins operation.
If contamination is found and the injuries are not critical, the
medical personnel should decontaminate the patients and transfer
them to the appropriate receiving medical facility. NCRP Report
No. 138 (NCRP, 2001), Section 4.3.2, provides guidance for patient
radiological assessment.
REAC/TS can provide real-time advice on radiological evalua-
tions and treatment. When requested, a response team including a
physician, nurse, and a health physicist can activate within 2 h and
deploy to provide on-scene consultation. Arrival time will typically
be in the 6 to 12 h time frame depending on the incident location
and weather. REAC/TS provides training and continuing education
courses in radiation emergency medicine for physicians, physicians’
 7.5 TREATMENT CHALLENGES / 93

assistants, nurses, emergency medical technicians, health physi-

cists, and emergency responders in the medical management of a
radiation incident.
NCRP Report No. 161 (NCRP, 2008) has modified a REAC/TS
chart that shows the decision tree for evaluation and treatment of
a radiation victim which will be useful in guiding decision makers
in handling affected individuals. More information can be found at
REAC/TS website (ORISE, 2010).

7.5.3 Management of Individuals at Community

Reception Centers

In a small-scale incident, if TDCs are activated, uninjured mem-

bers of the general public who require an evaluation for contamina-
tion after an incident should initially be referred to a TDC, given
directions on how to self-decontaminate at home, or directly
referred to a community reception center (CRC), when available.
This would include the concerned citizens who may exhibit varying
degrees of behavioral disturbances after such a traumatic incident.
At CRC, contamination screening and registration for long-term
population health monitoring would be performed, and information
would be provided to answer questions from members of the gen-
eral public such as ‘What should I do next?’ and ‘Will I get cancer?’
External decontamination would be performed at a CRC and
this process will be useful in initially categorizing those with possi-
ble internal contamination. Those individuals with a high probabil-
ity of internal contamination include those who have:

• injury or illness due to the incident;

• documented contamination of face, anterior nares, neck,
scalp, hair, or chest;
• persistent elevated survey meter count rate over chest and
abdomen after decontamination (gamma-emitting radionu-
clides only);
• elevated count rate in laboratory analysis of urine sample;
• history of prolonged extrication from the severe-damage
zone or area of high contamination;
• history of prolonged transit time from the severe-damage
zone or area of high contamination without respiratory pro-
tection; and
• history of close proximity to the incident.

Those individuals with a lower probability of internal contami-

nation include those who have:
94 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

• no detectable external contamination (provided they have

not washed and changed clothes);
• no additional high-risk factors from list above; and
• showed external contamination only below the waist.

Those individuals who require special consideration for internal

contamination include those who are:

• pregnant;
• children under 15 y of age; and
• shown to have contamination on the interior of the nose or
mouth.

7.5.4 Management of Individuals at Alternative Medical

Treatment Sites

Alternative medical treatment sites (AMTSs) would receive

individuals of lesser medical severity than would hospitals and
could serve as early as well as longer-term medical care facilities.
Other than hospitals, AMTSs are the more likely initial locations
where more definitive assessments would be performed for expo-
sure from external sources and internal contamination.

7.5.5 Diagnosis of Early Health Effects and Assessment of

Internal Contamination

An outdoor explosion of an RDD would not be likely to deliver

sufficient doses to people to cause early health effects, except per-
haps for a few people close to the explosion who inhale aerosols from
the concentrated plume (Musolino and Harper, 2006). Early radio-
logical injuries [e.g., dose delivered in a short time (minutes to
hours)] are possible from an incident with an RED. As described in
Section 6, early radiological injuries on a large-scale will result
from an IND. Time-to-vomiting determinations, making allowances
for psychogenic etiologies, would be part of the diagnostic evalua-
tion for external whole-body radiation doses. Serial lymphocyte
counts for lymphocyte depletion (available in several hours using
most clinical laboratories) as well as lymphocyte cytogenetics
(available in several days from specialty laboratories) would also
assist such a diagnosis (IAEA, 2001; Parker, 2007). Internal deposi-
tion of radionuclides could be determined by appropriate bioassay
techniques but would depend on the availability of testing materi-
als, equipment, and trained personnel (NCRP, 2008). Methods such
as whole-body counting, lung counting, thyroid counting, and count-
ing of urine samples may be useful after a radiological terrorism
 7.5 TREATMENT CHALLENGES / 95

incident (Ansari, 2009). Hospitals and AMTSs would be the most

likely venues to conduct these types of diagnostic evaluations or col-
lect the samples for transfer to outside specialty laboratories. These
evaluations are discussed further in Section 7.7.

7.5.6 Hospital Management of Radiation Casualties

Hospital accreditation organizations require all participating

healthcare systems to develop plans to prepare for and respond to
an incident (TJC, 2005). Many publications (AFRRI, 2003; NCRP,
2001; 2008; Waselenko et al., 2004) provide comprehensive guide-
lines for the evaluation and treatment of victims with early radio-
logical injuries. REAC/TS would also be available to advise
clinicians in handling radiological injuries (ORISE, 2010). In addi-
tion, the REMM website (DHHS, 2010) is an online reference
source for radiological patient management issues. The Radiation
Injury Treatment Network (NMDP, 2010) provides comprehensive
evaluation and treatment for victims of radiation exposure and
educates specialty care clinicians regarding their potential involve-
ment in a radiological or nuclear terrorism incident (NCRP, 2005;
Parker, 2007).
Hospitals should consider how to handle the previously-triaged
expectant patients that have been placed in this category due to
traumatic and/or radiation injuries. In a mass-casualty situation, a
reevaluation of these patients at the hospital could use the follow-
ing criteria: If individuals are so severely injured that they will die
of their injuries, possibly in hours or days (e.g., severe large-area
burns, severe trauma, lethal radiation dose), or in life-threatening
medical crises (e.g., cardiac arrest, septic shock) such that they
are unlikely to survive given the resources available, they should
be taken to a holding area and given palliative care, as required, to
reduce suffering (Berger et al., 2009; IAEA, 2005; IOM, 2009a).
Specialty care would be needed for those with severe ARS or
with significant internal contamination. Initially, care for severe
ARS may be provided locally, but, subsequently, those requiring
such care would probably need to be transferred to tertiary-care
facilities out of the region such as cancer centers, burn centers, or
trauma centers. Some persons with significant internal contamina-
tion, but without other major injuries, could be managed on an out-
patient basis.

7.5.7 Use of Countermeasures

For high whole-body doses, colony stimulating factors are

included in VMI and are available 24 to 36 h after a radiological
96 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

terrorism incident (Ansari, 2009; CDC, 2008b). NCRP Report

No. 161 (NCRP, 2008) provides comprehensive guidance on the use
of countermeasures for the internal contamination of individuals
with radionuclides. VMI also contains countermeasures, including
potassium iodide, Prussian blue [ferric ferrocyanide or ferric(III)
hexocyanoferrate(II)], and calcium and zinc DTPA (diethylenetri-
amine pentaacetic acid) for internal contamination by specific
radionuclides.

7.5.8 Medical Follow-Up of Individuals Exposed to

Ionizing Radiation

Long-term health monitoring of victims of a radiological or

nuclear terrorism incident is the responsibility of the local, state
or tribal public-health system perhaps with assistance from CDC,
especially in developing the population registry. Several reports
(CDC, 2007a; NCRP, 2001) provide information on long-term popu-
lation monitoring for potential health effects caused by ionizing
radiation.

7.6 Decontamination

Outside of the dangerous-radiation zone, medical stabilization

of the patient is the first priority. The stabilization of life-threaten-
ing injuries should never be delayed to address radionuclide con-
tamination of the patient or exposure to the healthcare provider
from such contamination. This unequivocal statement differs sig-
nificantly from the recommendations arising in the chemical and
biological hazards communities.

Recommendation: The public-health and medical-response

system must be prepared to assess and decontaminate the vic-
tims of an incident as soon as reasonably achievable.

It is usually not necessary to immediately decontaminate most

victims from a radiological or nuclear terrorism incident, but it is
done out of abundance of caution and to alleviate anxiety. Proper
decontamination is important to reduce the exposure to the con-
taminated person; reduce the amount of external contamination
that is taken into the person’s body by inhalation, ingestion, or
other means; prevent contamination of facilities and equipment;
and reduce exposure to other individuals including emergency
responders. It is also important for individuals who will undergo
 7.6 DECONTAMINATION / 97

in vivo bioassay procedures (NCRP, 2005). Internal contamination

from a radiological or nuclear terrorism incident is unlikely to be
the most immediate health risk.
Decontamination is used to remove or reduce to an acceptable
level radionuclide contamination of operational personnel and civil-
ian victims. Protection of emergency responders, support personnel,
and medical staff is the highest priority. The same decontamination
process for potential or actual contamination also applies to mem-
bers of the general public. Emergency responders should be aware
that the decontamination of equipment may also be required. Pre-
cautions should be taken to avoid unnecessary spreading of contam-
ination. Some contaminated objects may need to be preserved as
evidence. Local, regional and state planners should develop decon-
tamination action levels and protocols prior to an incident.
Emergency responders should be aware that some people arriv-
ing from areas with potential radionuclide contamination may
require decontamination. The incident commander should establish
a decontamination plan and procedures for decontamination of these
people, as well as ambulatory- and nonambulatory-injured persons,
and uninjured persons, as feasible. In the absence of other hazards
(chemical, biological, explosive material, etc.), all reasonable efforts
should be made to adequately remove radionuclide contamination
from victims. Injured persons should be prioritized for treatment and
transported as safely and expediently as possible (Smith et al., 2005).
Emergency decontamination of ambulatory and nonambulatory
victims can be accomplished by removing the outer clothing and
wrapping or redressing the victim in clean garments. This action can
remove most of the contamination on the person (Mettler and Voelz,
2002). Emergency responders should consider the use of sheets,
blankets, and disposable clothing (paper or cloth) which allows for
continued medical treatment in designated cold zone areas once
emergency decontamination is completed.
A scalable approach is required for decontamination planning.
Because radionuclide contamination is not likely to be an immedi-
ate health threat to the victims, the size of the incident will deter-
mine the type of decontamination procedures employed. For a
small-scale incident, showering at the scene or at TDCs may be
employed. For larger-scale incidents, dry decontamination (e.g.,
waterless hand cleaner and paper towels) techniques and self-
washing of exposed skin and hair may be sufficient for initial
decontamination (until an individual is able to shower), which may
occur at locations specified by authorities or at home with monitor-
ing and decontamination validation at CRCs or other locations
later when specified by authorities.
98 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

Ideally, all persons including emergency responders who have

radionuclide contamination on the surfaces of their bodies would be
decontaminated as soon as possible and in the vicinity of the inci-
dent. More than likely, depending on the particular situation,
decontamination on-scene would not be feasible and a possible
alternative would be self-decontamination at other sites such as at
their homes. This would be the situation for large-scale incidents
involving hundreds to thousands of individuals who would seek
decontamination and whose numbers would overwhelm TDCs,
HRDCs, and CRCs. The critical decision point involves reducing
radiation exposures by minimizing time spent waiting for decon-
tamination, which could lead to increased skin exposures due to the
extended time a radionuclide resides on the skin, or increased
quantity of radionuclides inhaled or ingested. Decontamination at
home may be the best choice but could result in incomplete decon-
tamination due to the lack of radiation detection equipment to mon-
itor the effectiveness of decontamination efforts, an increased
chance of contaminating others, and would probably result in the
contamination of home and automobile interiors. Domestic pets and
farm animals that may have been exposed to radionuclide contam-
ination should be decontaminated using the same techniques that
are applied to humans and plans for their decontamination should
be developed. Some people may have their pets with them when
they arrive at CRCs and may not agree to leave without their pets
as demonstrated in recent mass evacuation events (Basler, 2006).
As discussed above, the ability to decontaminate most or all
affected individuals near the scene of the incident decreases with
the expanding scope of the incident. In addition to the numbers of
people requiring decontamination, weather conditions, the number
of personnel and equipment available to perform decontamination,
the availability of sufficient and appropriately-sized replacement
clothing, and the availability of suitable nearby facilities for decon-
tamination also affect the ability to perform this function and
where it should occur.
TDCs could be opened at the discretion of an incident commander
or other emergency managers after a small-scale radiological terror-
ism incident to provide initial decontamination instructions and
capability. Alternatively, a TDC could be opened after a large-scale
incident to decontaminate a group of people believed to be highly
contaminated. Such a facility would be open to handle the uninjured
members of the general public who did not need a hospital evalua-
tion and who either cannot, or does not want to go home, or who want
an initial decontamination effort before they go home. A TDC would
help divert individuals away from hospitals and would provide them
 7.6 DECONTAMINATION / 99

with information on next steps such as immediate self-decontamina-

tion or home self-decontamination, until a CRC is opened to provide
more definitive evaluations. TDCs should be located near the site of
the radiological terrorism incident, but upwind, in a building located
in a noncontaminated area. Examples of suitable structures include
those with shower facilities such as gyms, transportation hubs such
as bus or train stations, or other locations with access to water. It
may not be feasible to prestock these locations with decontamination
supplies but local emergency management organizations should
have a list of such locations available for rapid supply of necessary
materials. At a minimum, decontamination supplies and capabili-
ties would include running water (preferred, but wet wipes could
offer an alternative); printed instructions for self-decontamination;
survey meters including pancake probes; and self-decontamination
kits that would consist of temporary replacement clothing. If not
already in place, these supplies would need to be transported to
TDCs by an appropriate agency that may provide initial staffing for
the facility such as fire, police, EMS, or public health. TDC should
open within an hour of an incident where radionuclide contamina-
tion is known or suspected and would remain open until CRCs are
established, up to 6 to 12 h after the radiological terrorism incident.
Those leaving the incident scene may go (self-refer) to the near-
est hospital. Local and regional hospitals should quickly (in less
than 2 h) establish HRDCs away from the EDs, as described in Sec-
tion 7.2. HRDC will send significantly-injured individuals to the
hospital ED. The uninjured, but potentially-contaminated individ-
uals would be provided initial radiological monitoring and/or decon-
tamination, or be sent to a TDC, or to their homes with instructions
for self-decontamination. Subsequently, these individuals may be
sent home or referred to a CRC or AMTS for further evaluation.
Communities surrounding major cities should plan for the con-
tingency of their citizens, who work in or visit the main metropoli-
tan area, returning in large numbers after a radiological or nuclear
terrorism incident. In a large metropolitan area into which people
commute using mass transit, mass-transit stations at the periph-
ery of the urban area may be suitable locations to establish decon-
tamination centers. If mass transit is functioning following an
incident, decontaminating persons fleeing the incident at or near
these stations would avoid contaminating the interiors of their
automobiles and homes.
Whenever people are decontaminated away from their homes,
they must be provided with replacement clothing. Large numbers
of the previously described decontamination kits should be avail-
able in the community for rapid placement at decontamination
100 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

locations. If people are decontaminated at a site other than their

homes and the weather is inclement, the people may require shel-
tering or transportation to a safe location.
If available, portal monitors that people can walk through
should be used to quickly survey large numbers of individuals. The
monitors should be wrapped in plastic so that loose contamination
can be easily and quickly removed (CRCPD, 2006).
It is recommended that planners consider any cultural and reli-
gious issues in the community that would affect decontamination
of members of the general public. It is recommended that jewelry,
personal effects, credit cards, etc., not be taken from victims (CDC,
2007c). These items are important for resumption of normalcy by
the general population. It may be prudent to store them in plastic
bags for future decontamination if the items are contaminated.
The progress of a potentially-contaminated person should begin
in the decontamination zone, with the removal of clothing, and
move to the cold zone, where he or she would be issued new clothing
and given treatment if needed. Emergency responders should be
aware of the potential for spreading contamination to themselves
and other response or reception staff and the potential introduction
of contaminants into the victim through open wounds and body
openings. Once immediate medical treatment is rendered onsite,
victims should be wrapped and/or clothed to allow for further eval-
uation and treatment. When possible, victims should be monitored
to determine the level of contamination present. Emergency
responders should record monitoring results on patients’ available
records for medical facility use and review. Victims receiving life-
saving procedures should not be monitored if the effort will signif-
icantly impede medical assessment and treatment (Smith et al.,
2005). Upon completion of treatment in the cold zone, and prior to
rendering additional victim aid, emergency responders should fol-
low standard protocols for self-decontamination prior to treatment
of additional victims.
There is no universally-accepted level of external or internal
activity above which a person is declared to be contaminated and
below which they are deemed to be decontaminated to a safe level.

Recommendation: Decontamination (skin and clothing)

should always be performed when the contamination level is
>0.1 mR h–1 exposure rate (~1 µGy h–1 air-kerma rate) at 10 cm,
>600,000 dpm cm–2 (10,000 Bq cm–2) beta and gamma surface
contamination, or >60,000 dpm cm–2 (1,000 Bq cm–2) for alpha
surface contamination.
 7.6 DECONTAMINATION / 101

The levels of contamination in the recommendation above could

represent a hazard from direct irradiation of the skin and/or from
intake by inadvertent ingestion, and could indicate that the person
has already inhaled or ingested a significant quantity of radioactive
material (IAEA, 2006).
Target levels for adequate decontamination should be in the
local and regional emergency plans, but may be modified at the time
of the response. These levels may be different than “any detectable
level of contamination” and depending on the number of people to
be monitored may make surveys with this level of detail impractical
(CRCPD, 2006; NCRP, 2005). If the incident is smaller and decon-
tamination resources allow, more restrictive guidelines may be
adopted, whereas these levels may have to be relaxed for larger
incidents if resources are insufficient. To maximize the efficiency of
the decontamination process, individuals who have been decontam-
inated to the appropriate standard should be identified by a wrist-
band, hand stamp, written form, or other convenient method so that
there is a visible means of showing that they have been evaluated.
For many victims, decontamination will be psychologically
stressful. Therefore, familiarizing people with the steps of the
decontamination process will help minimize delays and alleviate
their anxiety. People awaiting decontamination should be given a
brief document describing the steps to be taken for decontamina-
tion. See “Instructions to the Public Waiting for Decontamination at
the Scene of the Incident” in Appendix F (LA County, 2009). If there
are large numbers of people in the community who are not fluent
in English, it is recommended that the instructions be translated in
advance, so they will be available in a language that is understood
by the person or a family member with the person (CRCPD, 2006).
If there are large numbers of people (>100), emergency person-
nel should perform a limited screening survey rather than a more
detailed survey. It is acceptable to perform only a screening sur-
vey of the head, face and shoulders rather than a more detailed
survey. Contamination of the head, face and shoulders indicates
the possibility of internal contamination (CRCPD, 2006).
The person’s location during the incident is likely to be the best
indicator of potential internal contamination. Individuals who were
outside during the first 15 min, and, who were within the ~1,600 feet
(500 m) hot zone described in Section 2 for an RDD are considered
high priority to find and screen. Recommendations are the same for
alpha-, beta- and gamma-emitting radionuclides. If the survey of
the head, face and shoulder area indicates high levels of contamina-
tion (>100,000 cpm), it should be assumed that the person has inter-
nal contamination (CRCPD, 2006). It is not necessary to assess the
102 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

levels of internal contamination at the site, since the need for treat-
ment will be assessed and treatment will be administered by medi-
cal personnel at a hospital or other location such as an AMTS
(CRCPD, 2006). Plans for the establishment of decontamination
facilities should include protocols for radiological monitoring of the
established decontamination areas (to ensure that they are not con-
taminated) and for moving the decontamination facility based on
changing radiological conditions if needed.
Section 7.9 discusses handling of deceased persons contaminated
with radioactive material. Contamination of deceased persons pres-
ent special problems in the initial phase of an incident since decision
makers must minimize doses to staff while respecting familial and
cultural concerns. Special procedures are required for handling
deceased persons who may be contaminated with radioactive mate-
rial. Wood et al. (2007) provides guidance on this matter recommend-
ing each body be surveyed and, if there is a reading of t100 mR h–1
exposure rate (~1 mGy h–1 air-kerma rate) at 1 inch (2.54 cm), that
the body should be moved to a refrigeration unit at least 30 feet
(~9 m) from the work area. Bodies with levels less than this value
could be sent to a field morgue. If the deceased person is believed to
contain radioactive shrapnel, then this should be surgically removed
as soon as possible. Since the shrapnel may be considered crime-
scene evidence, consider the presence of law-enforcement and/or
forensic evidence recovery personnel during the surgical removal.
Decontamination may have to wait until forensic examination and
victim identification is complete. Personal effects such as watches or
rings can be decontaminated and returned to the family.
In summary, if individuals do not require immediate medical
attention, they may be decontaminated on-scene, allowed to go
home to decontaminate (Appendix F) or otherwise decontaminated
depending on the scope of the incident and available resources.
Proper decontamination is important to limit the radiation dose of
the individual, prevent contamination of facilities and equipment,
and to prevent exposure to other individuals. Removal of outer
clothing may reduce most of the contamination and wet wiping or
showering can remove the majority of the remaining contamina-
tion (CRCPD, 2006).

7.7 Bioassays for Internal

Contamination and Biodosimetry

7.7.1 Bioassays for Internal Contamination

In this Report, the term bioassay refers to the assessment of
radionuclides in a person’s body, called internal contamination,
 7.7 BIOASSAYS FOR INTERNAL CONTAMINATION / 103

either by direct (in vivo) means (e.g., whole-body counting or lung

counting) or by indirect (in vitro) methods (e.g., assays of excreta).
Bioassays permit estimation of intakes of radionuclides, the activity
in the body, the distribution of a specific radionuclides in the body,
and the absorbed doses imparted by the radionuclides. Bioassays can
provide information to guide the decision whether to treat a person
for an intake of radionuclides and can monitor the effectiveness of
such therapy. Treatment for internal contamination is called decor-
poration therapy and is discussed in Section 7.5.7. This Report only
addresses bioassays in the early (emergency) phase of an incident.
The behavior of a radionuclide in the body depends on its chem-
ical and physical form and its route into the body (e.g., inhalation,
ingestion, or introduction through a wound). For example, the frac-
tion of an inhaled radionuclide in the form of particles that is
retained in the body depends upon the particle size distribution
and solubility. Some radionuclides (e.g., those of americium and
plutonium in soluble form) are efficiently absorbed into the body if
inhaled, whereas, if ingested, are poorly absorbed by the gastroin-
testinal tract and are almost entirely excreted.
In the early phase after an IND detonation, bioassays are not
likely to be of significant utility. Although the number of people
with potential internal contamination will likely be very large, the
risk from internal contamination is dwarfed by other risks, partic-
ularly that of direct exposure to the gamma radiation from fallout.
Early treatment guidance (primarily a recommendation that peo-
ple with access to potassium iodide swallow it) can be issued with-
out bioassays.
For radiological terrorism incidents involving an RDD or the
deliberate contamination of food, water, or other consumables,
NCRP recommends that plans address bioassays. Although sam-
ples of excreta may be collected during the early phase of a radio-
logical terrorism incident for later analysis, the primary purpose of
bioassays in the early phase of a radiological terrorism incident is
to guide decisions regarding whether to initiate treatment for inter-
nal contamination. Treatment for internal contamination is not a
medical emergency but is more effective if begun soon after the
intake (NCRP, 2008). Highly accurate bioassays are desirable, but
may not be possible in the early phase of an incident; prompt
but less accurate bioassays may be of greater usefulness in the
early phase.

Recommendation: In the early phase of a radiological terror-

ism incident, the goal of bioassays should be to rapidly provide
104 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

information to decision makers regarding whether people

have received sufficiently large intakes to justify decorporation
therapy.

Currently, it is not likely that bioassays can be performed

promptly on all or even most people who may have internal contam-
ination from a large-scale radiological terrorism incident. Due
to the relatively mild side-effects of most decorporation therapies, a
possible strategy is to perform bioassays of a few people and use
that information to guide the decision whether to initiate treatment
of others whose exposure circumstances are similar. Examples of
groups from which samples of people might be assessed by bioassay
are people injured by an RDD, people with heavy external contam-
ination on their upper bodies, people who were outdoors in the
plume area within a specified distance [e.g., ~1,600 feet (500 m)]
when an RDD was detonated, and children and pregnant women
who were in the plume area. Indirect bioassays will be useful for
early decisions on therapy only if the sample processing turnaround
time is short, which would require onsite or nearby processing of
samples. Direct bioassay can provide data to support early therapy
decisions for some radionuclides.
If the chemical and physical forms of a radionuclide are not
known, a single bioassay of a person will not completely character-
ize the intake or predict the success of treatment. For example, a
single-lung or whole-body count can provide an estimate of the
activity of a radionuclide in the body following an intake by inhala-
tion, but will not differentiate between an insoluble material, much
of which will be retained by the lungs, and a soluble material which
will rapidly enter the systemic circulation. The estimation of an
intake from a urine count is based upon assumptions regarding the
solubility and chemical behavior of the radionuclide.
Thus, in the early phase of a radiological terrorism incident, in
which the radionuclide may be known but the chemical and physical
forms are unlikely to be fully characterized, bioassays may be help-
ful in the decision to initiate treatment for internal contamination,
but will not guarantee the success of treatment. Additional follow-up
bioassays may be performed after the early phase of the incident to
confirm the results of the initial bioassays, assess the effectiveness
of treatment, and determine whether it should be continued. NCRP
recommends that plans for bioassays in the early phase of a radio-
logical terrorism incident focus on radionuclides most likely to
be used in such an incident and for which treatments for internal
 7.7 BIOASSAYS FOR INTERNAL CONTAMINATION / 105

contamination are available. IAEA (2004a) and Musolino and

Harper (2006) provide information on radionuclides that are likely
to be used.
NCRP recommends that resources available for bioassays, such
as whole-body and organ counting systems, in and near each major
metropolitan area be identified. Medical, research and nuclear facil-
ities and national laboratories may have such resources. Hospital
nuclear-medicine departments commonly have equipment that can
be adapted for emergency bioassays for gamma-ray emitting radio-
nuclides with large CDGs6 such as 137Cs. This equipment includes
gamma well counters that may be used to assay samples of excreta,
thyroid probes that may be used for lung counting, and perhaps
gamma scintillation cameras. If this hospital equipment is to be
used for bioassays in a radiological terrorism incident, it should
be calibrated in advance for the radionuclides likely to be used in a
radiological terrorism incident, bioassay procedures should be devel-
oped, and the nuclear-medicine technologist staff should be trained
in them. A medical physicist or medical health physicist can perform
such calibrations and develop bioassay procedures. Portable radia-
tion survey instruments can be used to estimate the activities in the
body of gamma-ray emitting radionuclides with large CDGs. NCRP
Report No. 161 (NCRP, 2008) and a new unpublished NCRP report
provide more detailed information on equipment that can be used
for bioassays (NCRP, in press). A possible role for federal govern-
ment agencies is to facilitate the availability of sources and phan-
toms to calibrate hospital equipment for these bioassays.
Performing bioassays for radionuclides with very small CDGs is
far more difficult. For example, lung counting for inhaled 241Am
requires a sophisticated lung counter in a low background environ-
ment and bioassays of excreta for 241Am or plutonium require a
sophisticated radiochemistry laboratory and time-consuming sam-
ple processing. Where bioassay methods for identifying intakes
require significant turn-around time or highly specialized and there-
fore rare analytical equipment (e.g., chest counting or radiochemis-
try analysis for 241Am and plutonium), the decision to administer

6The
clinical decision guide (CDG) was defined to assist physicians in
making decisions in treatments to enhance decorporation of radionuclides
deposited in the body. CDG is the maximum once-in-a-lifetime intake of
a radionuclide that represents: (1) an acceptable stochastic risk, in the
range of those associated with dose limits for emergency situations; and
(2) avoidance of deterministic effects. A more detailed discussion of CDGs
and a table of CDGs for specific radionuclides may be found in NCRP
Report No. 161 (NCRP, 2008).
106 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

therapy may need to be based on relatively subjective field indica-

tions. Radionuclides such as 137Cs and 131I are much more readily
detectable using simple radiation surveys and thus lend themselves
to more objective therapy decisions based on such measurements.
Problems with bioassays during the early phase of a radiological
terrorism incident include contaminating the bioassay equipment;
in the case of direct bioassays, mistaking radionuclide contamina-
tion on the surface of the body or clothing for contamination inside
the body; and, in the case of indirect bioassays, contaminating a
sample of excreta with radionuclides from the surface of the per-
son’s body or clothing. Thus, a bioassay may indicate much higher
intake than actually occurred. Bioassay procedures should incorpo-
rate precautions to avoid these sources of error. Such precautions
include ensuring the patients have been decontaminated, having
clean sample collection kits, and collecting samples in areas free
of contamination. If a bioassay indicates an unexpectedly-high
intake, it may be wise to repeat it promptly, taking into account
these possible sources of error.
Bioassays using urine samples collected within the first 2 h
after an intake of radionuclides may significantly underestimate
intakes because of urine collected in the bladder prior to exposure
diluting the early sample concentration (NCRP, 2008). A more
accurate measurement can be obtained by having the person void
and collecting a sample later. However, an earlier and less accurate
urine sample is better than no sample for guiding treatment deci-
sions, particularly if it demonstrates a large intake.
Information obtained from bioassays in the early phase of an
incident will likely have large uncertainties. For example, esti-
mates of intakes from bioassays of urine samples collected within a
day after the intake may be in error by a factor of three or more.
Physicians using such bioassay data to make treatment decisions
should be made aware of these uncertainties.
Therapy for internal contamination affects the behavior of
radionuclides in the body and must be considered if performing bio-
assays after the initiation of treatment. For example, the adminis-
tration of Prussian blue for 137Cs internal contamination will
increase the excretion of cesium into the feces.
NCRP recommends that mechanisms be developed in the plan-
ning process so that the limited bioassay information available in
the early phase of an incident will be shared with all organizations
and institutions assessing and treating people who may have inter-
nal contamination. The information to be collected and shared in
the early phase should include the results of all bioassays, includ-
ing bioassays showing no intakes; basic demographic information
 7.7 BIOASSAYS FOR INTERNAL CONTAMINATION / 107

for each individual, particularly whether an adult or child; and the

exposure circumstances of each person receiving a bioassay. Local
public-health departments are likely the best organizations to col-
lect and disseminate these data.

7.7.2 Biodosimetry

During the early-phase response to an IND, and possibly for an

RDD, it is anticipated that some emergency responders could
receive significant radiation doses during the conduct of their
duties. In addition, members of the general public may experience
large doses in an IND incident or as a consequence of exposure to
an RED, although few if any would be likely to receive large doses
from an RDD. This section provides a brief overview of the applica-
tion and current capabilities for biological dosimetry, also known as
“biodosimetry,” (see Glossary) as part of the medical care of individ-
uals exposed during a nuclear terrorism incident.
Methods of biodosimetry available today include: assessment of
individuals’ signs and symptoms, particularly the time from expo-
sure to onset of vomiting; serial blood counts for lymphocyte deple-
tion (available in several hours using most clinical laboratories);
and assays of lymphocyte cytogenetics (available in several days
from specialty laboratories) (IAEA, 2001; ICRU, 2002; Parker and
Parker, 2007). The estimation of dose from time-to-vomiting is the
least accurate and the cytogenetic assays are the most accurate.
The best estimate of LD50 (lethal dose for causing death in 50 %
of exposed persons) within 60 d in humans is in the range of 300 to
450 rad (3 to 4.5 Gy) (Anno et al., 2003). However, this value can be
roughly doubled for people by the use of antibiotics, platelets and
cytokine treatment (Anno et al., 2003), so it is important that indi-
viduals who actually received whole-body doses >200 rad (2 Gy)
be identified. LD50 is significantly reduced in people with major
burns or other significant injuries. Most individuals, but not all,
exposed in the 200 to 500 rad (2 to 5 Gy) dose range would be iden-
tifiable due to early nausea, vomiting, and acute fatigue. Biodosim-
etry could play an important role in this dose range.
There is a narrow dose window, ~700 to 1,000 rad (7 to 10 Gy)
(Waselenko et al., 2004), in which bone-marrow transplantation
may be considered. For doses <700 rad (7 Gy), survival rates
are good solely with medication, but patients receiving doses
>1,000 rad (10 Gy) will generally have lethal gastrointestinal dam-
age (Weisdorf et al., 2007). Thus, it may be useful to know if a
patient’s dose is within this dose window to ascertain whether
a bone-marrow transplant would be a useful option.
108 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

Mass radiological triage will be important after a large-scale

nuclear terrorism incident because of the need to identify, as
quickly as possible, those individuals who will benefit from medical
intervention, and those who will not. Eliminating and reassuring
those patients who do not need medical intervention will be equally
important in what will be a highly resource-limited scenario.
Currently, however, the capabilities of biodosimetry are limited
and there is no accurate rapid assessment technique available for
use during the early-phase response to an IND incident. Other
groups have recommended a prioritized, multiple-assay, biodosi-
metric strategy for use in response to a nuclear terrorism incident
(Alexander et al., 2007). While the usefulness of biodosimetry, as
outlined above, is recognized by the scientific community as an
important research and development area (Blakely et al., 2009;
Garty et al., 2010; Pellmar et al., 2005), it is also clear that the capa-
bility to conduct such a mass radiological triage during the early-
phase response to an IND terrorism incident will be limited (per-
haps wasteful of valuable resources) and could divert the attention
of the emergency responders from their mission critical duties.

7.8 Population Monitoring

Recommendation: The public-health system must be pre-

pared to monitor individuals and the community for exposure
to or contamination from radioactive material, to prevent
short- and long-term health effects.

Population monitoring, also known as public monitoring,

describes the effort, after a radiological or nuclear terrorism inci-
dent, to identify, screen, measure and monitor affected people and
perhaps their pets, for exposure to and contamination from radio-
active material (NCRP, in press). Population monitoring begins
essentially immediately after an incident with an initial on-scene
evaluation and would continue at TDCs, HRDCs, hospital EDs,
CRCs, AMTSs, and, subsequently, by local, regional, state or tribal
public-health authorities as part of a long-term registry.
Specifically, population monitoring is instituted after a radiolog-
ical or nuclear terrorism incident and continues until all potentially-
affected members of the general public (and emergency responders)
have been assessed (using the six action steps below) (CDC, 2007c):
1. needed medical treatment;
2. the presence of radionuclide contamination on the body or
clothing;
 7.8 POPULATION MONITORING / 109

3. possible internal deposition of radionuclides;

4. decontamination of external and/or internal radionuclides;
5. determination of possible radiation dose received from
exposure to external and/or internal sources of radioactive
material and an evaluation of immediate health risks; and
6. establishing protocols to monitor for potential long-term
health effects.
Provision of the six action steps above should be implemented as
rapidly as possible after a radiological or nuclear terrorism inci-
dent. Involvement of the public-health system is needed in the
early phases of the response so that long-term health effects can be
followed using a population registry and epidemiologic studies last-
ing for decades.
The population to be monitored is comprised of individuals in the
immediate vicinity of an incident. In addition, those individuals at
variable distances downwind of the incident site may require assess-
ment and monitoring. Secondarily, monitoring may extend to the
pets of these individuals who also may have come in contact with the
radionuclide. However, the concept of population monitoring as pre-
scribed by CDC does not include the assessment of facilities, farm
animals, vegetation, or the food supply. These last four categories
have existing plans and are under the authority of EPA, U.S. Depart-
ment of Agriculture, and the U.S. Food and Drug Administration.
To provide population monitoring after an incident such as an
RDD, specific monitoring instruments are needed to survey for
radionuclide contamination on the human body (external contami-
nation). To assess internal contamination bioassays using whole-
body counters, organ-specific counters, or assays of excreta may be
required. However, techniques are being developed in which read-
ily available radiation survey equipment will be capable of provid-
ing an approximate estimate of internal contamination in a less
clinical environment. It is unlikely that an RDD would deliver
lethal or near lethal radiation doses to victims outside the
~1,600 feet (500 m) zone described in Section 2. For an RED, lethal
or near lethal levels are possible depending on the specific situa-
tion. But, external or internal radiation monitoring techniques will
not provide useful information. For an IND, those in the severe-
damage zone will, in most cases, receive fatal radiation doses or
fatal traumatic injuries. Further away from ground zero, there will
be reductions in radiation doses from the initial release of radiation
but consideration of downwind fallout exposures must be included.
In these cases, additional assessments may be needed using avail-
able methods to determine external and internal doses (AFRRI,
2007; NCRP, 2008; Waselenko et al., 2004).
110 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

CDC states that the following actions are required after a radio-
logical or nuclear terrorism incident (CDC, 2007c):

• identify victims from the incident (emergency responders and

members of the general public) whose immediate health may
be in danger and who require care due to critical injuries or
other significant medical needs, or require decontamination;
• determine affected individuals (emergency responders and
members of the general public) who need medical care for
internal and/or external radiation exposure/contamination,
continued evaluation, or short-term health monitoring;
• counsel affected individuals regarding their risks for long-
term health effects (e.g., cancer); and
• implement, using public-health resources, a population reg-
istry to provide long-term health monitoring.

DHHS has designated CDC as the lead federal agency for popu-
lation monitoring. The duties of this designation are described in
NRIA (FEMA, 2008b). DHHS, through Emergency Support Func-
tion No. 8 (of NFR), Public Health and Medical Services and in con-
sultation with the coordinating agency, coordinates federal support
for external monitoring of people. Under NRIA, CDC is responsible
for assisting local, state and tribal governments in monitoring peo-
ple for internal contamination. CDC is also responsible for support-
ing local, state and tribal governments in decontaminating people
who are internally contaminated by providing guidance on provi-
sion of countermeasures that can increase the rate of removal of
radionuclides from victims (CDC, 2008a). CDC will also assist local,
state and tribal health departments in creating a registry of people
who might have been exposed to radiation from the incident and
help determine how much dose they may have received.

7.9 Handling Contaminated Waste

A radiological or nuclear terrorism incident may generate large
quantity of radioactive waste, which must be handled appropri-
ately. This waste will likely include contaminated debris, clothing,
waste water, and other material. Most is expected to be of the type
classified as low-level radioactive waste. However, high activity
waste materials may be present, for example, as shrapnel after an
RDD. In the case of a nuclear terrorism incident (e.g., IND detona-
tion), after 2 d, the levels of activity in the contaminated material
will have decreased significantly due to radioactive decay.
Initially, radioactive-waste issues are secondary to provisions of
lifesaving and critical infrastructure sustainment activities by
 7.9 HANDLING CONTAMINATED WASTE / 111

emergency responders. Concerns regarding contaminated water

runoff from decontamination of people and critical equipment
should not impede decontamination efforts (EPA, 2008a). This sub-
sequently will become a significant problem whose solution must
still be determined by governmental authorities.
Disposal of radioactive waste is a complex issue, not only
because of the nature of the waste, but also because of the compli-
cated regulatory structure for dealing with radioactive waste. There
are a variety of stakeholders affected, and there are a number of
regulatory entities involved. Federal agencies involved in radioac-
tive-waste management include EPA, NRC, DOE, and the U.S.
Department of Transportation. In addition, the states and affected
tribes play a prominent role in protecting members of the general
public against the hazards of radioactive waste (EPA, 2008a).
In cases in which no agency or state is responsible for the radio-
active waste involved in a terrorism incident, EPA assumes the
coordinating federal agency role from DOE for the environmental
cleanup and site restoration phases of the response (EPA, 2008b;
FEMA, 2008b). The U.S. Department of Defense and the U.S. Army
Corps of Engineers may have some responsibility for environmen-
tal remediation after a radiological terrorism incident.
If possible, radioactively-contaminated clothing obtained from
individuals during decontamination should be appropriately pack-
aged and labeled (name, location, time and date, and marked
clearly with: RADIOACTIVE – DO NOT DISCARD). This clothing
may be needed later for criminal forensics and/or for a dose recon-
struction project. The scope of the incident (i.e., small- versus large-
scale RDD or IND), and the resources available, will determine the
feasibility of this action.
Packaging of radioactive waste should be addressed by planners.
The question of who will handle the radioactive waste and what
PPE they will require also should be addressed. Packaging of waste
should occur at all locations where decontamination may take place
such as on the scene of the incident, TDCs, hospital reception (tri-
age) and decontamination centers, hospital EDs, CRCs, or other
locations. In addition, many individuals will go home to decontam-
inate; in large-scale incidents this may be the preferred advice pro-
vided to members of the general public. In this event, written
instruction on home decontamination should be distributed to indi-
viduals and through the media. Planning should address how to
handle presumably contaminated clothes, automobiles and homes
as the timeline of the incident unfolds. Possibly, commercial radio-
active-waste handling companies could be contracted to dispose of
the radioactive waste.
112 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

7.10 Handling Contaminated Deceased Persons

Recommendation: Planners should ensure that deceased vic-

tims of a radiological or nuclear terrorism incident, who may be
contaminated with radioactive material, are handled safely
and appropriately.

Radiological terrorism may produce a relatively small number

of deceased persons with radionuclide contamination, whereas an
IND explosion in a populated area will result in large numbers of
contaminated injured and fatal casualties. For medical examiners
and mortuary personnel, it is important to control contamination
in the work area, thereby minimizing risk to these workers. Deci-
sion points are needed for handling deceased persons with loose
surface contamination, internal contamination, or shrapnel on or
in deceased persons (Wood et al., 2007).
There are two federal Disaster Mortuary Operational Response
Teams (DMORTs) under the National Disaster Medical System as
part of DHHS:

• Office of Preparedness and Response, under Emergency

Support Function No. 8; and
• Public Health and Medical Care (FEMA, 2008a).

The function of DMORTs is to provide victim identification and

mortuary services (DHHS, 2008). DMORT responsibilities include:

• temporary morgue facilities;

• victim identification;
• forensic dental pathology;
• forensic anthropology methods;
• processing;
• preparation; and
• disposition of remains.

DMORTs are composed of private citizens, each with a particular

field of expertise, who are activated in the event of a disaster. Dur-
ing an emergency response, DMORTs work under the guidance of
local authorities by providing technical assistance and personnel to
recover, identify and process deceased victims. Teams are composed
of funeral directors, medical examiners, coroners, pathologists,
forensic anthropologists, medical records technicians, transcribers,
finger-print specialists, forensic odontologists, dental assistants,
 7.10 HANDLING CONTAMINATED DECEASED PERSONS / 113

x-ray technologists, behavioral health specialists, computer profes-

sionals, administrative support staff, and security and investigative
personnel (DHHS, 2008).
The FEMA Response Division, in support of DMORT program,
maintains two disaster portable morgue units. A disaster portable
morgue unit is a depository of equipment and supplies for deploy-
ment to a disaster site. It contains a complete morgue with desig-
nated workstations for each processing element and prepackaged
equipment and supplies (DHHS, 2008).
Persons involved in radiological or nuclear terrorism incidents
are likely to be contaminated, perhaps heavily, so their bodies may
remain contaminated after their death. Although dose rates from
even relatively-high levels of contamination are not likely to be sig-
nificant, certain precautions are still recommended. High radiation
levels from deceased persons after an IND will quickly decay allow-
ing access to the remains after a matter of days. In particular, all
persons handling contaminated bodies must take appropriate mea-
sures to minimize their doses using the ALARA principle, and the
deceased persons should be treated in such a way as to minimize
the spread of contamination (Section 7.6). Many of these precau-
tions are similar to those that would be taken due to standard
(blood-borne) precautions (NCRP, 2008).
Although there are laws regulating the medical use of byproduct
material in patients (NRC, 2006), there are no federal regulations
concerning radioactive material on or in human remains. Guidance
is available on handling radioactively-contaminated deceased per-
sons from medical sources (NCRP, 1991), from transportation acci-
dents (DOE, 2000), and by the military (JCS, 1997). Each state has
policies for transporting deceased persons and there are federal
regulations for shipment of radioactive material (DOT, 1977).
Guidelines are available for dealing with contaminated deceased
persons from the National Association of Medical Examiners
(NAME, 2006).
Radionuclide contamination can be found externally on clothes
and skin, internally lodged in organs, or present as shrapnel in bod-
ies. Most external radionuclide contamination is likely to be elimi-
nated by removing clothes and rinsing the exposed skin (Hanzlick
et al., 2007). Section 7.6 discusses the issue of decontamination in
greater detail. Internal contamination usually occurs in a living
person by breathing contaminated air or ingesting contaminated
foodstuffs. Intake of radioactive material stops upon the person’s
death. After death, the internal contamination cannot be removed
from the body but is usually not hazardous to emergency respond-
ers such as the medical examiner’s staff. However, small pieces of
114 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

radioactive material embedded in tissue by the force of an explo-

sion (shrapnel) could emit enough radiation to cause emergency
responders including medical examiners and their staff to exceed
occupational dose limits or experience deterministic effects (Smith
et al., 2005). NCRP recommends early surveying of the bodies for
radiation levels and quantity of contamination so that this mate-
rial can be surgically removed during initial evaluation by the med-
ical examiner (Wood et al., 2007).
NCRP Commentary No. 19 (NCRP, 2005) defines emergency
responder to include healthcare staff involved in forensic investiga-
tions and who, as such, would be subject to the effective dose limit
set for such workers (NCRP, 2005). Mortuary or funeral-director
staff may be designated as emergency responders and would then
be subject to an effective dose limit of 5 rem y–1 (50 mSv y–1) (NRC,
1993).
As stated above, there are no specific laws regulating the proper
handling of deceased persons contaminated with radioactive mate-
rial, nor is there a specific right or wrong procedure. Medical exam-
iners, coroners, funeral directors, and health physicists will have to
devise working methodologies for each situation. The objectives, in
priority order, are (Wood et al., 2007):

• Deterministic effects will be avoided: If workers keep their

doses below the annual occupational dose limit (NRC, 1993)
they will not incur any deterministic effects. Medical exam-
iners or coroners will perform a professional medical and
legal investigation to identify deceased persons scientifi-
cally and determine the cause and manner of death. Medical
examiners will receive some radiation exposure performing
their work both at the scene and in the morgue. They are
classified as emergency responders and would be subject to
appropriate dose limits set for this classification.
• Human remains will be treated with dignity and respect:
Human remains will be processed as expeditiously as possi-
ble and released to the families. If bereaved family members
want a funeral with a viewing or the religious practice of the
decedent calls for a ceremonial washing, this will be allowed
even though it causes some additional radiation exposure.
Informed consent would be needed so that individuals, other
than the emergency responder, were aware of the increased
risk of these practices, as feasible.
• Medical examiners will minimize the spread of contami-
nation: Deceased persons will be transported to a field mor-
gue with clothing and personal effects intact, even though
 7.11 RECRUITMENT AND CREDENTIALING / 115

this may spread contamination. However, the practices

employed in the morgue will prevent any further spread.
• Radiation exposures should be optimized for maximum pro-
tection of human health: No one should receive a radiation
exposure unless there is some benefit. Conducting a proper
investigation is required by law, and respecting the religious
or emotional needs of the bereaved family is a benefit.
• The bodies of deceased victims may contain crime-scene evi-
dence: Law enforcement may be expected to work closely
with the medical examiners to preserve vital crime-scene
evidence.

7.11 Recruitment and Credentialing

of Supplementary Personnel

Acquiring an adequate number of medical, nursing, radiation

safety, and other professionals to staff TDCs, CRCs, AMTSs, hospi-
tals, and other locations in a disaster situation may be quite chal-
lenging. Current planning calls for a variety of trained professionals
and volunteers, both local and from outside the region, being uti-
lized to cover staffing shortages. It is necessary to ensure that these
individuals are properly qualified and credentialed for the work
they will be asked to perform.

Recommendation: Ensure that physicians, nurses, radiation

safety staff (radiologic technologists, nuclear-medicine technol-
ogists, medical physicists, and health physicists), and other
professionals who will augment the staff at hospitals, AMTSs,
CRCs, and other sites are credentialed and have identification
documents.

All public-health and medical responders should be creden-

tialed. Hospital, public-health, and other medical staff should have
appropriate credentialing. However, supplemental staff should be
credentialed based upon existing standards.
A credentialing process must be established with local access
capability by administrative personnel at the victim receiving ven-
ues such as hospitals and with local, state and tribal public-health
authorities. Many states have laws that waive certain credential-
ing requirements during disasters while others use gubernatorial
disaster declarations to provide relief from some regulations gov-
erning staff qualification requirements.
116 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

The DHHS Office of the Assistant Secretary for Preparedness

and Response has developed the Emergency System for Advance
Registration of Volunteer Health Professionals to establish a
national network of state-based programs that facilitate the use of
health-professional volunteers in local, regional, state, tribal and
federal emergency responses. Under this program, most states
have developed emergency-health volunteer registries that are
involved with the recruitment, advanced registration, licensure
and credential verification, assignment of standardized credential
levels, and mobilization of volunteers.
MRC, a component of DHHS Citizen Corps, is a readily available
locally-sponsored entity found in many communities nationwide
that provides preparedness and response training and increased
capabilities for health professionals and others including radiation
professionals (MRC, 2008). MRCs are commonly located within
local public-health departments and, as such, the volunteers are,
when activated, considered employees of that organization (Ansari,
2009). Training in the incident command system, public health pre-
paredness, and other topics is available to MRC members. Just-in-
time training would be provided as needed.
The healthcare accrediting organizations require facilities such
as hospitals to have specific protocols for emergency credentialing.
These systems, along with other credential verification procedures,
should be used in the interim for any disaster activations. Federal
assignees such as those with the National Disaster Medical System
as disaster medical-assistance teams or as state medical-response
teams or the like will be already credentialed. Local, state and
tribal public-health and other government employees will likewise
be credentialed through their sponsoring agency. At a minimum,
the credentialing process should be able to verify the following
information:
• name;
• address and contact information;
• agency affiliation;
• licensure;
• level of training;
• level of experience;
• any pending legal action, and
• qualification for assigned task.

Individuals arriving at the scene of an incident or to any specific

venue requesting to assist should be directed to the incident com-
mand operations branch that handles these types of volunteers. If
they are from the same state, then those who have registered with
 7.11 RECRUITMENT AND CREDENTIALING / 117

that state’s emergency-health volunteer registry can be readily

identified and credentialed onsite by contacting the state registry.
The state licensure of those licensed by the same state but who
have not registered can be verified by that state’s health depart-
ment or other licensing agency. Ideally, out-of-state volunteers
who have registered with their own state’s emergency registry
could have their credentialing information verified by a state-to-
state registry communication, if available. Currently, volunteers
from other states who are not registered will be difficult to creden-
tial and their status will depend on individual state laws and local
authority discretion until uniform credentialing procedures are
adopted.
Because of the problems associated with credentialing inter-
state and even intrastate healthcare professionals after Hurricanes
Katrina and Rita, the Uniform Emergency Volunteer Health Prac-
titioners Act (UEVHPA, 2007) was developed by the National Con-
ference of Commissioners on Uniform State Laws. This Act was
developed to establish uniform procedures across all states who
adopted this as law to facilitate the deployment and use of licensed
health professionals to provide health and veterinary services in
response to a declared disaster. The public and private sector
healthcare professionals covered by this Act would be used to sup-
plement the resources provided by local, state and tribal govern-
ment employees and other emergency responders. The specific
provisions of the Act:

• establishes a system for the use of volunteer health practi-

tioners capable of functioning autonomously even when rou-
tine methods of communication are disrupted;
• provides reasonable safeguards to ensure that volunteer
health practitioners are appropriately licensed and regu-
lated to protect the health of members of the general public;
• allows states to regulate, direct and restrict the scope and
extent of services provided by volunteer health practitioners
to promote disaster recovery operations;
• provides limitations on the exposure of volunteer health
practitioners to civil liability to create a legal environment
conducive to volunteerism; and
• allows volunteer health practitioners who suffer injury or
death while providing services pursuant to this Act the
option to elect workers’ compensation benefits from the host
state if such coverage is not otherwise available (UEVHPA,
2007).
118 / 7. PREPARING THE MEDICAL SYSTEM RESPONSE

After verification of credentials, they would then be issued iden-

tification documents to facilitate access to the site where they are
needed and integrated into the response. Documentation of individ-
uals staffing facilities after a radiological or nuclear terrorism inci-
dent should be performed so that long-term health monitoring can
occur following any work-related exposure.
Appendix A

Employer and
Emergency Responder
Responsibilities

Most personnel engaged in the response to a radiological terror-

ism incident (i.e., the emergency responders) who may incur radia-
tion exposures shall be considered occupationally-exposed workers.
Organizations that employ them are termed employers. Both work-
ers and employers should be subjected to requirements of occupa-
tional radiation protection standards. Examples of emergency
responders include firefighters and examples of employers are fire-
fighting departments. Voluntary comforters are usually not consid-
ered “workers” and are therefore not subject to the occupational
requirements of radiation protection standards [they are subject to
the dose limit for members of the general public [i.e., 100 mrem y–1
(1 mSv y–1) effective dose]. However, any dose to individual comfort-
ers incurred knowingly while voluntarily helping in the care, sup-
port or comfort of victims shall be specifically constrained to
prevent or minimize radiation exposure.
In general, under routine, nonemergency-response operations,
occupational radiation protection responsibilities of employers and
emergency responders are as follows.
Employers shall be responsible for:

• protecting the emergency responders and complying with

relevant requirements of the occupational radiation protec-
tion standards, ensuring in particular that:
- occupational doses are limited as specified in the rele-
vant requirements; and
- occupational doses are consistent with the ALARA prin-
ciple.

119
120 / APPENDIX A

• ensuring that decisions regarding measures for occupa-

tional protection and safety be recorded and made available
to emergency responders;
• establishing policies, procedures, and organizational
arrangements for protection and safety to implement rele-
vant requirements, with priority given to measures for con-
trolling occupational exposures;
• providing suitable and adequate facilities, equipment and
services for protection and safety, the nature and extent
of which are commensurate with the expected magnitude
and likelihood of the occupational exposure;
• providing necessary health surveillance and health services;
• providing appropriate protective devices and monitoring
equipment and arranging for their proper use;
• providing suitable and adequate human resources and
appropriate training in protection and safety, as well as
periodic retraining and updating as recommended in order
to ensure the necessary level of competence, keeping records
of the training provided to individual emergency responders;
• consultation and cooperation with emergency responders
with respect to protection and safety, about all measures nec-
essary to achieve the effective implementation of require-
ments;
• promoting a safety culture, which is defined as the collective
actions and attitudes of an institution and its workers
which elevate the priority of safety issues to the proper level
and encourage the adoption of the best available safety tech-
nology and standards-of-practice (NCRP, 2009);
• in consultation with emergency responders, developing and
writing procedures as are necessary to ensure adequate lev-
els of protection and safety, including values of any relevant
dose level that require investigation or specific authoriza-
tion and the procedure to be followed in the event that any
such value is exceeded; making such procedures and their
protective measures and safety provisions known to those
emergency responders to whom they apply;
• supervising any work involving occupational exposures and
ensuring that all reasonable steps are taken to ensure that
the regulations, procedures, protective measures, and safety
provisions are observed;
• providing information on the health risks due to poten-
tial occupational exposures that may occur during such
responses, instruction and training on protection and safety,
 A. EMPLOYER AND RESPONDER RESPONSIBILITIES / 121

and information on the significance for protection and safety

of response actions;
• obtaining, as a precondition for engagement of emergency
responders, the previous occupational exposure histories of
such emergency responders and other information as may
be necessary to provide protection and safety;
• taking administrative actions as are necessary to ensure
emergency responders are informed that protection and
safety are integral parts of a general occupational health
and safety program in which they have certain obligations
and responsibilities for their own protection and the protec-
tion of others, and in particular record any report received
from an emergency responder that identifies circumstances
which could affect compliance, and take appropriate action;
• arranging for the assessment of occupational exposures of
emergency responders, on the basis of personal monitoring
where appropriate, and ensuring that adequate arrange-
ments are made with appropriate dosimetry services under
an adequate quality-assurance program;
• arranging for appropriate health surveillance, if needed
post-incident, based on the general principles of occupa-
tional health and designed to assess the initial and continu-
ing fitness of emergency responders for their intended tasks;
• maintaining exposure records for each emergency responder,
which shall include:
- information on the general nature of the work in the
response involving occupational exposures;
- information on doses, exposures and intakes at or above
the relevant recording levels and the data upon which
the dose assessments have been based;
- when an emergency responder is or has been occupation-
ally exposed while in the employ of more than one
employer, information on the dates of employment with
each employer and the doses, exposures and intakes
in each such employment; and
- records of any doses, exposures or intakes due to other
emergency interventions or accidents.
• providing for access by emergency responders to informa-
tion in their own exposure records and for access to the
exposure records by the supervisor of the health surveil-
lance program and facilitating the provision of copies of
emergency responders’ exposure records to new employers
when emergency responders change employment, and pre-
serving such records during the emergency responder’s
122 / APPENDIX A

working life and afterwards; at least until the worker

attains or would have attained the age of 75 y, and for not
less than 30 y after the termination of the work involving
occupational exposure; and
• facilitating compliance by emergency responders with the
occupational radiation protection requirements.

Emergency responders shall be responsible for:

• following any applicable regulations and procedures for pro-

tection and safety specified by the employer;
• accepting such information, instruction and training con-
cerning radiological protection and safety to enable them to
conduct their work in accordance with the requirements of
occupational radiation protection standards;
• using proper personal monitoring devices and protective
equipment and clothing, as necessary;
• cooperating with the employer with respect to protection
and safety and the operation of radiological health surveil-
lance and dose assessment programs;
• providing to the employer information on their past and cur-
rent work as is relevant to ensure effective and comprehen-
sive protection and safety for themselves and others;
• abstaining from any willful action that could put themselves
or others in situations that contravene the requirements;
and
• reporting to the employer, as soon as feasible, circumstances
that could adversely affect compliance with the standards, if
for any reason a worker is able to identify such circum-
stances (e.g., lifesaving activities involving radiation doses
exceeding the occupational limits).

Conditions of service for emergency responders shall be inde-

pendent of the existence or the possibility of occupational exposure.
Special compensatory arrangements or preferential treatment with
respect to salary or special insurance coverage, working hours,
length of vacation, additional holidays, or retirement benefits shall
neither be granted nor used as substitutes for the provision of
proper protection and safety measures to ensure compliance with
the requirements of the relevant occupational radiation protection
standards. The notification of pregnancy or nursing shall not be
considered a reason to exclude a female emergency responder from
work, However, the employer of a female emergency responder
who has notified her employer in writing of her pregnancy should
 A. EMPLOYER AND RESPONDER RESPONSIBILITIES / 123

ensure that the embryo or fetus, or the nursing infant is afforded

the same broad level of protection as recommend for members
of the general public.
For the extreme situations that may likely occur after a radio-
logical or nuclear terrorism incident, the following actions are
recommended:

• For emergency responders undertaking rescue operations

that involve saving life, no dose restrictions are recom-
mended. In these instances, applying the ALARA principle
is viewed as making every reasonable and practical effort to
both maintain doses to radiation below the levels that cause
early health effects, and to reduce the risk of stochastic
effects, so as to maximize lifesaving and protection of criti-
cal infrastructure.
• Otherwise, for rescue operations involving the prevention of
serious injury or the development of catastrophic conditions,
every effort should be made to prevent deterministic effects
on health.
• For emergency responders undertaking other immediate
and urgent rescue actions to prevent injuries or large doses
to many people, all reasonable efforts should be made to
keep absorbed doses consistent with the ALARA principle.

Rescuers undertaking actions in which the effective dose may

exceed 5 rem (50 mSv) should be volunteers, and should be well
prepared for dealing with the effects on the health of emergency
responders (i.e., they should be clearly and comprehensively
informed in advance of the associated health risk) and, to the
extent feasible, be trained in the actions that may be recom-
mended, including the use of protective measures such as PPE,
means of shielding, and use of medical countermeasures (if war-
ranted) (IAEA, 1996).
Appendix B

Public Information
Statements

B.1 In the Event of a Radiological Dispersal Device

RDD: Public Information Statement No. 1

(Can be used immediately after the explosion, as soon as the fire
department arrives and detects radiation.)

There has been an explosion at __________ [site of explosion].

Fire and police personnel are on the scene. A radionuclide was
spread by the explosion. People should stay away to facilitate
response efforts and reduce the possibility of radiation exposure
from this incident. We request that people avoid using telephones,
including cell phones, to ensure lines are available for emergency
responders.
We will provide a follow-up message on this issue in 1 h or
sooner if additional information becomes available. This follow-up
message is estimated to be issued not later than __________ [e.g.,
give time as X:XX am/pm].

RDD: Public Information Statement No. 2

(Can be used when additional information is available.)

There has been an explosion at __________ [site of explosion].

The fire, police and health departments are on the scene. A radio-
nuclide was spread by the explosion. This was NOT a nuclear
bomb. The highest levels of radionuclide contamination are in the
area near the explosion, but we will be determining if the activity
has traveled from the site of the explosion. Members of the general
public should stay away to facilitate response efforts, and to reduce
the possibility of radiation exposure from this incident.

124
 B.1 IN THE EVENT OF A RADIOLOGICAL DISPERSAL DEVICE / 125

Although we do not have evidence that radioactive material has

spread beyond the area near the explosion, the wind may have car-
ried small quantity away from the site of the explosion. As a pre-
caution, people should stay indoors for their personal safety. If you
are located [north, south, east, west] of __________, and within
__________ miles of the explosion, you should close the doors and
windows and turn off fans that bring in air from the outside.
In-room fans that only recirculate air are OK to use. Air condition-
ing systems that do not bring in air from the outside may be oper-
ated. If you are in a large building [office, retail, industrial or other]
you should move to the center of the building and the maintenance
staff should put the system on “recirculation.”
To minimize your risk of radionuclide contamination, those who
were at the __________, [explosion site] or outdoors since __________
[time of the explosion] in the __________ area, are advised to change
clothes and place the clothes you had been wearing in a plastic bag.
As most of the contamination will be on your clothes, removing the
clothing reduces any contamination by ~80 to 90 % depending on
the amount of the body covered by clothing. Place the plastic bag in
a garage, or other remote location. If possible, take a shower with
warm, not hot, water and gently wash your body and hair with ordi-
nary soap and shampoo that does not contain a conditioner. Do not
apply conditioner after you have washed your hair. Children, if
home, should also be given a shower or bath under supervision of a
parent or other adult. Again, we recommend you stay indoors. If we
determine that you would be safer in another location, we will
advise you where to go. You should not go to a hospital unless you
were injured in the explosion, or have another medical emergency
requiring immediate treatment, such as a heart attack.
If you have a pet that was outside, the pet can be washed as you
normally would wash the pet, but inside, either in your shower or
bathtub, or in a tub. Be sure to take a shower yourself, after you
have washed the pet.
You may drink or bathe in the water from your faucet. You may
eat the food in your house. Food that was outdoors since __________
[time] today, within a few miles of __________ [explosion site]
may need to be avoided.
We request that members of the general public avoid using tele-
phones, including cell phones, to ensure lines are available for
emergency responders. We also request that the media not fly over
the scene so that airspace is available for emergency air respond-
ers, and to reduce air movement around the scene.
We will continue to monitor the area to establish the extent of
radionuclide contamination to ensure the safety of members of the
126 / APPENDIX B

general public. You should listen to the radio or television for

announcements; following the instructions from public officials will
best ensure your safety. We will provide a follow-up message on this
issue in 1 h or sooner if additional information becomes available.
This follow-up message is estimated to be issued not later than
__________ [e.g., give time as X:XX am/pm].

RDD: Public Information Statement No. 3

(Can be delivered within a few hours of the incident.)

There has been an explosion at __________ [site of explosion].

The fire, police and health departments are on the scene. A radio-
nuclide was spread by the explosion. This was NOT a nuclear
bomb. People should stay away to facilitate response efforts, and to
reduce the possibility of radiation exposure from this incident.
Over the last hour we have determined that some radioactive
material was carried __________ [north, south, east, west] of the
explosion site by the wind. At this point, we do not know the extent
to which the winds have carried the radioactive material, so we
continue to advise people to stay indoors for their personal safety.
As a precaution, if you are located within __________ miles
(__________ km) __________ [north, south, east, west] of __________
[explosion site], you should close the doors and windows and turn
off fans that bring in air from the outside. In-room fans that only
recirculate air are OK to use. Air conditioning systems that do not
bring in air from the outside may be operated. If you were at
__________ [explosion site] when there was an explosion but have
left and are not yet home, you may either continue home and
shower there, or go to __________ [evacuation location(s)].
To minimize your risk of radionuclide contamination, those who
were outdoors since __________ [time of the explosion] and within
__________ miles __________ [north, south, west, east] of the
__________ [location of the explosion] are advised to change clothes
and place the clothes you had been wearing in a plastic bag, which
will likely reduce any contamination by ~80 to 90 % depending on
the amount of the body covered by clothing. If possible, take a
shower with warm, not hot, water and gently wash your body and
hair with ordinary soap and shampoo that does not contain a con-
ditioner. Do not apply conditioner after you have washed your hair.
Again, we recommend you stay indoors. If we determine that you
would be safer in another location, we will advise you where to go.
You should not go to a hospital unless you were injured in the explo-
sion or have a medical emergency requiring immediate treatment,
such as a heart attack. Right now, the safest place for you is indoors.
 B.1 IN THE EVENT OF A RADIOLOGICAL DISPERSAL DEVICE / 127

You may drink or bathe in the water from your faucet. You may
eat the food in your house. Food that was outdoors since __________
[time] today, within a few miles of __________ [explosion site]
may need to be avoided.
We have received questions about using potassium iodide (KI)
pills. KI is not useful for the radionuclide used in this explosion and
will not provide protection from radiation. Therefore, we do not
advise the use of KI pills. Sheltering, or evacuation if public offi-
cials make that recommendation, provides the best protection.
We request that members of the general public avoid using tele-
phones, including cell phones, to ensure lines are available for
emergency responders. We also request that the media not fly over
the scene so that airspace is available for emergency air respond-
ers, and to reduce air movement around the scene.
We will continue to monitor the area to establish the extent of
radionuclide contamination to ensure safety of members of the gen-
eral public. We will provide a follow-up message on this issue in 1 h
or sooner if additional information becomes available. This follow-
up message will be issued not later than __________ [e.g., give time
as X:XX am/pm].

RDD: Public Information Statement No. 4

(Can be used after the presence of radioactive material
has been confirmed and when recommending evacuation of
designated areas.)
There was an explosion at __________ [site of the explosion]. The
fire, police and health departments are on the scene. A radionuclide
was spread by the explosion. This was NOT a nuclear bomb.
Although the highest levels of radionuclide contamination are in
the area near the explosion, radioactive material was carried by the
wind in a __________ [northern, southern, eastern, western] direc-
tion from the site of the explosion. As a precaution, we are evacuat-
ing residents closer than __________ mile __________ [north, south,
east, west] of the explosion site. That is, those within the area north
of __________ [street, avenue, etc.], south of __________ [street,
avenue, etc.], east of __________ [street, avenue, etc.] and west of
__________ [street, avenue, etc.]. These residents should report to
__________ [name the evacuation center(s) and give address(es)],
where staff will determine if radionuclide contamination is present
and provide additional decontamination if needed. ONLY the indi-
viduals within this designated area are advised to evacuate. If
we determine that additional evacuations are advisable, you will be
told when and where to go. If you do not have transportation, please
call XXX-XXX-XXXX, and you will be given more instructions.
128 / APPENDIX B

As a precaution, if you are located within __________ miles

__________ [compass direction] of the __________ [explosion site],
you should continue to stay indoors, keep the doors and windows
closed and turn off fans that bring in air from the outside. In-room
fans that only recirculate air are OK to use. Air conditioning sys-
tems that do not bring in air from the outside may be operated.
You may drink or bathe in the water from your faucet. You may
eat the food in your house. Food that was outdoors since __________
[time] yesterday may need to be avoided.
We have received questions about using potassium iodide (KI)
pills. KI is not useful for the radionuclide used in this explosion.
Therefore, we do not advise the use of KI pills.
(This paragraph may not be needed by day two.) We request peo-
ple avoid using telephones, including cell phones, to ensure lines
are available for emergency responders. We also request the media
not fly over the scene so that airspace is available for emergency air
responders, and to reduce air movement around the scene.
We will continue to monitor the area to establish the extent of
radionuclide contamination to ensure the safety of members of the
general public. We will provide a follow-up message in 3 h or sooner
if additional information becomes available. This follow-up mes-
sage is estimated to be issued not later than __________ [e.g., give
time as X:XX am/pm].

B.2 In the Event of an Improvised Nuclear Device

IND: Public Information Statement No. 1

(Can be used immediately after the explosion, as soon as the fire
department arrives and detects radiation and it appears to have
been a nuclear terrorism incident.)

There has been an explosion at __________ [site of detonation].

Fire and police personnel are responding. Because of the size and
extent of the explosion, and the presence of significant radiation
levels, this may have been a nuclear explosion, releasing large
quantity of radioactive material. People should stay away to facili-
tate response efforts and reduce the possibility of radiation expo-
sure from this incident. If you are outside, go inside the nearest
stable building. If you are inside a building, you should stay inside.
If the building has a basement, you should go to the lowest level. If
the building does not have a basement, you should get as close as
possible to the center of the building and go up two or three floors
if it is a multistory building.
 B.2 IN THE EVENT OF AN IMPROVISED NUCLEAR DEVICE / 129

We request that people avoid using telephones, including cell

phones, to ensure lines are available for emergency responders.
We will provide a follow-up message on this issue in 1 h or
sooner if additional information becomes available. This follow-up
message is estimated to be issued not later than __________ [e.g.,
give time as X:XX am/pm].

IND: Public Information Statement No. 2

(Can be used when additional information is available.)
There has been a nuclear explosion at __________ [site of the det-
onation]. The fire, police and health departments are assisting
injured people. The highest levels of radionuclide contamination
are near the explosion, and downwind from the explosion, going
from the __________ [north, south, east, west] to the __________
[north, south, east, west]. People should stay away from this area to
allow response efforts to take place, and to reduce the possibility of
radiation exposure from the incident. If you are outside, you should
go to the nearest stable building. The building may have windows
that have been blown out, but if that appears to be the only damage
and the building appears to be structurally sound, go inside the
building if no other building is nearby that still has windows. If you
are inside a building, you should stay inside. If the building has
a basement, go to the lowest level. If the building does not have a
basement, you should get as close as possible to the center of the
building and go up two or three floors if it is a multistory building.
You need to stay in this location unless advised differently by
authorities.
The radiation levels are expected to significantly decrease over
the next 24 to 48 h. You will be endangering yourself and others if
you try to leave the building you are in. We understand how diffi-
cult this will be, but you will endanger your children’s lives, as well
as your own, if you try to retrieve your children from school. Schools
have prepared for taking care of the children, and children are saf-
est staying in their schools. We also understand your desire to
return home, and to gather your family. But taking that action
could endanger everyone’s lives. Please stay where you are. We will
provide further instructions on reuniting with your family as
quickly as we can.
Even if you are not downwind and do not appear to have any
structural damage in your location, stay indoors for your personal
safety. You should close the doors and windows and turn off fans
that bring in air from the outside. In-room fans that only recircu-
late air are OK to use. Air conditioning systems that do not bring
in air from the outside may be operated.
130 / APPENDIX B

To minimize your risk of radionuclide contamination, people

who were near the __________ [explosion site], or outdoors since
__________ [time of the explosion] in the potentially-contaminated
area, are advised to change clothes and place the clothes you had
been wearing in a plastic bag. Because most of the contamination
will be on your clothes, removing your clothing reduces any con-
tamination by ~80 to 90 %. Place the plastic bag in a garage or
other remote location. If possible, take a shower with warm, not
hot, water and gently wash your body and hair with ordinary soap
and shampoo that does not contain a conditioner. Do not apply con-
ditioner after you have washed your hair. You should stay indoors.
If we determine that you would be safer in another location, we will
advise you where to go. You should not go to a hospital unless you
were injured in the explosion, or have another medical emergency
requiring immediate treatment, such as a heart attack.
You may drink or bathe in the water from your faucet. You may
eat the food in your house. Do not eat food or water that has been
outside.
We request that people avoid using telephones, including cell
phones, to ensure lines are available for emergency responders. We
also request that the media not fly over the scene so that airspace
is available for emergency air responders, and to reduce air move-
ment around the scene.
We will continue to respond and monitor the area to establish
the extent of radionuclide contamination and structural damage to
ensure the safety of members of the general public. We will provide
an update in 1 h or sooner if additional information becomes avail-
able. This follow-up message is estimated to be issued not later
than __________ [e.g., give time as X:XX am/pm].

IND: Public Information Statement No. 3

(Can be delivered within a few hours of the incident.)

There has been a nuclear explosion at __________ [site of detona-

tion]. The fire, police and health departments are implementing
their emergency-response plans. People should stay away to facili-
tate response efforts, and to reduce their radiation exposure from
this incident.
We have determined that a radionuclide was carried __________
[north, south, west or east; name neighborhoods, cities, towns, or
other locations in addition to the compass direction, if possible]
of the explosion site by the wind. At this point, we do not know
the extent to which the winds have carried the radioactive mate-
rial, so we continue to advise people to stay indoors for their own,
 B.2 IN THE EVENT OF AN IMPROVISED NUCLEAR DEVICE / 131

and others, safety. If you are located within __________ miles

(__________ km) __________ of __________ [explosion site], you
should close the doors and windows and turn off fans that bring in
air from the outside. In-room fans that only recirculate air are OK
to use. Air conditioning systems that do not bring in air from the
outside may be operated. This applies to a residential home, not an
office building. If you were outside and saw the explosion and are
not yet home, you may either continue home and shower there, or
go to one of the following __________ [name the evacuation center(s)
and give address(es)].
To minimize your risk of radionuclide contamination, people who
were outdoors since __________ [time of the explosion] and within
__________ miles [north, south, east, west] of the __________ [loca-
tion of the explosion] should change clothes and place the clothes
you were wearing in a plastic bag, which will likely reduce any
contamination by ~80 to 90 % depending on the amount of the body
covered by clothing. If possible, take a shower with warm, not hot,
water and gently wash your body and hair with ordinary soap and
shampoo. Children, if home, should also be given a shower or bath
under supervision of a parent or other adult. Again, we recommend
you stay indoors. If we determine that you would be safer in another
location, we will advise you where to go. You should not go to a hos-
pital unless you were injured in the explosion, or have a medical
emergency requiring immediate treatment, such as a heart attack.
Right now, the safest place for you is indoors.
You may drink or bathe in the water from your faucet. You may
eat the food in your house. Food that was outdoors since __________
[time] today, within a few miles of __________ [explosion site]
may need to be avoided.
We have received questions about using potassium iodide (KI)
pills. KI will only reduce the radiation dose to one organ, the thy-
roid, and should be taken as soon as possible after being exposed,
as the KI pills’ effectiveness decreases rapidly. Begin taking
KI within the first hour or two after the explosion, or as soon as you
can. Continue taking KI until told it is OK to stop. The dose of KI
varies according to size in children and age in adults, and also is
different for pregnant women.
We request that people avoid using telephones, including cell
phones, to ensure lines are available for emergency responders. We
also request that the media not fly over the scene so that airspace
is available for emergency air responders, and to reduce air move-
ment around the scene.
We will continue to monitor the area to establish the extent
of damage and radionuclide contamination to ensure the safety of
132 / APPENDIX B

members of the general public. We will provide a follow-up message

on this issue in 1 h or sooner if additional information becomes
available. This follow-up message is estimated to be issued not
later than __________ [e.g., give time as X:XX am/pm].

IND: Public Information Statement No. 4

(Can be used when evacuation of designated areas is
recommended.)

There was a nuclear explosion at __________ [site of the detona-

tion]. The fire, police and health departments have activated emer-
gency plans. Although the highest levels of radionuclide
contamination are within about a mile radius from the explosion,
radioactive material was carried by the wind in a __________
[northern, southern, eastern, western] direction from the site of the
explosion. We are evacuating residents closer than __________ mile
__________ [north, south, east, west] of the explosion site. That is,
those within the area north of __________ [street, avenue, etc.],
__________ south of __________ [street, avenue, etc.], east of
__________ [street, avenue, etc.], and west of __________ [street, ave-
nue, etc.]. These residents may report to __________ [name the evac-
uation center(s) and give address(es)], where staff will be onsite to
determine if contamination is present, and provide additional
decontamination if needed. ONLY the individuals within this des-
ignated area are advised to evacuate. If we determine that addi-
tional evacuations are advisable, you will be told where to go.
As a precaution, if you are located within __________ miles
__________ [compass direction] of the __________ [explosion site],
you should continue to stay indoors, keep the doors and windows
closed and turn off fans that bring in air from the outside. In-room
fans that only recirculate air are OK to use. Air conditioning sys-
tems that do not bring in air from the outside may be operated.
You may drink or bathe in the water from your faucet. You may
eat the food in your house. Food that was outdoors since __________
[time] yesterday may need to be avoided.
We have received questions about using potassium iodide (KI)
pills. KI will only reduce the radiation dose to one organ, the thy-
roid, and should be taken as soon as possible after the exposure, as
KI pills’ effectiveness decreases rapidly. Begin taking KI within the
first hour or two after the explosion, or as soon as you can. Continue
taking KI until told it is OK to stop. The dose of KI varies according
to size in children and age in adults, and also is different for preg-
nant women.
 B.2 IN THE EVENT OF AN IMPROVISED NUCLEAR DEVICE / 133

We request people avoid using telephones, including cell phones,

to ensure lines are available for emergency responders. We also
request the media not fly over the scene so that airspace is avail-
able for emergency air responders, and to reduce air movement
around the scene.
We will continue to monitor the area to establish the extent of
radionuclide contamination to ensure safety of members of the gen-
eral public. We will provide a follow-up message in 3 h or sooner if
additional information becomes available. This follow-up message
is estimated to be issued not later than __________ [e.g., give time
as X:XX am/pm].
Appendix C

Key Decisions for

Federal Decision
Makers (as they relate
to international
conventions and
agreements)

C.1 Introduction
Should a radiological or nuclear terrorism incident occur in a
territory under the jurisdiction or control of the United States,
there would be a number of key international decisions to make.
These would naturally be the responsibility of the federal govern-
ment and therefore federal decision makers. Federal decisions
would relate with compliance of obligations undertaken by the U.S.
government in relevant international conventions. Conventions
that could be invoked in such an incident are the Convention on
Early Notification of a Nuclear Accident (so-termed Notification
Convention), Convention on Assistance in the Case of a Nuclear
Accident or Radiological Emergency (so-termed Assistance Con-
vention), and the Joint Convention on the Safety of Spent Fuel
Management and on the Safety of Radioactive Waste Management
(so-termed Joint Convention) would apply. The Joint Convention
would apply in managing waste from cleanup after terrorism inci-
dents involving radiological and/or nuclear material.
This appendix summarizes key decisions that federal decision
makers should consider for ensuring that the U.S. government ful-
fills its international obligations undertaken in the above described
international conventions in a timely manner.
Since these conventions were ratified at a time when possible
malevolent use of ionizing radiation and radioactive material were

134
 C.2 NOTIFICATION / 135

not considered to be an international issue, it might be legally pos-

sible to exclude from the obligations of these conventions the safety
implications of a terrorist attack. However, a decision to ignore the
obligations of the U.S. government under the conventions, while
possible from a legal viewpoint, may become politically unfeasible;
particularly if the incident is located near a border with a neighbor
party of the conventions (e.g., Mexico or Canada) or has potential
transboundary implications.

C.2 Notification
C.2.1 Background
Any radiological or nuclear terrorism incident may be considered
a release of radioactive material that could be radiologically signif-
icant for another state and therefore be subject to the obligations
undertaken by the U.S. government as a party of the Notification
Convention. This Convention shall apply in the event of any acci-
dent involving facilities or activities of a state party or of persons or
legal entities under its jurisdiction or control, from which a release
of radioactive material occurs or is likely to occur and which has
resulted or may result in an international transboundary release
that could be of radiological safety significance for another state.
WHO International Health Regulations require international noti-
fication of radiation emergencies [e.g., Member States must notify
WHO in a timely way of any threat that qualifies as a public health
emergency of international concern (whether infectious, chemical,
biological or radiological)]. In the United States, CDC implements
these notifications for DHHS which are then passed on to WHO.
C.2.2 Key Decisions
The first and more important decision refers to the applicability
of the Notification Convention. This could be made a priori of the
incident, at the planning stage. There are three possible decisions,
namely:
• U.S. government considers that the Notification Convention
is always applicable to malevolent incidents involving sig-
nificant releases of radioactive material;
• it will consider its applicability on a case-by-case-basis; or
• it will consider that the obligations under the Convention
are not applicable to malevolent incidents.

It should be noted that this decision will have implications on the

behavior of other parties to the Convention and can be a cause of
dispute.
136 / APPENDIX C

If the first decision is that the Notification Convention is appli-

cable to the radiological or nuclear terrorism incident, then the
major decision to make is to establish the mechanisms for:
• notifying, directly or through IAEA, those countries which
are or may be physically affected, and IAEA, of the radiolog-
ical or nuclear terrorism incident, its nature, the time of its
occurrence, and its exact location.
• promptly providing those countries, directly or through
IAEA, and IAEA, with such available information relevant
to minimizing the radiological consequences in those coun-
tries. The information to be provided shall comprise the fol-
lowing data as then available to the U.S. government:
- time, exact location where appropriate, and the nature of
the incident;
- activity involved;
- assumed or established or foreseeable development of the
incident relevant to the transboundary release of radio-
active material;
- general characteristics of the radioactive release, includ-
ing, as far as is practicable and appropriate, the nature,
probable physical and chemical form and the quantity,
composition and effective height of the radioactive release;
- information on current and forecast meteorological and
hydrological conditions necessary for forecasting the
transboundary release of radioactive material;
- results of environmental monitoring relevant to the trans-
boundary release of radioactive material;
- offsite protective measures taken or planned; and the
predicted behavior over time of the radioactive release.
Such information shall be supplemented at appropriate
intervals by further relevant information on the develop-
ment of the emergency situation, including its foreseeable or
actual termination. The decision maker shall decide whether
the information conveyed to other countries of the Conven-
tion may be used without restriction, or is provided in confi-
dence by the U.S. government.
• responding promptly to a request for further information or
consultations sought by affected countries with a view to
minimizing the radiological consequences in those states.
• making known to IAEA and to other countries, directly or
through IAEA, its competent authorities and point of contact
responsible for issuing and receiving the notification and
information referred to heretofore. Such points of contact
and a focal point within IAEA shall be available continuously.
 C.3 ASSISTANCE / 137

(Note: a U.S. point of contact with IAEA already exists for

radiological emergencies and nuclear accidents but it should
be made clear whether this is the point of contact for malevo-
lent incidents).
• concluding bilateral or multilateral arrangements relating
to the subject matter of the Notification Convention in rela-
tion to malevolent incidents.
C.3 Assistance
C.3.1 Background
As in the case of the Notification Convention, any radiological or
nuclear terrorism incident subject to the rights and obligations
undertaken by the U.S. government are binding. This will imply
both, rights to receive assistance from other countries and obliga-
tions to provide assistance to other countries.
It should be noted that even a country with powerful resources
like the United States can benefit from assistance from other coun-
tries. For instance, a relatively simple radiological terrorism inci-
dent can overwhelm all biological dosimetry services in the United
States. Under the rights given to it by being a part of the Assistance
Convention, the United States can make use of such services from
their countries.
C.3.2 Key Decisions
As in the case of the Notification Convention the first and more
important decision refers to the applicability of the Assistance Con-
vention to a radiological or nuclear terrorism incident. This could
be made a priori of the incident, at the planning stage. In this case,
however, the applicability is more obvious than in the case of the
Notification Convention.
If the first decision is that the Notification Convention is appli-
cable to the radiological or nuclear terrorism incident, then the
major decision to be made is to establish the mechanisms for:
• calling for assistance in the event of a radiological or nuclear
terrorism incident, whether or not such accident or emer-
gency originates within U.S. territory, jurisdiction or control,
from any other country, directly or through IAEA, and from
IAEA, or, where appropriate, from other international inter-
governmental organizations (hereinafter referred to as
“international organizations”).
• specifying the scope and type of assistance, recommending
and, where practicable, providing the assisting party with
such information as may be necessary for that party to
138 / APPENDIX C

determine the extent to which it is able to meet the request.

In the event that it is not practicable for the decision maker
to specify the scope and type of assistance recommended, the
decision maker and the assisting party shall, in consulta-
tion, decide upon the scope and type of assistance necessary.
• requesting assistance relating to medical treatment or tem-
porary relocation into the territory of another country of
people involved in a terrorist incident.
• for an assistance request made to the United States,
promptly deciding and notifying the requesting country,
directly or through IAEA, whether the United States is in a
position to render the assistance requested and the scope
and terms of the assistance that might be rendered.
• identify and notify IAEA of experts, equipment and materi-
als that could be made available for the provision of assis-
tance to other countries in the event of a terrorist incident
as well as the terms, especially financial, under which such
assistance could be provided.

If the United States is the provider of assistance, since the over-

all direction, control, coordination and supervision of the assistance
shall be the responsibility within its territory of the requesting
country, the decision maker should, where the assistance involves
personnel, designate in consultation with the requesting country,
the person who should be in charge of and retain immediate opera-
tional supervision over the personnel and the equipment provided
by it. (The designated person should be expected to exercise such
supervision in cooperation with the appropriate authorities of the
requesting country.)
If the United States is the requesting country, the decision mak-
ers shall provide, to the extent of their capabilities, local and
regional facilities and services, for the proper and effective admin-
istration of the assistance. It shall also ensure the protection of per-
sonnel, equipment and materials brought into U.S. territory by or
on behalf of the assisting party for such purpose. Moreover, since
ownership of equipment and materials provided by either party
during the periods of assistance shall be unaffected, the decision
maker should ensure the return of such equipment and materials.

C.4 Radioactive-Waste Management

C.4.1 Background
A radiological or nuclear terrorism incident will generate huge
quantity of radioactive waste, mainly of the type termed low-level
 C.4 RADIOACTIVE-WASTE MANAGEMENT / 139

radioactive waste. The U.S. government has undertaken interna-

tional obligations on the safety of radioactive-waste management,
which are established in the Joint Convention. When and if, as a
result of a radiological or nuclear terrorism incident, the need
arises for the disposal of the resulting low-level radioactive waste,
the U.S. government would be solely responsible for the identifica-
tion of an appropriate disposal facility. The Joint Convention pro-
vides issues to be addressed and resolved (see details below).

C.4.2 Key Decisions

Since the Joint Convention’s scope of application for radioactive

waste, including discharges, is limited, the decision maker shall
decide what radioactive waste generated by the radiological or
nuclear terrorism incident shall be declared by the U.S. govern-
ment as radioactive waste and discharges and who shall be the reg-
ulatory body for the purposes of the Joint Convention.
The decision maker shall plan for taking the appropriate steps
to ensure that at all stages of radioactive-waste management, indi-
viduals, society and the environment are adequately protected
against radiological and other hazards, in order to comply with the
obligations under the Joint Convention. In particular, the decision
maker shall plan for taking the appropriate steps to ensure that
procedures are established and implemented for a proposed radio-
active-waste management facility, including:

• evaluation of all relevant site-related factors likely to affect

the safety of such a facility during its operating lifetime as
well as that of a disposal facility after closure;
• evaluation of the likely safety impact of such a facility on
individuals, society and the environment, taking into
account possible evolution of the site conditions of disposal
facilities after closure;
• making information on the safety of such a facility available
to members of the general public; and
• fundamentally, consulting Contracting Parties of the Joint
Convention in the vicinity of such a facility, insofar as they
are likely to be affected by that facility, and provide them,
upon their request, with general data relating to the facility
to enable them to evaluate the likely safety impact of the
facility upon their territory. (In so doing, the decision maker
shall take the appropriate steps to ensure that such facili-
ties shall not have unacceptable effects on other Contracting
Parties of the Joint Convention by being cited in accordance
with the general requirement of the Joint Convention.)
140 / APPENDIX C

The decision maker shall particularly ensure that the design

and construction of a radioactive-waste management facility pro-
vide for suitable measures to limit possible radiological impacts on
individuals, society and the environment, including those from dis-
charges or uncontrolled releases. Specifically, the decision maker
shall take appropriate steps to ensure that discharges shall be lim-
ited to keep exposure to radiation consistent with the ALARA prin-
ciple; and so that no individual shall receive, in normal situations,
a radiation dose that exceeds national prescriptions for dose limi-
tation which have due regard to internationally endorsed stan-
dards on radiation protection.
Appendix D

Controlling Consumer
Products — Food,
Water, etc.
(international
implications)

D.1 Introduction

Consumer products generally used by members of the general

public, such as water, food, and other commodities of public con-
sumption, can be deliberately contaminated with radioactive sub-
stances as a result of terrorist actions. The decision-making process
for controlling such contamination is extremely difficult and con-
troversial. However, experience from radiological accidents indi-
cates that decisions are best made promptly, due mainly to public
pressure. International radiation protection criteria for radionu-
clides in consumer products are available and could facilitate the
decision-making process.
Consumer products always contain some amount of “contamina-
tion” by naturally-occurring radionuclides as a result of natural
processes in the environment. This extant contamination is not
perceived as such by members of the general public and may con-
fuse the decision-making process in cases of deliberate addition.
These naturally-occurring radionuclides deliver exposures that are
essentially unamenable to control. However, in addition to “natu-
ral” contamination, consumer products can also contain radioactive
material incorporated as a direct result of controllable human
activities. This “human-introduced” radioactive material, which
can be from both natural and artificial origins, may have been
incorporated either as a result of the operation of regulated activi-
ties or as a result of radioactive residues from past regulated or

141
142 / APPENDIX D

unregulated activities or from radioactive material that were

cleared of regulatory control and recycled into the market.

D.2 Radiation Protection Considerations

Specific and deliberate contamination of some products can con-
ceivably lead to a large internal contamination of a few individuals,
which can be sufficiently high as to be life threatening. However,
massive contamination of consumer products is unlikely to lead to
a significant internal contamination of a large number of people
due to the large quantity of radioactive material that would be
required to reach high levels of contamination in mass-produced or
distributed supplies. One important timely challenge for decision
makers will be a large number of people requesting monitoring for
internal contamination, which in turn will lead to an impairment
of the available monitoring facilities.
Ideally, decision makers should establish in advance “interven-
tion exemption levels” for contaminated consumer products. Con-
sumer products that are above such exemption levels would be
subject to intervention and those that are below could be exempted
from any intervention. These intervention exemption levels could
in principle be decided on the basis of the anticipated situation.
However, mainly due to the trade in consumer products and market
globalization, the exemption levels may not be amenable to ad hoc
decisions; they may not be established on a case-by-case basis
but need to be standardized. The reasons are linked to obvious con-
sumer reaction patterns. It is very unlikely that consumers would
accept decisions that lead to levels of contamination higher than
those established by other competent authorities and this will
probably be the case, even in the aftermath of a terrorist incident.
The issue of how to regulate trade in consumer products contain-
ing a small quantity of radioactive material is not straightforward
and has been subject to intense international debate. ICRP has
dealt with the issue in a number of publications (ICRP, 1999; 2005;
2007; 2008) and the relevant international intergovernmental orga-
nizations have issued guidance on the relevant protection criteria
(CAC, 2006; IAEA, 2004c; WHO, 2004). The exposure situations
resulting from contaminated consumer products could be charac-
terized as planned, emergency or existing, depending on the cir-
cumstances. Control measures could conceptually be implemented
following ICRP recommendations for dealing with each type of sit-
uation. However, for the reason discussed before, it has been recog-
nized that mainly due to the implications of any control on trade,
regulation of radioactive material in consumer products cannot be
established on a case-by-case basis but needs to be standardized.
 D.3 INTERNATIONAL INTERGOVERNMENTAL AGREEMENTS / 143

It has been assumed that it is not likely that several types of

consumer products would be simultaneous sources of high expo-
sure to any given individual. On the basis of this presumption, it
has been internationally recommended that a dose-based generic
intervention exemption level of 100 mrem (1 mSv) for the maxi-
mum individual annual effective dose expected from a dominant
type of consumer goods be established; drinking water however has
been treated as an exception to this generic recommendation (see
Section D.3.3 for guidance on drinking water levels).
On this basis, international intergovernmental organizations
have established criteria for radionuclides in commodities of vari-
ous types (ICRP, 1999).

D.3 International Intergovernmental Agreements

A number of recent international intergovernmental agree-

ments have reached some consensus on radiological criteria for
radionuclides in nonedible consumer products and also in food-
stuffs and drinking water. Relevant U.S. local, state, tribal, and fed-
eral authorities may wish to consider such a consensus in deciding
control measures on consumer products that could be contaminated
as a consequence of a radiological terrorism incident. This interna-
tional consensus establishes activity concentration values for radio-
nuclides of artificial and natural origin in bulk quantity of material
to be exempted from radiation protection control measures.

D.3.1 Nonedible Consumer Products

Following ICRP advice on consumer products, the policy-mak-

ing organs of international governmental organizations tackled the
issue of consumer products. In 2004, IAEA General Conference
decided that IAEA, in collaboration with the competent organs of
the United Nations and the specialized agencies concerned, should
develop “radiological criteria for long-lived radionuclides in con-
sumer products, particularly foodstuffs and wood” (IAEA, 2004a).
The established levels for nonedible consumer products were
issued as the international safety guide on the Application of the
Concepts of Exclusion, Exemption and Clearance (IAEA, 2004a),
which provides values of activity concentrations of radionuclides
(both natural and artificial) in bulk quantity of nonedible materials
that would be applicable to international trade. A graded approach
consistent with the requirement of optimization of protection
would be applied (IAEA, 1997) in the event of values exceeding the
values prescribed.
144 / APPENDIX D

It has been noted that perhaps it would have been appropriate

to distinguish between the nonedible consumer products, which are
the main subject of the above global intergovernmental agreement,
and nonedible industrial consumer products that are extensively
traded. Consumer products have greater potential for public expo-
sure and are unrestricted in usage pattern. Industrial consumer
products, on the other hand, are used for certain specific, limited
purposes, usually in a workplace setting.
The agreement reached is an important step for international
harmonization. Intergovernmental organizations have been encour-
aged to refine and expand the agreements already reached on non-
edible consumer products and, in particular, to develop practical
guidance on the recommended graded approach to regulation.

D.3.2 Edible Consumer Products (other than drinking water)

As for edible consumer products, in 1989, the Codex Alimentar-
ius Commission (CAC) of the joint FAO/WHO adopted guideline
levels for radionuclides in foods following accidental nuclear con-
tamination for use in international trade (hereinafter referred to as
the “Codex levels”) (CAC, 2004), applicable for six radionuclides,
namely 90Sr, 131I, 137Cs, 134Cs, 239Pu, and 241Am. It should be noted,
however, that Codex Alimentarius defines a contaminant as fol-
lows: “Any substance not intentionally added to food, which is pres-
ent in such food as a result of the production (including operations
carried out in crop husbandry, animal husbandry and veterinary
medicine), manufacture, processing, preparation, treatment, pack-
ing, packaging, transport or holding of such food or as a result of
environmental contamination…” Whether radionuclides added
deliberatively as a result of a terrorist action should be considered
contaminants in the Codex language is a matter of legal debate.
Codex levels were adopted in the Basic Safety Standard (IAEA,
1996) and were originally designed to be applicable for 1 y following
a nuclear accident or radiological emergency. The levels were
intended to be maximum acceptable concentrations in the after-
math of a radiological accident, only to be tolerated under very
exceptional circumstances and for a limited period of time. They
were issued in the aftermath of the Chernobyl nuclear reactor acci-
dent, and were not proposed for application to regular circum-
stances and to the general exchange and consumption of foodstuffs,
but remained applicable for 1 y following a nuclear accident. They
were based on an effective dose of 100 mrem y–1 (1 mSv y–1). Long-
term exposures presume a mixing of contaminated foodstuffs with
uncontaminated materials, which will result in a lower annual
exposure in subsequent years. Therefore, it has been suggested
 D.3 INTERNATIONAL INTERGOVERNMENTAL AGREEMENTS / 145

that foodstuffs containing radionuclides in activity concentrations

less than the Codex levels should be automatically regulated.
The Codex levels have evolved in recent years, taking account of
improvements in the assessment of radiation doses resulting from
the human intake of radioactive substances and the recognized need
to establish wider guidance. In view of these developments, CAC
considered broadening the scope, and referred the issue to the Codex
Committee on Food Additives and Contaminants (CCFAC) for
consideration. CCFAC agreed to request collaboration from inter-
governmental organizations and governments to prepare a revised
version of the Codex levels, and CAC approved the revision, includ-
ing the development of guideline levels for long-term use. In
response to this request, a meeting of experts was convened under
the chairmanship of the ICRP chairman and including representa-
tives of the United Nations Scientific Committee on the Effects of
Atomic Radiation, the European Commission, and the Joint
FAO/IAEA Division of Nuclear Techniques in Food and Agriculture.
This resulted in revised Codex levels, which were transmitted for
consideration by CCFAC together with a separate submission by the
European Commission, which in turn agreed to forward the pro-
posed revised levels to CAC for preliminary adoption.
CAC adopted the proposed revised levels and noted a number of
reservations. Thus, draft revised Codex levels were considered by
CCFAC along with written comments submitted by intergovern-
mental organizations and states, which decided that a further revi-
sion was required involving these organizations and all interested
states. CCFAC finally agreed to forward the revised Guideline Lev-
els for Radionuclides in Foods Contaminated Following a Nuclear
or Radiological Emergency for Use in International Trade to CAC,
which were adopted as a final Codex text at the 29th Session of the
CAC. The revised, Codex levels were subsequently published in
Schedule I, Radionuclides of the Codex General Standard for Con-
taminants and Toxins in Foods (CAC, 2006) and is the current stan-
dard for toxins in food.

D.3.3 Drinking Water

WHO developed specific guidance levels for radionuclides in

drinking water and is responsible for international regulation.
These levels have been incorporated into the third edition of Guide-
lines for Drinking-Water Quality (WHO, 2004). The drinking-water
recommendations are based on 10 mrem (0.1 mSv) effective dose
for 1 y consumption of drinking water, which is one order of magni-
tude less than the Codex Alimentarius criteria of 100 mrem y–1
146 / APPENDIX D

(1 mSv y–1) effective dose (despite the fact that WHO is part of
CAC). It has been recognized however that some of WHO guidance
levels may exceed the target dose. Drinking water containing radio-
nuclides in activity concentrations less than WHO guidance levels
should not be automatically regulated but should be considered on
a case-by-case basis.

D.4 Dealing with Consumer Products

After Radiological or Nuclear Terrorism Incidents
ICRP has indicated that the above described international inter-
governmental agreements provide a good basis for generic and uni-
versal radiological protection criteria for radionuclides in consumer
products. In addition, in its recommendations on radiological protec-
tion in prolonged exposure situations in ICRP Publication 82 (ICRP,
1999), and in the aftermath of a terrorist attack in ICRP Publica-
tion 96 (ICRP, 2005), ICRP addressed the issue of a large amount
of consumer products, including foodstuffs and water, remaining
contaminated in the aftermath of a radiological emergency. With
necessary changes these recommendations can be applied to the
aftermath of a radiological or nuclear terrorism incident.
While recognizing that the international intergovernmental
agreements on radiological criteria for consumer products described
above would provide an adequate provisional basis for regulating
the trade of commodities after such incidents, in ICRP (1999) rec-
ommended how to deal specifically with consumer products that are
produced in an area affected by the emergency. This type of situa-
tion presents a particularly difficult problem; if the corresponding
activity levels are higher than those in produce from neighboring
areas, issues of market acceptance could arise if there are trans-
boundary movements of the consumer products.
ICRP considers that if the annual doses in the area affected by
the accident are acceptable because the protection strategy has
been optimized, the situation outside the affected area may be
acceptable. This is because the individual annual doses elsewhere
from the use of consumer products produced in the affected area
would not be higher than those in the affected area. However, the
production of consumer products in areas affected by an emergency
could commence some years after the incident; this possibility
should be considered in any protection strategy applied after the
incident. If the restrictions on consumer products produced in the
area affected by an emergency have not been lifted, production of
the restricted consumer products should not be restarted; con-
versely, if the restrictions have been lifted, production can be
restarted. If an increase in production is proposed, it could proceed
 D.5 HANDLING SITUATIONS INVOLVING “HOT PARTICLES” / 147

subject to appropriate justification. In circumstances where restric-

tions have been lifted as part of a decision to return to normal liv-
ing, the resumption of and potential increase in production in the
affected area should have been considered as part of that decision
and should not require further consideration. It has been noted that
economic and social conditions may be different inside and outside
the area affected by a radiological or nuclear terrorism incident,
and that this may legitimately lead to different decisions (as has in
fact, occurred in real situations).
Therefore, decision makers may wish to consider a similar
approach in a case of a radiological or nuclear terrorism incident.
Measures for control of contaminated consumer products are
expected to be initially applied within the area affected by the inci-
dent. Consumer products produced or subject to commerce within
the area of influence of the incident would present an exceptionally
difficult situation for decision makers. If the corresponding activity
levels are higher than those in produce from neighboring areas,
issues of market acceptance could arise, particularly if there are
transboundary movements of the consumer products. If the annual
doses in the area are below those established a priori in the inter-
vention strategy; the situation outside the affected area should also
be acceptable because the individual annual doses elsewhere from
the use of consumer products produced in the affected area would
normally not be higher than those in the affected area. If the
restrictions on consumer products produced in the affected area
have not been lifted, production of the restricted consumer prod-
ucts should not be restarted; conversely, if the restrictions have
been lifted, production can be restarted. If an increase in produc-
tion is proposed, it could proceed subject to appropriate justifica-
tion. In circumstances where restrictions have been lifted as part
of a decision to return to “normal” living, the resumption and poten-
tial increase of production in the affected area should have been
considered as part of that decision and should not require further
consideration.

D.5 Handling Situations Involving “Hot Particles”

In some scenarios, it can be imagined that radioactive residues
may become very sparsely distributed in the environment (e.g., as
“hot particles”), giving rise to situations where there is the poten-
tial but not the certainty that the contamination of consumer prod-
ucts with such particles will actually occur. Building materials, in
particular, could be affected by these situations. There are avail-
able international recommendations for dealing with potential
exposure situations (IAEA, 1990; ICRP, 1993; 1997). Protection in
148 / APPENDIX D

situations involving hot particles is not a new issue (IAEA, 1998).

For these situations, ICRP has issued criteria of acceptability, as
follows: action levels should be derived on the basis of the uncondi-
tional probability that members of the general public would
develop fatal stochastic health effects attributable to the exposure
situation. That probability should be assessed by combining the fol-
lowing probabilities:

• being exposed to the hot particles;

• incorporating a hot particle into the body as a result of such
exposure;
• incurring a dose as a result of such incorporation; and
• developing a fatal stochastic effect from that dose.

(These probabilities should be integrated over the full range of situ-

ations and possible doses). In establishing such action levels, consid-
eration should be given to the possibility that localized deterministic
effects may also occur as a result of the incorporation of hot particles.
Appendix E

Resources of the U.S.

Department of Energy

Below is a list of DOE Radiological Emergency-Response Assets

with a brief description of each. Figure E.1 is a timeline describing
the approximate activation time after initial notification.

E.1 Radiological Assistance Program

The Radiological Assistance Program (RAP) mission is to pro-

vide first response radiological assistance to protect the health and
safety of members of the general public and the environment. They

Fig. E.1. DOE radiological emergency-response asset timeline (DOE,

2010).

149
150 / APPENDIX E

assist local, state, tribal and federal agencies in the detection, iden-
tification, analysis, and response to incidents involving the release
of radiological materials in the environment. RAP advises decision
makers and assists local authorities to minimize the hazards of a
radiological terrorism incident. RAP is implemented on a regional
basis, with coordination between the emergency-response elements
of local, state, tribal and federal agencies.
Each region has a minimum of three RAP teams. Teams can coor-
dinate with one another when assistance is necessary. Each RAP
team consists of six to eight team members, which includes a DOE
team lead, a team captain, and health-physics support personnel.
If a radiological or nuclear terrorism incident has occurred,
other DOE assets will be activated as per NRF, and RAP will coor-
dinate with them in conjunction with local emergency responders.

E.2 Consequence Management Home Team

The primary role of the Consequence Management Home Team

(CMHT) is to support the incident response while Consequence
Management Response Team Phase I (CMRT I) is en route to the
incident scene. CMHT provides analysis and interpretation of
the initial source term and early data, along with predictive map
products. CMHT is operational and ready to assist within 2 h of
notification. CMHT will receive data from RAP and local emer-
gency responders who collect radiological data. CMHT support
includes analyzing incident data (e.g., monitoring data), evaluating
hazards, and providing incident information and data products
(e.g., plume maps) to protective-action decision makers. CMHT can
provide assistance and data products to RAP team(s) that have
been deployed to support the response until CMRT assets are
established at the incident. In coordination with DHS, the conse-
quence management federal team leader approves release of infor-
mation to authorized local, state and tribal officials.
CMHT can communicate to the CMRT I in real-time while they
are en route to provide status information. Generally, CMHT data
assessment capability will be transferred to CMRT I once those
assets have been established at the incident.

E.3 Consequence Management

Response Team Phase I

DOE will respond to a request for assistance by deploying the

Consequence Management Response Team (CMRT). CMRT uses a
phased approach to deploy personnel and resources into the field in
a timely fashion. CMRT I, consisting of technical and management
 E.5 CONSEQUENCE MANAGEMENT RESPONSE TEAM / 151

personnel, is ready to deploy within 4 h of notification and can be

operational and gathering data within 3 h of establishing a base
of operations. CMRT I initiates all technical aspects of a FRMAC
response and serves as the command and control element of
FRMAC initially. CMRT I includes 200 cubic feet (2,500 pounds)
of equipment and 24 on-call personnel. The team will incorporate
all the disciplines necessary to support operations but only on a
limited scale. These disciplines include radiation monitoring, sam-
pling, analysis, assessment, health and safety, and support and
logistics functions. CMRT I is capable of sustaining 24 h operations
for up to 72 h.

E.4 Consequence Management

Response Team Phase II

Consequence Management Response Team Phase II (CMRT II)

follow the Phase I resources within 12 h of activation and provides
a more robust response team by providing additional personnel and
equipment. CMRT assets along with the interagency resources that
respond form a fully-operational FRMAC 24 to 36 h after the initial
request for assistance. CMRT II includes 32 personnel and an addi-
tional 2,400 cubic feet (39,000 pounds) of equipment. CMRT II
response team deploys with consumables to support operations for
96 h without resupply and is prepared to support 24 h d–1 operations
for several weeks. CMRT II will focus on extensive field monitoring
(collection, assessment, compilation and archiving of data) and ini-
tial sample collection and sample processing for characterization.

E.5 Consequence Management Response

Team-Augmentation/Federal Radiological
Monitoring and Assessment Center

If requested, DOE can call upon trained professionals from DOE

facilities and national laboratories, RAP regions, and additional
personnel and equipment will be deployed to augment and assist
federal radiological monitoring and assessment center (FRMAC)
operations. FRMAC is established “at or near the scene of an inci-
dent to coordinate radiological assessment and monitoring.”
FRMAC is a federal interagency center responsible for coordinat-
ing offsite monitoring and assessment activities with the affected
local, state and tribal agencies. FRMAC protective actions focus on
accurately defining areas where contamination levels of air, water,
crops, forage and livestock may lead to concentrations in excess of
nationally-accepted guidelines. The response during a FRMAC
focuses on extensive sampling, sample processing and analysis,
152 / APPENDIX E

and further collection, assessment, compilation and archiving of

data in order to characterize the radiological conditions as specified
by NRIA. FRMAC is prepared to support 24 h d–1 operations for
several weeks as determined by the severity of the emergency.

E.6 Aerial Measuring System

The Aerial Measuring System characterizes ground-deposited

radiation from aerial platforms. These platforms include fixed- and
rotary-wing aircraft with radiological measuring equipment, com-
puter analysis of aerial measurements, and equipment to locate
lost radioactive sources, conduct aerial surveys, or map large areas
of contamination.

E.7 National Atmospheric Release Advisory Center

FRMAC has access to the National Atmospheric Release Advi-

sory Center (NARAC), which provides tools and services that map
the probable spread of HAZMAT accidentally or intentionally
released into the atmosphere. NARAC has access to full scale atmo-
spheric modeling with real-time meteorological data. NARAC is
co-located with the IMAAC. NARAC provides atmospheric plume
predictions in enough time for an emergency manager to decide if
taking protective action is necessary to protect the health and
safety of people in affected areas.

E.8 Radiation Emergency Assistance

Center/Training Site

FRMAC has access to Radiation Emergency Assistance Center/

Training Site (REAC/TS) physicians, nurses, health physicists,
radiobiologists, and emergency coordinators specializing in assist-
ing local and regional medical personnel in treating and diagnosing
radiation effects on human health.
Appendix F

Decontamination
of People

This appendix contains information for instructing people to

self-decontaminate at home or while waiting for decontamination
at the scene of an incident (LA County, 2009).

F.1 Instructions on How to Perform

Decontamination at Home

Radioactive materials from the incident may have settled on

your hair, skin and clothing as dust, sand or ash. Because radiation
cannot be seen, smelled, felt or tasted, you and others will not know
if you have radioactive material on you, unless radiation detection
equipment is available. You are not in immediate danger from this
radioactive material. However, you should go home or to another
designated area to decontaminate (clean off the radioactive mate-
rial). Removal of outer clothing should reduce your external con-
tamination by up to 90 %. Washing exposed skin and hair will
remove most of the rest.
To protect your health and safety as well as others, please follow
these directions.

• Leave the immediate area quickly:

- go directly home, inside the nearest safe building, or to
an area to which you are directed by law enforcement or
health officials.
- do not go to a hospital unless you have a medical condi-
tion that requires treatment.
• Remove your clothes (read all of the instructions below
before starting this process):
- if radioactive material are on your clothes, prompt
removal of your clothing will also reduce the amount of
radiation you receive.

153
154 / APPENDIX F

- removal of clothes should be done in a garage or outside

storage area if possible. If not, remove clothes in a room
where the floors can be easily cleaned, such as a laundry
room or a bathroom (in the tub or shower). Clothing
should be rolled up with the contaminated side “in” to
avoid spreading contamination.
- when removing clothing, be careful of any clothing that
has to be pulled over the head. Try to either cut it off or
prevent the outer layer from touching your nose and
mouth. You may also hold your breath while carefully
pulling the article over your head.
- if possible, put the clothing in a plastic bag (double bag-
ging is best to reduce the chances of a rupture), and leave
it in an out-of-the-way area, such as a garage, outside
location, the corner of a room, or a closet. Keep people
away from it. You may be asked to bring this bag for fol-
low-up readings or for disposal at a later time.
- keep cuts and abrasions covered when handling contami-
nated items to avoid getting radioactive material in the
wound.
• Wash yourself and your valuables:
- shower and wash your body and hair using lots of soap
and lukewarm water to remove contamination. Washing
will remove most of the radioactive material. Do not
use abrasive cleaners or scrub too hard. Do not use hair
conditioners.
- gently blow your nose and wash out your eyes, ears and
mouth.
- put on clean clothes.
- wash valuables and identification cards that may have
been contaminated and wash your hands again.
• If you cannot shower or remove all of your clothes, removing
your outer clothing and washing exposed parts of your body,
such as your head and neck, hair, hands, and arms, will
remove most of the contamination.
• If you are going to a monitoring location, it is best to shower
and change clothes before being monitored.

F.2 Instructions to Members of the

General Public Waiting for Decontamination
at the Scene of an Incident
You may have been exposed to radioactive material. The radio-
active material may have settled as dust, sand or ash on your
 F.2 INSTRUCTIONS TO THE PUBLIC / 155

clothes or body. To protect your health, you may be asked to go to a

decontamination center. Your health is not in immediate danger. At
the decontamination center, you will be checked for radioactive
material on your clothes, skin and hair. If you have a lot of radioac-
tive material on your body, you will wash it off and be given clean
clothes to wear. This process is called decontamination.
Follow these directions to prepare for decontamination:

• go to the designated area.

• do not touch your face or put anything into your mouth.
• enter the screening area and stand for a screening (survey)
of yourself while clothed, and provide the workers with nec-
essary personal information.
• after you are screened, you will be directed to leave if little
or no contamination is present. If contamination is found,
you will be directed to a wash area, or you may be sent home
with instructions on how to cleanup (decontaminate) there.
• if you are directed to a wash area, you will be grouped with
people of your gender. To the extent possible, families will be
kept together. Prepare to remove your outer clothes behind
a privacy curtain. If radioactive material is on your clothes,
removing them will reduce the amount of radiation you
receive.
• when removing clothing, be careful of any clothing that has
to be pulled over the head. Try to either cut it off or prevent
the outer layer from touching your nose and mouth. You
may also hold your breath while carefully pulling the article
over your head.
• you will be given plastic bags. Put all of your clothing in one
bag and your valuables in another plastic bag and seal
them. You may be asked to double bag your belongings to
minimize the potential for bag rupture.
• you will be allowed to keep your valuables. If your clothing
is contaminated, we will keep it. If there is any chance your
valuables may be contaminated; remove items from the bag
they are in carefully while wearing gloves and clean your
valuables with soap and water when you get home.
• pass through the wash area.
• when you reach the end of the wash station, you will be
given clothing to put on, and then be directed to the exit.
Glossary

absorbed dose: The energy imparted by ionizing radiation to matter per

unit mass at the point of interest. In SI, the unit is joule per kilogram
(J kg–1), with the special name gray (Gy) (see rad and cumulative
absorbed dose).
activity: The average number of spontaneous nuclear transformations
occurring in a radioactive material per unit time. The unit for activity
in the SI system is reciprocal second (s–1) (i.e., one nuclear transforma-
tion per second), with the special name becquerel (Bq). The special unit
previously used was curie (Ci); 1 Ci = 3.7 u 1010 Bq. In this Report,
activity is also expressed as disintegrations per minute per unit area
(dpm cm–2) with regard to surface contamination.
acute radiation syndrome (sickness) (ARS): A broad term used to
describe a range of early signs and symptoms that reflect severe dam-
age to specific organ systems that can lead to death within hours or sev-
eral weeks.
air kerma (kerma in air): Kerma (kinetic energy released per unit mass)
is the sum of the initial kinetic energies of all the charged particles lib-
erated by uncharged particles per unit mass of a specified material.
The SI unit of kerma is joule per kilogram (J kg–1), with the special
name gray (Gy). Kerma can be quoted for any specified material at a
point in free space or in an absorbing medium (in this case air).
as low as reasonably achievable (ALARA): A principle of radiation pro-
tection philosophy that requires that exposures to ionizing radiation
should be kept as low as reasonably achievable, economic and social
factors being taken into account. The ALARA principle is satisfied
when the expenditure of further resources would be unwarranted by
the reduction in exposure that would be achieved.
becquerel (Bq): (see radiation units and names).
bioassay: A technique used to identify, quantify and/or specify the location
of radionuclides in the body by direct (in vivo) or indirect (in vitro) anal-
ysis of tissues or excretions from the body.
biodosimetry: A technique used to determine radiation dose to people
using the assessment of individual biological data such as assessment
of individuals’ signs and symptoms, particularly the time from expo-
sure to onset of vomiting, serial blood counts for lymphocyte depletion,
and assays of lymphocyte cytogenetics.
bunker gear: A firefighter’s protective clothing. Bunker gear usually con-
sists of boots, pants, coat, gloves, hood, helmet, and self-contained
breathing apparatus (also called personal protection equipment).
calibration: The act of standardizing an instrument to a known source, or
a laboratory procedure to a known result.

156
 GLOSSARY / 157

combined injury: Radiation injury exacerbated by other types of bodily

injury (e.g., skin burns, open wounds).
concerned citizens: The term that has been used extensively in the past
for these individuals is “worried well”; the Centers for Disease Control
and Prevention and other federal agencies prefer to use the term “con-
cerned citizens.” Concerned citizens may well overwhelm the capabili-
ties of hospital emergency rooms when they do not have traumatic
injuries, but are concerned because they may have been exposed to
radiation or contaminated with radioactive material.
contamination (radionuclide): Radioactive material that is present in
undesired locations such as on the surface of or inside structures, areas,
objects or individuals.
cumulative absorbed dose: In this Report, a real-time integration of
absorbed dose to the whole body from photons.
curie (Ci): (see radiation units and names).
decision dose: In this Report, a cumulative absorbed dose to the whole
body (from photons) of 50 rad (0.5 Gy) to a specific emergency
responder. At that whole-body absorbed dose, the decision at the com-
mand level is whether the emergency responder should be withdrawn
from the radiation control zones.
decontamination: The removal of radionuclide contaminants from sur-
faces (e.g., skin) by cleaning and washing.
detector: A device or component designed to produce a quantifiable
response to ionizing radiation, normally measured electronically.
deterministic effects: Effects that occur in all individuals who receive
greater than a threshold dose; the severity of the effect varies with the
dose above the threshold. Examples are radiation-induced cataracts
(lens of the eye) and radiation-induced erythema (skin).
dose: In this Report, used as a generic term when not referring to a specific
quantity, such as absorbed dose.
effective dose: The sum over specified tissues of the products of the
equivalent dose in a tissue or organ and the tissue weighting factor for
that tissue or organ. The tissue weighting factor represents the fraction
of the total radiation detriment to the whole body attributed to that tis-
sue when the whole body is irradiated uniformly. The SI unit for effec-
tive dose is joule per kilogram (J kg–1), with the special name sievert
(Sv).
equivalent dose: A quantity used for radiation protection purposes
that takes into account the different probabilities of stochastic effects
that occur with the same absorbed dose delivered by radiations with
different radiation weighting factors (the factor by which the mean
absorbed dose in a tissue or organ is modified to account for the type
and energy of radiation in determining the probability of stochastic
effects). The SI unit of equivalent dose is joule per kilogram (J kg–1),
with the special name sievert (Sv) (also see stochastic effects).
mean absorbed dose: The total energy imparted to an organ or tissue
divided by the mass of the organ or tissue. The SI unit of mean absorbed
dose is joule per kilogram (J kg–1), with the special name gray (Gy).
158 / GLOSSARY

exposure: In this Report, exposure is used often in its general sense,

meaning an irradiation. When used as a defined radiation quantity,
exposure is a measure of the ionization produced in air by x or gamma
radiation. The SI unit of exposure is coulomb per kilogram (C kg–1). The
special unit for exposure is roentgen (R), where 1 R = 2.58 × 10–4 C kg–1.
Air kerma is often used in place of exposure. An exposure of 1 R corre-
sponds to an air kerma of 0.87 rad (8.7 mGy) (also see rad, roentgen,
gray, air kerma).
exposure rate: The exposure per unit time [e.g., 1 R h–1 (8.7 mGy h–1)
(~10 mGy h–1 air-kerma rate)].
fallout: Radioactive material falling from the atmosphere to the Earth’s
surface after a nuclear incident, such as a weapons test, accident, or
detonation of an improvised nuclear device.
footprint: Refers to the area contaminated with radioactive material from
the radiological or nuclear terrorism incident.
gamma rays: (see radiation types).
gray (Gy): (see radiation units and names).
instrument: A complete system consisting of one or more assemblies to
quantify one or more characteristics of radiation or radioactive material.
monitoring: Means provided to indicate continuously or intermittently
the level of activity or radiation exposure.
neutrons: (see radiation types).
nuclear yield: The amount of energy that is released when a nuclear
weapon is detonated, expressed usually as the equivalent mass of trin-
itrotoluene (TNT) [e.g., in kilotons (thousands of tons of TNT)].
personal dose equivalent (at 10 mm): An operational quantity used in
personal monitoring. In this case, measured at a depth of 10 mm.
personal protection equipment (PPE): (see bunker gear).
personal radiation detector: A device worn by an individual to monitor
the radiation dose received by the individual.
photons: (see radiation types).
prodromal: Relating to prodrome (an early or premonitory symptom of a
disease).
rad: (see radiation units and names).
radiation control zones: In this Report, radiation control zones are cat-
egorized by exposure rate. Three zones are defined:
• cold [outdoor exposure rate d10 mR h–1 (~0.1 mGy h–1 air-kerma
rate)];
• hot [!10 mR h–1 (~0.1 mGy h–1)]; or
• or dangerous-radiation zones [t10 R h–1 (~0.1 Gy h–1)].
radiation types (ionizing):
alpha particles: Energetic nuclei of helium atoms, consisting of two
protons and two neutrons emitted spontaneously from nuclei in the
decay of some radionuclides (e.g., 226Ra). Alpha particles have very low
penetrating power (e.g., typically stopped by a few centimeters of air or
the outer dead layer of skin). Alpha particles are generally not a health
problem unless the source is taken into the body via inhalation, inges-
tion or absorption, or through wounds.
 GLOSSARY / 159

beta particles: Energetic electrons or positrons (i.e., positively

charged electrons) emitted spontaneously from nuclei in the decay of
some radionuclides (e.g., 90Sr). Beta particles are not highly penetrat-
ing (e.g., the lower-energy beta particles are typically stopped by a few
millimeters of tissue; the higher-energy beta particles can be stopped
by a few centimeters of tissue). However, beta particles on the skin can
cause significant injury if not removed by timely decontamination.
gamma rays: High-energy electromagnetic radiation (photons) emit-
ted in nuclear transitions (e.g., radioactive decay of 137Cs) with energies
particular to the transition. Gamma rays have moderate-to-high pene-
trating power, are often able to penetrate deep into the body, and
require thick shielding, such as up to ~3 feet (1 m) of concrete.
neutrons: Uncharged particles found in the nucleus of every atom
except 1H. Energetic neutrons are produced in spontaneous fission of
nuclei (e.g., 252Cf), fission induced by absorption of neutrons by nuclei
(e.g., 239Pu), and by absorption of other particles by nuclei (e.g., absorp-
tion of alpha particles by 9Be). Neutrons have no electric charge, are
usually highly penetrating, have an enhanced ability to cause biologi-
cal damage, and require thick shielding.
photons: Quanta of electromagnetic radiation, having no charge or
mass, but having momentum (see gamma rays and x rays).
x rays: Electromagnetic radiation (photons) emitted in transitions of
atomic orbital electrons after ionization or excitation of atoms (yielding
characteristic x rays), or in the deceleration of energetic charged parti-
cles (e.g., electrons) in passing through matter (bremsstrahlung).
X rays are typically of lower energy than gamma rays, but some orbital
electron transitions are of higher energy than some nuclear transitions,
so there can be an overlap between the low-energy gamma rays and
high-energy x rays. X rays have moderate-to-high penetrating power,
are able to penetrate deep into the body, and may require shielding of
up to a few tens of centimeters of concrete.
radiation units and names:
becquerel (Bq): The SI special name for the unit [disintegration per
second (s–1)] of activity. 1 Bq = 1 disintegration per second (see activity
and curie).
curie (Ci): The previous special unit for activity. 1 curie = 3.7 × 1010
disintegrations per second = 3.7 × 1010 Bq (see activity and becquerel).
gray (Gy): The SI special name for the unit (J kg–1) of absorbed dose.
1 Gy = 1 J kg–1 (see absorbed dose and rad).
rad: The previous special unit for absorbed dose. 1 rad = 0.01 J kg–1;
100 rad = 1 Gy (see absorbed dose and gray).
rem: The previous special unit for equivalent dose and effective dose.
1 rem = 0.01 J kg–1; 100 rem = 1 Sv (see equivalent dose, effective dose,
and sievert).
roentgen (R): The previous special unit for exposure. 1 R = 2.58 × 10–4
coulombs per kilogram (C kg–1) (see exposure).
160 / GLOSSARY

sievert (Sv): The SI special name for the unit (J kg–1) of equivalent
dose and effective dose. 1 Sv = 1 J kg–1 (see equivalent dose, effective
dose, and rem).
radioactivity: The property of some atomic nuclei of spontaneously emit-
ting gamma rays or subatomic particles (e.g., alpha and beta particles).
radiological: A general term pertaining to radiation and radioactive
material.
radionuclide: A radioactive element, man-made or from natural sources,
with a specific atomic weight.
rem: (see radiation units and names).
roentgen (R): (see radiation units and names).
sensitivity: A measure of the ability of a radiation measuring device to
detect small doses or low levels of contamination.
sievert (Sv): (see radiation units and names).
stochastic effects: Health effects, the probability of which, rather than
their severity, is assumed to be a function of radiation dose without a
threshold.
terrorism: The unlawful use of force against individuals or property to
intimidate a government, the civilian population, or any segment
thereof, in the furtherance of political objectives.
therapy: The practical treatment for remediation of diseases or disorders.
threshold: The point at which a stimulus first produces an effect
(response).
time-to-vomiting: A symptom of acute radiation syndrome; the time
lapse from radiation exposure to when vomiting initially occurs.
triage: Medical screening of patients prior to treatment to determine their
relative priority for treatment, with separation into one of three
groups: (1) those who cannot be expected to survive even with treat-
ment; (2) those who will recover without treatment; and (3) the highest
priority, those who will or may survive with treatment. Triage is also
used as a tool to sort individuals who may have been exposed to large
doses of radiation. The triage for persons exposed to radiation is to sort
them into categories of high, intermediate and low, and is associated
with acute radiation syndrome.
urban canyon: An artifact of an urban environment similar to a natural
canyon. It is caused by streets cutting through dense blocks of struc-
tures, especially skyscrapers, which cause a canyon effect that chan-
nels the wind.
x rays: (see radiation types).
Abbreviations and Acronyms

ALARA as low as is reasonably achievable

AMTS alternative medical treatment site
ARS acute radiation syndrome (sickness)
CAC Codex Alimentarius Commission (FAO/WHO)
CCFAC Codex Committee on Food Additives and Contaminants
CDG Clinical Decision Guide
CMHT Consequence Management Home Team
CMRT Consequence Management Response Team
CRC community reception center
DMORT Disaster Mortuary Operational Response Team (DHHS)
ED emergency department (of a hospital or medical center)
EOC emergency operations center
EMP electromagnetic pulse
FAO Food and Agriculture Organization (UN)
FEMA Federal Emergency Management Agency (DNS)
FRMAC Federal Radiological Monitoring and Assessment Center
(DOE)
EMS emergency medical services
HAZMAT hazardous material
HRDC hospital reception and decontamination center
IMAAC Interagency Modeling and Atmospheric Assessment
Center (DHS)
IND improvised nuclear device
JIC joint information center
KI potassium iodide
LD50 lethal dose for causing death in 50 % of exposed persons
(can also be defined for any other percentage of the
population)
MRC Medical Reserve Corps
NARAC National Atmospheric Release Advisory Center
NIMS National Incident Management System (FEMA)
NRF National Response Framework (FEMA)
NRIA Nuclear/Radiological Incident Annex (FEMA)
PAG Protective Action Guide
PF protection factor
PPE personal protection equipment
RAP Radiological Assistance Program (DOE)
RDD radiological dispersal device
REAC/TS Radiation Emergency Assistance Center/Training Site

161
162 / ABBREVIATIONS AND ACRONYMS

RED radiation exposure device

SI Systeme Internationale (International System) of Units
TDC temporary decontamination center
SNS Strategic National Stockpile (CDC)
VMI Vendor Managed Inventory (CDC)
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The NCRP

The National Council on Radiation Protection and Measurements is a non-

profit corporation chartered by Congress in 1964 to:

1. Collect, analyze, develop and disseminate in the public interest infor-

mation and recommendations about (a) protection against radiation and
(b) radiation measurements, quantities and units, particularly those
concerned with radiation protection.
2. Provide a means by which organizations concerned with the scientific and
related aspects of radiation protection and of radiation quantities, units
and measurements may cooperate for effective utilization of their com-
bined resources, and to stimulate the work of such organizations.
3. Develop basic concepts about radiation quantities, units and mea-
surements, about the application of these concepts, and about radiation
protection.
4. Cooperate with the International Commission on Radiological Protection,
the International Commission on Radiation Units and Measurements,
and other national and international organizations, governmental and
private, concerned with radiation quantities, units and measurements
and with radiation protection.

The Council is the successor to the unincorporated association of scientists

known as the National Committee on Radiation Protection and Measurements
and was formed to carry on the work begun by the Committee in 1929.
The participants in the Council’s work are the Council members and mem-
bers of scientific and administrative committees. Council members are selected
solely on the basis of their scientific expertise and serve as individuals, not as
representatives of any particular organization. The scientific committees, com-
posed of experts having detailed knowledge and competence in the particular
area of the committee's interest, draft proposed recommendations. These are
then submitted to the full membership of the Council for careful review and
approval before being published.
The following comprise the current officers and membership of the Council:

Officers

President Thomas S. Tenforde

Senior Vice President Kenneth R. Kase
Secretary and Treasurer David A. Schauer

173
174 / THE NCRP

Members
John F. Ahearne Donald P. Frush Andrea K. Ng
Edward S. Amis, Jr. Ronald E. Goans Carl J. Paperiello
Sally A. Amundson Robert L. Goldberg Terry C. Pellmar
Kimberly E. Applegate Raymond A. Guilmette R. Julian Preston
Benjamin R. Archer Roger W. Harms Jerome C. Puskin
Stephen Balter Kathryn Held Abram Recht
Steven M. Becker F. Owen Hoffman Michael T. Ryan
Joel S. Bedford Roger W. Howell Adela Salame-Alfie
Mythreyi Bhargavan Timothy J. Jorgensen Beth A. Schueler
Eleanor A. Blakely Kenneth R. Kase Thomas M. Seed
William F. Blakely Ann R. Kennedy J. Anthony Seibert
Wesley E. Bolch William E. Kennedy, Jr. Stephen M. Seltzer
Thomas B. Borak David C. Kocher Edward A. Sickles
Andre Bouville Ritsuko Komaki Steven L. Simon
Leslie A. Braby Amy Kronenberg Paul Slovic
David J. Brenner Susan M. Langhorst Christopher G. Soares
James A. Brink Edwin M. Leidholdt Daniel J. Strom
Brooke R. Buddemeier Howard L. Liber Thomas S. Tenforde
Jerrold T. Bushberg James C. Lin Julie E.K. Timins
John F. Cardella Jill A. Lipoti Richard E. Toohey
Charles E. Chambers Paul A. Locke Lawrence W. Townsend
Polly Y. Chang Jay H. Lubin Elizabeth L. Travis
S.Y. Chen C. Douglas Maynard Fong Y. Tsai
Mary E. Clark Debra McBaugh Richard J. Vetter
Michael L. Corradini Ruth E. McBurney Chris G. Whipple
Allen G. Croff Fred A. Mettler, Jr. Robert C. Whitcomb, Jr.
Paul M. DeLuca Charles W. Miller Stuart C. White
Christine A. Donahue Donald L. Miller Gayle E. Woloschak
David A. Eastmond William H. Miller Shiao Y. Woo
Stephen A. Feig William F. Morgan Andrew J. Wyrobek
Alan J. Fischman Stephen V. Musolino X. George Xu
Patricia A. Fleming David S. Myers R. Craig Yoder
John R. Frazier Bruce A. Napier Marco A. Zaider
Gregory A. Nelson
Distinguished Emeritus Members
Warren K. Sinclair, President Emeritus; Charles B. Meinhold, President Emeritus
S. James Adelstein, Honorary Vice President
W. Roger Ney, Executive Director Emeritus
William M. Beckner, Executive Director Emeritus
Seymour Abrahamson R.J. Michael Fry Dade W. Moeller
Lynn R. Anspaugh Thomas F. Gesell A. Alan Moghissi
John A. Auxier Ethel S. Gilbert Wesley L. Nyborg
William J. Bair Robert O. Gorson John W. Poston, Sr.
Harold L. Beck Joel E. Gray Andrew K. Poznanski
Bruce B. Boecker Arthur W. Guy Genevieve S. Roessler
John D. Boice, Jr. Eric J. Hall Marvin Rosenstein
Robert L. Brent Naomi H. Harley Lawrence N. Rothenberg
Antone L. Brooks William R. Hendee Henry D. Royal
Randall S. Caswell Donald G. Jacobs William J. Schull
J. Donald Cossairt Bernd Kahn Roy E. Shore
James F. Crow Charles E. Land John E. Till
Gerald D. Dodd John B. Little Robert L. Ullrich
Sarah S. Donaldson Roger O. McClellan Arthur C. Upton
William P. Dornsife Barbara J. McNeil F. Ward Whicker
Keith F. Eckerman Kenneth L. Miller Susan D. Wiltshire
Thomas S. Ely Marvin C. Ziskin
 THE NCRP / 175

Lauriston S. Taylor Lecturers

Charles E. Land (2010) Radiation Protection and Public Policy in an Uncertain
World
John D. Boice, Jr. (2009) Radiation Epidemiology: The Golden Age and Remain-
ing Challenges
Dade W. Moeller (2008) Radiation Standards, Dose/Risk Assessments, Public
Interactions, and Yucca Mountain: Thinking Outside the Box
Patricia W. Durbin (2007) The Quest for Therapeutic Actinide Chelators
Robert L. Brent (2006) Fifty Years of Scientific Research: The Importance of
Scholarship and the Influence of Politics and Controversy
John B. Little (2005) Nontargeted Effects of Radiation: Implications for
Low-Dose Exposures
Abel J. Gonzalez (2004) Radiation Protection in the Aftermath of a Terrorist
Attack Involving Exposure to Ionizing Radiation
Charles B. Meinhold (2003) The Evolution of Radiation Protection: From Ery-
thema to Genetic Risks to Risks of Cancer to ?
R. Julian Preston (2002) Developing Mechanistic Data for Incorporation into
Cancer Risk Assessment: Old Problems and New Approaches
Wesley L. Nyborg (2001) Assuring the Safety of Medical Diagnostic Ultrasound
S. James Adelstein (2000) Administered Radioactivity: Unde Venimus Quoque
Imus
Naomi H. Harley (1999) Back to Background
Eric J. Hall (1998) From Chimney Sweeps to Astronauts: Cancer Risks in the
Workplace
William J. Bair (1997) Radionuclides in the Body: Meeting the Challenge!
Seymour Abrahamson (1996) 70 Years of Radiation Genetics: Fruit Flies, Mice
and Humans
Albrecht Kellerer (1995) Certainty and Uncertainty in Radiation Protection
R.J. Michael Fry (1994) Mice, Myths and Men
Warren K. Sinclair (1993) Science, Radiation Protection and the NCRP
Edward W. Webster (1992) Dose and Risk in Diagnostic Radiology: How Big?
How Little?
Victor P. Bond (1991) When is a Dose Not a Dose?
J. Newell Stannard (1990) Radiation Protection and the Internal Emitter Saga
Arthur C. Upton (1989) Radiobiology and Radiation Protection: The Past Cen-
tury and Prospects for the Future
Bo Lindell (1988) How Safe is Safe Enough?
Seymour Jablon (1987) How to be Quantitative about Radiation Risk Estimates
Herman P. Schwan (1986) Biological Effects of Non-ionizing Radiations: Cellu-
lar Properties and Interactions
John H. Harley (1985) Truth (and Beauty) in Radiation Measurement
Harald H. Rossi (1984) Limitation and Assessment in Radiation Protection
Merril Eisenbud (1983) The Human Environment—Past, Present and Future
Eugene L. Saenger (1982) Ethics, Trade-Offs and Medical Radiation
James F. Crow (1981) How Well Can We Assess Genetic Risk? Not Very
Harold O. Wyckoff (1980) From “Quantity of Radiation” and “Dose” to “Expo-
sure” and “Absorbed Dose”—An Historical Review
Hymer L. Friedell (1979) Radiation Protection—Concepts and Trade Offs
Sir Edward Pochin (1978) Why be Quantitative about Radiation Risk
Estimates?
176 / THE NCRP

Herbert M. Parker (1977) The Squares of the Natural Numbers in Radiation

Protection

Currently, the following committees are actively engaged in formulating

recommendations:
Program Area Committee 1: Basic Criteria, Epidemiology,
Radiobiology, and Risk
SC 1-13 Impact of Individual Susceptibility and Previous Radiation
Exposure on Radiation Risk for Astronauts
SC 1-15 Radiation Safety in NASA Lunar Missions’
SC 1-16 Uncertainties in the Estimation of Radiation Risks and Probability
of Disease Causation
SC 1-17 Second Cancers and Cardiopulmonary Effects After Radiotherapy
SC 1-18 Use of Ionizing Radiation Screen Systems for Detection of
Radioactive Materials that Could Represent a Threat to Homeland
Security
SC 1-19 Health Protection Issues Associated with Use of Active Detection
Technology Security Systems for Detection of Radioactive Threat
Materials
SC 1-20 Biological Effectiveness of Photons as a Function of Energy
Program Area Committee 2: Operational Radiation Safety
SC 2-3 Radiation Safety Issues for Image-Guided Interventional Medical
Procedures
SC 2-5 Investigation of Radiological Incidents
Program Area Committee 3: Nuclear and Radiological Security
and Safety
Program Area Committee 4: Radiation Protection in Medicine
SC 4-2 Population Monitoring and Decontamination Following a Nuclear/
Radiological Incident
SC 4-3 Diagnostic Reference Levels in Medical Imaging: Recommendations
for Application in the United States
SC 4-4 Risks of Ionizing Radiation to the Developing Embryo, Fetus and
Nursing Infant
Program Area Committee 5: Environmental Radiation and
Radioactive Waste Issues
SC 5-1 Approach to Optimizing Decision Making for Late-Phase Recovery
from Nuclear or Radiological Terrorism Incidents
SC 64-22 Design of Effective Effluent and Environmental Monitoring
Programs
Program Area Committee 6: Radiation Measurements and
Dosimetry
In recognition of its responsibility to facilitate and stimulate cooperation
among organizations concerned with the scientific and related aspects of radia-
tion protection and measurement, the Council has created a category of
NCRP Collaborating Organizations. Organizations or groups of organizations
that are national or international in scope and are concerned with scientific
problems involving radiation quantities, units, measurements and effects, or
radiation protection may be admitted to collaborating status by the Council.
Collaborating Organizations provide a means by which NCRP can gain input
 THE NCRP / 177

into its activities from a wider segment of society. At the same time, the relation-
ships with the Collaborating Organizations facilitate wider dissemination of
information about the Council's activities, interests and concerns. Collaborating
Organizations have the opportunity to comment on draft reports (at the time
that these are submitted to the members of the Council). This is intended to cap-
italize on the fact that Collaborating Organizations are in an excellent position
to both contribute to the identification of what needs to be treated in NCRP
reports and to identify problems that might result from proposed recommenda-
tions. The present Collaborating Organizations with which NCRP maintains
liaison are as follows:

American Academy of Dermatology

American Academy of Environmental Engineers
American Academy of Health Physics
American Academy of Orthopaedic Surgeons
American Association of Physicists in Medicine
American Bracytherapy Society
American College of Cardiology
American College of Medical Physics
American College of Nuclear Physicians
American College of Occupational and Environmental Medicine
American College of Radiology
American Conference of Governmental Industrial Hygienists
American Dental Association
American Industrial Hygiene Association
American Institute of Ultrasound in Medicine
American Medical Association
American Nuclear Society
American Pharmaceutical Association
American Podiatric Medical Association
American Public Health Association
American Radium Society
American Roentgen Ray Society
American Society for Radiation Oncology
American Society of Emergency Radiology
American Society of Health-System Pharmacists
American Society of Nuclear Cardiology
American Society of Radiologic Technologists
Association of Educators in Imaging and Radiological Sciences
Association of University Radiologists
Bioelectromagnetics Society
Campus Radiation Safety Officers
College of American Pathologists
Conference of Radiation Control Program Directors, Inc.
Council on Radionuclides and Radiopharmaceuticals
Defense Threat Reduction Agency
Electric Power Research Institute
Federal Aviation Administration
Federal Communications Commission
Federal Emergency Management Agency
Genetics Society of America
178 / THE NCRP

Health Physics Society

Institute of Electrical and Electronics Engineers, Inc.
Institute of Nuclear Power Operations
International Brotherhood of Electrical Workers
National Aeronautics and Space Administration
National Association of Environmental Professionals
National Center for Environmental Health/Agency for Toxic Substances
National Electrical Manufacturers Association
National Institute for Occupational Safety and Health
National Institute of Standards and Technology
Nuclear Energy Institute
Office of Science and Technology Policy
Paper, Allied-Industrial, Chemical and Energy Workers International
Union
Product Stewardship Institute
Radiation Research Society
Radiological Society of North America
Society for Cardiovascular Angiography and Interventions
Society for Pediatric Radiology
Society for Risk Analysis
Society of Cardiovascular Computed Tomography
Society of Chairmen of Academic Radiology Departments
Society of Interventional Radiology
Society of Nuclear Medicine
Society of Radiologists in Ultrasound
Society of Skeletal Radiology
U.S. Air Force
U.S. Army
U.S. Coast Guard
U.S. Department of Energy
U.S. Department of Housing and Urban Development
U.S. Department of Labor
U.S. Department of Transportation
U.S. Environmental Protection Agency
U.S. Navy
U.S. Nuclear Regulatory Commission
U.S. Public Health Service
Utility Workers Union of America

NCRP has found its relationships with these organizations to be extremely

valuable to continued progress in its program.
Another aspect of the cooperative efforts of NCRP relates to the Special
Liaison relationships established with various governmental organizations
that have an interest in radiation protection and measurements. This liaison
relationship provides: (1) an opportunity for participating organizations to des-
ignate an individual to provide liaison between the organization and NCRP;
(2) that the individual designated will receive copies of draft NCRP reports (at
the time that these are submitted to the members of the Council) with an invi-
tation to comment, but not vote; and (3) that new NCRP efforts might be dis-
cussed with liaison individuals as appropriate, so that they might have an
 THE NCRP / 179

opportunity to make suggestions on new studies and related matters. The fol-
lowing organizations participate in the Special Liaison Program:

Australian Radiation Laboratory

Bundesamt fur Strahlenschutz (Germany)
Canadian Association of Medical Radiation Technologists
Canadian Nuclear Safety Commission
Central Laboratory for Radiological Protection (Poland)
China Institute for Radiation Protection
Commissariat a l’Energie Atomique (France)
Commonwealth Scientific Instrumentation Research Organization
(Australia)
European Commission
Health Council of the Netherlands
Health Protection Agency
International Commission on Non-ionizing Radiation Protection
International Commission on Radiation Units and Measurements
International Commission on Radiological Protection
International Radiation Protection Association
Japanese Nuclear Safety Commission
Japan Radiation Council
Korea Institute of Nuclear Safety
Russian Scientific Commission on Radiation Protection
South African Forum for Radiation Protection
World Association of Nuclear Operators
World Health Organization, Radiation and Environmental Health

NCRP values highly the participation of these organizations in the Special

Liaison Program.
The Council also benefits significantly from the relationships established
pursuant to the Corporate Sponsor's Program. The program facilitates the
interchange of information and ideas and corporate sponsors provide valuable
fiscal support for the Council's program. This developing program currently
includes the following Corporate Sponsors:

3M
GE Healthcare
Global Dosimetry Solutions, Inc.
Landauer, Inc.
Nuclear Energy Institute

The Council's activities have been made possible by the voluntary contribu-
tion of time and effort by its members and participants and the generous
support of the following organizations:

3M Health Physics Services

Agfa Corporation
Alfred P. Sloan Foundation
Alliance of American Insurers
American Academy of Dermatology
American Academy of Health Physics
American Academy of Oral and Maxillofacial Radiology
180 / THE NCRP

American Association of Physicists in Medicine

American Cancer Society
American College of Medical Physics
American College of Nuclear Physicians
American College of Occupational and Environmental Medicine
American College of Radiology
American College of Radiology Foundation
American Dental Association
American Healthcare Radiology Administrators
American Industrial Hygiene Association
American Insurance Services Group
American Medical Association
American Nuclear Society
American Osteopathic College of Radiology
American Podiatric Medical Association
American Public Health Association
American Radium Society
American Roentgen Ray Society
American Society for Radiation Oncology
American Society for Therapeutic Radiology and Oncology
American Society of Radiologic Technologists
American Veterinary Medical Association
American Veterinary Radiology Society
Association of Educators in Radiological Sciences, Inc.
Association of University Radiologists
Battelle Memorial Institute
Canberra Industries, Inc.
Chem Nuclear Systems
Center for Devices and Radiological Health
College of American Pathologists
Committee on Interagency Radiation Research and Policy Coordination
Commonwealth Edison
Commonwealth of Pennsylvania
Consolidated Edison
Consumers Power Company
Council on Radionuclides and Radiopharmaceuticals
Defense Nuclear Agency
Defense Threat Reduction Agency
Duke Energy Corporation
Eastman Kodak Company
Edison Electric Institute
Edward Mallinckrodt, Jr. Foundation
EG&G Idaho, Inc.
Electric Power Research Institute
Electromagnetic Energy Association
Federal Emergency Management Agency
Florida Institute of Phosphate Research
Florida Power Corporation
Fuji Medical Systems, U.S.A., Inc.
Genetics Society of America
 THE NCRP / 181

Global Dosimetry Solutions

Health Effects Research Foundation (Japan)
Health Physics Society
ICN Biomedicals, Inc.
Institute of Nuclear Power Operations
James Picker Foundation
Martin Marietta Corporation
Motorola Foundation
National Aeronautics and Space Administration
National Association of Photographic Manufacturers
National Cancer Institute
National Electrical Manufacturers Association
National Institute of Standards and Technology
New York Power Authority
Philips Medical Systems
Picker International
Public Service Electric and Gas Company
Radiation Research Society
Radiological Society of North America
Richard Lounsbery Foundation
Sandia National Laboratory
Siemens Medical Systems, Inc.
Society of Nuclear Medicine
Society of Pediatric Radiology
Southern California Edison Company
U.S. Department of Energy
U.S. Department of Labor
U.S. Environmental Protection Agency
U.S. Navy
U.S. Nuclear Regulatory Commission
Victoreen, Inc.
Westinghouse Electric Corporation

Initial funds for publication of NCRP reports were provided by a grant from
the James Picker Foundation.
NCRP seeks to promulgate information and recommendations based on
leading scientific judgment on matters of radiation protection and measure-
ment and to foster cooperation among organizations concerned with these mat-
ters. These efforts are intended to serve the public interest and the Council
welcomes comments and suggestions on its reports or activities.
NCRP Publications

NCRP publications can be obtained online in both hard- and soft-copy

(downloadable PDF) formats at http://NCRPpublications.org. Professional soci-
eties can arrange for discounts for their members by contacting NCRP. Addi-
tional information on NCRP publications may be obtained from the NCRP
website (http://NCRPonline.org) or by telephone (800-229-2652, ext. 25) and
fax (301-907-8768). The mailing address is:

NCRP Publications
7910 Woodmont Avenue
Suite 400
Bethesda, MD 20814-3095

Abstracts of NCRP reports published since 1980, abstracts of all NCRP com-
mentaries, and the text of all NCRP statements are available at the NCRP
website. Currently available publications are listed below.

NCRP Reports
No. Title
8 Control and Removal of Radioactive Contamination in Laboratories
(1951)
22 Maximum Permissible Body Burdens and Maximum Permissible
Concentrations of Radionuclides in Air and in Water for Occupational
Exposure (1959) [includes Addendum 1 issued in August 1963]
25 Measurement of Absorbed Dose of Neutrons, and of Mixtures of
Neutrons and Gamma Rays (1961)
27 Stopping Powers for Use with Cavity Chambers (1961)
30 Safe Handling of Radioactive Materials (1964)
32 Radiation Protection in Educational Institutions (1966)
35 Dental X-Ray Protection (1970)
36 Radiation Protection in Veterinary Medicine (1970)
37 Precautions in the Management of Patients Who Have Received
Therapeutic Amounts of Radionuclides (1970)
38 Protection Against Neutron Radiation (1971)
40 Protection Against Radiation from Brachytherapy Sources (1972)
41 Specification of Gamma-Ray Brachytherapy Sources (1974)
42 Radiological Factors Affecting Decision-Making in a Nuclear Attack
(1974)
44 Krypton-85 in the Atmosphere—Accumulation, Biological
Significance, and Control Technology (1975)
46 Alpha-Emitting Particles in Lungs (1975)

182
 NCRP PUBLICATIONS / 183

47 Tritium Measurement Techniques (1976)

49 Structural Shielding Design and Evaluation for Medical Use of
X Rays and Gamma Rays of Energies Up to 10 MeV (1976)
50 Environmental Radiation Measurements (1976)
52 Cesium-137 from the Environment to Man: Metabolism and Dose
(1977)
54 Medical Radiation Exposure of Pregnant and Potentially Pregnant
Women (1977)
55 Protection of the Thyroid Gland in the Event of Releases of
Radioiodine (1977)
57 Instrumentation and Monitoring Methods for Radiation Protection
(1978)
58 A Handbook of Radioactivity Measurements Procedures, 2nd ed.
(1985)
60 Physical, Chemical, and Biological Properties of Radiocerium
Relevant to Radiation Protection Guidelines (1978)
61 Radiation Safety Training Criteria for Industrial Radiography (1978)
62 Tritium in the Environment (1979)
63 Tritium and Other Radionuclide Labeled Organic Compounds
Incorporated in Genetic Material (1979)
64 Influence of Dose and Its Distribution in Time on Dose-Response
Relationships for Low-LET Radiations (1980)
65 Management of Persons Accidentally Contaminated with
Radionuclides (1980)
67 Radiofrequency Electromagnetic Fields—Properties, Quantities and
Units, Biophysical Interaction, and Measurements (1981)
68 Radiation Protection in Pediatric Radiology (1981)
69 Dosimetry of X-Ray and Gamma-Ray Beams for Radiation Therapy in
the Energy Range 10 keV to 50 MeV (1981)
70 Nuclear Medicine—Factors Influencing the Choice and Use of
Radionuclides in Diagnosis and Therapy (1982)
72 Radiation Protection and Measurement for Low-Voltage Neutron
Generators (1983)
73 Protection in Nuclear Medicine and Ultrasound Diagnostic
Procedures in Children (1983)
74 Biological Effects of Ultrasound: Mechanisms and Clinical
Implications (1983)
75 Iodine-129: Evaluation of Releases from Nuclear Power Generation
(1983)
76 Radiological Assessment: Predicting the Transport, Bioaccumulation,
and Uptake by Man of Radionuclides Released to the Environment
(1984)
77 Exposures from the Uranium Series with Emphasis on Radon and Its
Daughters (1984)
78 Evaluation of Occupational and Environmental Exposures to Radon
and Radon Daughters in the United States (1984)
79 Neutron Contamination from Medical Electron Accelerators (1984)
80 Induction of Thyroid Cancer by Ionizing Radiation (1985)
81 Carbon-14 in the Environment (1985)
82 SI Units in Radiation Protection and Measurements (1985)
184 / NCRP PUBLICATIONS

83 The Experimental Basis for Absorbed-Dose Calculations in Medical

Uses of Radionuclides (1985)
84 General Concepts for the Dosimetry of Internally Deposited
Radionuclides (1985)
86 Biological Effects and Exposure Criteria for Radiofrequency
Electromagnetic Fields (1986)
87 Use of Bioassay Procedures for Assessment of Internal Radionuclide
Deposition (1987)
88 Radiation Alarms and Access Control Systems (1986)
89 Genetic Effects from Internally Deposited Radionuclides (1987)
90 Neptunium: Radiation Protection Guidelines (1988)
92 Public Radiation Exposure from Nuclear Power Generation in the
United States (1987)
93 Ionizing Radiation Exposure of the Population of the United States
(1987)
94 Exposure of the Population in the United States and Canada from
Natural Background Radiation (1987)
95 Radiation Exposure of the U.S. Population from Consumer Products
and Miscellaneous Sources (1987)
96 Comparative Carcinogenicity of Ionizing Radiation and Chemicals
(1989)
97 Measurement of Radon and Radon Daughters in Air (1988)
99 Quality Assurance for Diagnostic Imaging (1988)
100 Exposure of the U.S. Population from Diagnostic Medical Radiation
(1989)
101 Exposure of the U.S. Population from Occupational Radiation (1989)
102 Medical X-Ray, Electron Beam and Gamma-Ray Protection for
Energies Up to 50 MeV (Equipment Design, Performance and Use)
(1989)
103 Control of Radon in Houses (1989)
104 The Relative Biological Effectiveness of Radiations of Different
Quality (1990)
105 Radiation Protection for Medical and Allied Health Personnel (1989)
106 Limit for Exposure to “Hot Particles” on the Skin (1989)
107 Implementation of the Principle of As Low As Reasonably Achievable
(ALARA) for Medical and Dental Personnel (1990)
108 Conceptual Basis for Calculations of Absorbed-Dose Distributions
(1991)
109 Effects of Ionizing Radiation on Aquatic Organisms (1991)
110 Some Aspects of Strontium Radiobiology (1991)
111 Developing Radiation Emergency Plans for Academic, Medical or
Industrial Facilities (1991)
112 Calibration of Survey Instruments Used in Radiation Protection for
the Assessment of Ionizing Radiation Fields and Radioactive Surface
Contamination (1991)
113 Exposure Criteria for Medical Diagnostic Ultrasound: I. Criteria
Based on Thermal Mechanisms (1992)
114 Maintaining Radiation Protection Records (1992)
115 Risk Estimates for Radiation Protection (1993)
116 Limitation of Exposure to Ionizing Radiation (1993)
 NCRP PUBLICATIONS / 185

117 Research Needs for Radiation Protection (1993)

118 Radiation Protection in the Mineral Extraction Industry (1993)
119 A Practical Guide to the Determination of Human Exposure to
Radiofrequency Fields (1993)
120 Dose Control at Nuclear Power Plants (1994)
121 Principles and Application of Collective Dose in Radiation Protection
(1995)
122 Use of Personal Monitors to Estimate Effective Dose Equivalent and
Effective Dose to Workers for External Exposure to Low-LET
Radiation (1995)
123 Screening Models for Releases of Radionuclides to Atmosphere,
Surface Water, and Ground (1996)
124 Sources and Magnitude of Occupational and Public Exposures from
Nuclear Medicine Procedures (1996)
125 Deposition, Retention and Dosimetry of Inhaled Radioactive
Substances (1997)
126 Uncertainties in Fatal Cancer Risk Estimates Used in Radiation
Protection (1997)
127 Operational Radiation Safety Program (1998)
128 Radionuclide Exposure of the Embryo/Fetus (1998)
129 Recommended Screening Limits for Contaminated Surface Soil and
Review of Factors Relevant to Site-Specific Studies (1999)
130 Biological Effects and Exposure Limits for “Hot Particles” (1999)
131 Scientific Basis for Evaluating the Risks to Populations from Space
Applications of Plutonium (2001)
132 Radiation Protection Guidance for Activities in Low-Earth Orbit
(2000)
133 Radiation Protection for Procedures Performed Outside the Radiology
Department (2000)
134 Operational Radiation Safety Training (2000)
135 Liver Cancer Risk from Internally-Deposited Radionuclides (2001)
136 Evaluation of the Linear-Nonthreshold Dose-Response Model for
Ionizing Radiation (2001)
137 Fluence-Based and Microdosimetric Event-Based Methods for
Radiation Protection in Space (2001)
138 Management of Terrorist Events Involving Radioactive Material
(2001)
139 Risk-Based Classification of Radioactive and Hazardous Chemical
Wastes (2002)
140 Exposure Criteria for Medical Diagnostic Ultrasound: II. Criteria
Based on all Known Mechanisms (2002)
141 Managing Potentially Radioactive Scrap Metal (2002)
142 Operational Radiation Safety Program for Astronauts in Low-Earth
Orbit: A Basic Framework (2002)
143 Management Techniques for Laboratories and Other Small
Institutional Generators to Minimize Off-Site Disposal of Low-Level
Radioactive Waste (2003)
144 Radiation Protection for Particle Accelerator Facilities (2003)
145 Radiation Protection in Dentistry (2003)
186 / NCRP PUBLICATIONS

146 Approaches to Risk Management in Remediation of Radioactively

Contaminated Sites (2004)
147 Structural Shielding Design for Medical X-Ray Imaging Facilities
(2004)
148 Radiation Protection in Veterinary Medicine (2004)
149 A Guide to Mammography and Other Breast Imaging Procedures
(2004)
150 Extrapolation of Radiation-Induced Cancer Risks from Nonhuman
Experimental Systems to Humans (2005)
151 Structural Shielding Design and Evaluation for Megavoltage X- and
Gamma-Ray Radiotherapy Facilities (2005)
152 Performance Assessment of Near-Surface Facilities for Disposal of
Low-Level Radioactive Waste (2005)
153 Information Needed to Make Radiation Protection Recommendations
for Space Missions Beyond Low-Earth Orbit (2006)
154 Cesium-137 in the Environment: Radioecology and Approaches to
Assessment and Management (2006)
155 Management of Radionuclide Therapy Patients (2006)
156 Development of a Biokinetic Model for Radionuclide-Contaminated
Wounds and Procedures for Their Assessment, Dosimetry and
Treatment (2006)
157 Radiation Protection in Educational Institutions (2007)
158 Uncertainties in the Measurement and Dosimetry of External
Radiation (2007)
159 Risk to the Thyroid from Ionizing Radiation (2008)
160 Ionizing Radiation Exposure of the Population of the United States
(2009)
161 Management of Persons Contaminated with Radionuclides (2008)
162 Self Assessment of Radiation-Safety Programs (2009)
163 Radiation Dose Reconstruction: Principles and Practices (2009)
164 Uncertainties in Internal Radiation Dose Assessment (2009)
165 Responding to a Radiological or Nuclear Terrorism Incident: A Guide
for Decision Makers (2010)

Binders for NCRP reports are available. Two sizes make it possible to col-
lect into small binders the “old series” of reports (NCRP Reports Nos. 8–30) and
into large binders the more recent publications (NCRP Reports Nos. 32–165).
Each binder will accommodate from five to seven reports. The binders carry the
identification “NCRP Reports” and come with label holders which permit the
user to attach labels showing the reports contained in each binder.
The following bound sets of NCRP reports are also available:

Volume I. NCRP Reports Nos. 8, 22

Volume II. NCRP Reports Nos. 23, 25, 27, 30
Volume III. NCRP Reports Nos. 32, 35, 36, 37
Volume IV. NCRP Reports Nos. 38, 40, 41
Volume V. NCRP Reports Nos. 42, 44, 46
Volume VI. NCRP Reports Nos. 47, 49, 50, 51
Volume VII. NCRP Reports Nos. 52, 53, 54, 55, 57
Volume VIII. NCRP Report No. 58
 NCRP PUBLICATIONS / 187

Volume IX. NCRP Reports Nos. 59, 60, 61, 62, 63

Volume X. NCRP Reports Nos. 64, 65, 66, 67
Volume XI. NCRP Reports Nos. 68, 69, 70, 71, 72
Volume XII. NCRP Reports Nos. 73, 74, 75, 76
Volume XIII. NCRP Reports Nos. 77, 78, 79, 80
Volume XIV. NCRP Reports Nos. 81, 82, 83, 84, 85
Volume XV. NCRP Reports Nos. 86, 87, 88, 89
Volume XVI. NCRP Reports Nos. 90, 91, 92, 93
Volume XVII. NCRP Reports Nos. 94, 95, 96, 97
Volume XVIII. NCRP Reports Nos. 98, 99, 100
Volume XIX. NCRP Reports Nos. 101, 102, 103, 104
Volume XX. NCRP Reports Nos. 105, 106, 107, 108
Volume XXI. NCRP Reports Nos. 109, 110, 111
Volume XXII. NCRP Reports Nos. 112, 113, 114
Volume XXIII. NCRP Reports Nos. 115, 116, 117, 118
Volume XXIV. NCRP Reports Nos. 119, 120, 121, 122
Volume XXV. NCRP Report No. 123I and 123II
Volume XXVI. NCRP Reports Nos. 124, 125, 126, 127
Volume XXVII. NCRP Reports Nos. 128, 129, 130
Volume XXVIII. NCRP Reports Nos. 131, 132, 133
Volume XXIX. NCRP Reports Nos. 134, 135, 136, 137
Volume XXX. NCRP Reports Nos. 138, 139
Volume XXXI. NCRP Report No. 140
Volume XXXII. NCRP Reports Nos. 141, 142, 143
Volume XXXIII. NCRP Report No. 144
Volume XXXIV. NCRP Reports Nos. 145, 146, 147
Volume XXXV. NCRP Reports Nos. 148, 149
Volume XXXVI. NCRP Reports Nos. 150, 151, 152
Volume XXXVII, NCRP Reports Nos. 153, 154, 155
Volume XXXVIII, NCRP Reports Nos. 156, 157, 158
Volume XXXIX, NCRP Reports Nos. 159, 160
Volume XL. NCRP Report No. 161 (Vol I and II)
Volume XLI. NCRP Reports Nos. 162, 163

(Titles of the individual reports contained in each volume are given

previously.)

NCRP Commentaries
No. Title
1 Krypton-85 in the Atmosphere—With Specific Reference to the Public
Health Significance of the Proposed Controlled Release at Three Mile
Island (1980)
4 Guidelines for the Release of Waste Water from Nuclear Facilities with
Special Reference to the Public Health Significance of the Proposed
Release of Treated Waste Waters at Three Mile Island (1987)
5 Review of the Publication, Living Without Landfills (1989)
6 Radon Exposure of the U.S. Population—Status of the Problem (1991)
188 / NCRP PUBLICATIONS

7 Misadministration of Radioactive Material in Medicine—Scientific

Background (1991)
8 Uncertainty in NCRP Screening Models Relating to Atmospheric
Transport, Deposition and Uptake by Humans (1993)
9 Considerations Regarding the Unintended Radiation Exposure of the
Embryo, Fetus or Nursing Child (1994)
10 Advising the Public about Radiation Emergencies: A Document for
Public Comment (1994)
11 Dose Limits for Individuals Who Receive Exposure from Radionuclide
Therapy Patients (1995)
12 Radiation Exposure and High-Altitude Flight (1995)
13 An Introduction to Efficacy in Diagnostic Radiology and Nuclear
Medicine (Justification of Medical Radiation Exposure) (1995)
14 A Guide for Uncertainty Analysis in Dose and Risk Assessments
Related to Environmental Contamination (1996)
15 Evaluating the Reliability of Biokinetic and Dosimetric Models and
Parameters Used to Assess Individual Doses for Risk Assessment
Purposes (1998)
16 Screening of Humans for Security Purposes Using Ionizing Radiation
Scanning Systems (2003)
17 Pulsed Fast Neutron Analysis System Used in Security Surveillance
(2003)
18 Biological Effects of Modulated Radiofrequency Fields (2003)
19 Key Elements of Preparing Emergency Responders for Nuclear and
Radiological Terrorism (2005)
20 Radiation Protection and Measurement Issues Related to Cargo
Scanning with Accelerator-Produced High-Energy X Rays (2007)

Proceedings of the Annual Meeting

No. Title
1 Perceptions of Risk, Proceedings of the Fifteenth Annual Meeting held
on March 14-15, 1979 (including Taylor Lecture No. 3) (1980)
3 Critical Issues in Setting Radiation Dose Limits, Proceedings of the
Seventeenth Annual Meeting held on April 8-9, 1981 (including
Taylor Lecture No. 5) (1982)
4 Radiation Protection and New Medical Diagnostic Approaches,
Proceedings of the Eighteenth Annual Meeting held on April 6-7,
1982 (including Taylor Lecture No. 6) (1983)
5 Environmental Radioactivity, Proceedings of the Nineteenth Annual
Meeting held on April 6-7, 1983 (including Taylor Lecture No. 7)
(1983)
6 Some Issues Important in Developing Basic Radiation Protection
Recommendations, Proceedings of the Twentieth Annual Meeting
held on April 4-5, 1984 (including Taylor Lecture No. 8) (1985)
7 Radioactive Waste, Proceedings of the Twenty-First Annual Meeting
held on April 3-4, 1985 (including Taylor Lecture No. 9)(1986)
8 Nonionizing Electromagnetic Radiations and Ultrasound,
Proceedings of the Twenty-Second Annual Meeting held on April 2-3,
1986 (including Taylor Lecture No. 10) (1988)
 NCRP PUBLICATIONS / 189

9 New Dosimetry at Hiroshima and Nagasaki and Its Implications for

Risk Estimates, Proceedings of the Twenty-Third Annual Meeting
held on April 8-9, 1987 (including Taylor Lecture No. 11) (1988)
10 Radon, Proceedings of the Twenty-Fourth Annual Meeting held on
March 30-31, 1988 (including Taylor Lecture No. 12) (1989)
11 Radiation Protection Today—The NCRP at Sixty Years, Proceedings
of the Twenty-Fifth Annual Meeting held on April 5-6, 1989
(including Taylor Lecture No. 13) (1990)
12 Health and Ecological Implications of Radioactively Contaminated
Environments, Proceedings of the Twenty-Sixth Annual Meeting held
on April 4-5, 1990 (including Taylor Lecture No. 14) (1991)
13 Genes, Cancer and Radiation Protection, Proceedings of the
Twenty-Seventh Annual Meeting held on April 3-4, 1991 (including
Taylor Lecture No. 15) (1992)
14 Radiation Protection in Medicine, Proceedings of the Twenty-Eighth
Annual Meeting held on April 1-2, 1992 (including Taylor Lecture
No. 16) (1993)
15 Radiation Science and Societal Decision Making, Proceedings of the
Twenty-Ninth Annual Meeting held on April 7-8, 1993 (including
Taylor Lecture No. 17) (1994)
16 Extremely-Low-Frequency Electromagnetic Fields: Issues in
Biological Effects and Public Health, Proceedings of the Thirtieth
Annual Meeting held on April 6-7, 1994 (not published).
17 Environmental Dose Reconstruction and Risk Implications,
Proceedings of the Thirty-First Annual Meeting held on April 12-13,
1995 (including Taylor Lecture No. 19) (1996)
18 Implications of New Data on Radiation Cancer Risk, Proceedings of
the Thirty-Second Annual Meeting held on April 3-4, 1996 (including
Taylor Lecture No. 20) (1997)
19 The Effects of Pre- and Postconception Exposure to Radiation,
Proceedings of the Thirty-Third Annual Meeting held on April 2-3,
1997, Teratology 59, 181–317 (1999)
20 Cosmic Radiation Exposure of Airline Crews, Passengers and
Astronauts, Proceedings of the Thirty-Fourth Annual Meeting held on
April 1-2, 1998, Health Phys. 79, 466–613 (2000)
21 Radiation Protection in Medicine: Contemporary Issues, Proceedings
of the Thirty-Fifth Annual Meeting held on April 7-8, 1999 (including
Taylor Lecture No. 23) (1999)
22 Ionizing Radiation Science and Protection in the 21st Century,
Proceedings of the Thirty-Sixth Annual Meeting held on April 5-6,
2000, Health Phys. 80, 317–402 (2001)
23 Fallout from Atmospheric Nuclear Tests—Impact on Science and
Society, Proceedings of the Thirty-Seventh Annual Meeting held on
April 4-5, 2001, Health Phys. 82, 573–748 (2002)
24 Where the New Biology Meets Epidemiology: Impact on Radiation
Risk Estimates, Proceedings of the Thirty-Eighth Annual Meeting
held on April 10-11, 2002, Health Phys. 85, 1–108 (2003)
25 Radiation Protection at the Beginning of the 21st Century–A Look
Forward, Proceedings of the Thirty-Ninth Annual Meeting held on
April 9–10, 2003, Health Phys. 87, 237–319 (2004)
190 / NCRP PUBLICATIONS

26 Advances in Consequence Management for Radiological Terrorism

Events, Proceedings of the Fortieth Annual Meeting held on
April 14–15, 2004, Health Phys. 89, 415–588 (2005)
27 Managing the Disposition of Low-Activity Radioactive Materials,
Proceedings of the Forty-First Annual Meeting held on March 30–31,
2005, Health Phys. 91, 413–536 (2006)
28 Chernobyl at Twenty, Proceedings of the Forty-Second Annual
Meeting held on April 3–4, 2006, Health Phys. 93, 345–595 (2007)
29 Advances in Radiation Protection in Medicine, Proceedings of the
Forty-Third Annual Meeting held on April 16-17, 2007, Health Phys.
95, 461–686 (2008)
30 Low Dose and Low Dose-Rate Radiation Effects and Models,
Proceedings of the Forty-Fourth Annual Meeting held on April 14–15,
2008, Health Phys. 97, 373–541 (2009)

Lauriston S. Taylor Lectures

No. Title
1 The Squares of the Natural Numbers in Radiation Protection by
Herbert M. Parker (1977)
2 Why be Quantitative about Radiation Risk Estimates? by Sir Edward
Pochin (1978)
3 Radiation Protection—Concepts and Trade Offs by Hymer L. Friedell
(1979) [available also in Perceptions of Risk, see above]
4 From “Quantity of Radiation” and “Dose” to “Exposure” and “Absorbed
Dose”—An Historical Review by Harold O. Wyckoff (1980)
5 How Well Can We Assess Genetic Risk? Not Very by James F. Crow
(1981) [available also in Critical Issues in Setting Radiation Dose
Limits, see above]
6 Ethics, Trade-offs and Medical Radiation by Eugene L. Saenger
(1982) [available also in Radiation Protection and New Medical
Diagnostic Approaches, see above]
7 The Human Environment—Past, Present and Future by Merril
Eisenbud (1983) [available also in Environmental Radioactivity, see
above]
8 Limitation and Assessment in Radiation Protection by Harald H.
Rossi (1984) [available also in Some Issues Important in Developing
Basic Radiation Protection Recommendations, see above]
9 Truth (and Beauty) in Radiation Measurement by John H. Harley
(1985) [available also in Radioactive Waste, see above]
10 Biological Effects of Non-ionizing Radiations: Cellular Properties and
Interactions by Herman P. Schwan (1987) [available also in
Nonionizing Electromagnetic Radiations and Ultrasound, see above]
11 How to be Quantitative about Radiation Risk Estimates by Seymour
Jablon (1988) [available also in New Dosimetry at Hiroshima and
Nagasaki and its Implications for Risk Estimates, see above]
12 How Safe is Safe Enough? by Bo Lindell (1988) [available also in
Radon, see above]
 NCRP PUBLICATIONS / 191

13 Radiobiology and Radiation Protection: The Past Century and

Prospects for the Future by Arthur C. Upton (1989) [available also in
Radiation Protection Today, see above]
14 Radiation Protection and the Internal Emitter Saga by J. Newell
Stannard (1990) [available also in Health and Ecological Implications
of Radioactively Contaminated Environments, see above]
15 When is a Dose Not a Dose? by Victor P. Bond (1992) [available also in
Genes, Cancer and Radiation Protection, see above]
16 Dose and Risk in Diagnostic Radiology: How Big? How Little? by
Edward W. Webster (1992) [available also in Radiation Protection in
Medicine, see above]
17 Science, Radiation Protection and the NCRP by Warren K. Sinclair
(1993) [available also in Radiation Science and Societal Decision
Making, see above]
18 Mice, Myths and Men by R.J. Michael Fry (1995)
19 Certainty and Uncertainty in Radiation Research by Albrecht M.
Kellerer. Health Phys. 69, 446–453 (1995)
20 70 Years of Radiation Genetics: Fruit Flies, Mice and Humans by
Seymour Abrahamson. Health Phys. 71, 624–633 (1996)
21 Radionuclides in the Body: Meeting the Challenge by William J. Bair.
Health Phys. 73, 423–432 (1997)
22 From Chimney Sweeps to Astronauts: Cancer Risks in the Work Place
by Eric J. Hall. Health Phys. 75, 357–366 (1998)
23 Back to Background: Natural Radiation and Radioactivity Exposed
by Naomi H. Harley. Health Phys. 79, 121–128 (2000)
24 Administered Radioactivity: Unde Venimus Quoque Imus by S. James
Adelstein. Health Phys. 80, 317–324 (2001)
25 Assuring the Safety of Medical Diagnostic Ultrasound by Wesley L.
Nyborg. Health Phys. 82, 578–587 (2002)
26 Developing Mechanistic Data for Incorporation into Cancer and
Genetic Risk Assessments: Old Problems and New Approaches by R.
Julian Preston. Health Phys. 85, 4–12 (2003)
27 The Evolution of Radiation Protection–From Erythema to Genetic
Risks to Risks of Cancer to ? by Charles B. Meinhold, Health Phys. 87,
240–248 (2004)
28 Radiation Protection in the Aftermath of a Terrorist Attack Involving
Exposure to Ionizing Radiation by Abel J. Gonzalez, Health Phys. 89,
418–446 (2005)
29 Nontargeted Effects of Radiation: Implications for Low Dose
Exposures by John B. Little, Health Phys. 91, 416–426 (2006)
30 Fifty Years of Scientific Research: The Importance of Scholarship and
the Influence of Politics and Controversy by Robert L. Brent, Health
Phys. 93, 348–379 (2007)
31 The Quest for Therapeutic Actinide Chelators by Patricia W. Durbin,
Health Phys. 95, 465–492 (2008)
32 Yucca Mountain Radiation Standards, Dose/Risk Assessments,
Thinking Outside the Box, Evaluations, and Recommendations by
Dade W. Moeller, Health Phys. 97, 376–391 (2009)
192 / NCRP PUBLICATIONS

Symposium Proceedings
No. Title
1 The Control of Exposure of the Public to Ionizing Radiation in the
Event of Accident or Attack, Proceedings of a Symposium held
April 27-29, 1981 (1982)
2 Radioactive and Mixed Waste—Risk as a Basis for Waste
Classification, Proceedings of a Symposium held November 9, 1994
(1995)
3 Acceptability of Risk from Radiation—Application to Human Space
Flight, Proceedings of a Symposium held May 29, 1996 (1997)
4 21st Century Biodosimetry: Quantifying the Past and Predicting the
Future, Proceedings of a Symposium held February 22, 2001, Radiat.
Prot. Dosim. 97(1), (2001)
5 National Conference on Dose Reduction in CT, with an Emphasis on
Pediatric Patients, Summary of a Symposium held November 6-7,
2002, Am. J. Roentgenol. 181(2), 321–339 (2003)

NCRP Statements
No. Title
1 “Blood Counts, Statement of the National Committee on Radiation
Protection,” Radiology 63, 428 (1954)
2 “Statements on Maximum Permissible Dose from Television
Receivers and Maximum Permissible Dose to the Skin of the Whole
Body,” Am. J. Roentgenol., Radium Ther. and Nucl. Med. 84, 152
(1960) and Radiology 75, 122 (1960)
3 X-Ray Protection Standards for Home Television Receivers, Interim
Statement of the National Council on Radiation Protection and
Measurements (1968)
4 Specification of Units of Natural Uranium and Natural Thorium,
Statement of the National Council on Radiation Protection and
Measurements (1973)
5 NCRP Statement on Dose Limit for Neutrons (1980)
6 Control of Air Emissions of Radionuclides (1984)
7 The Probability That a Particular Malignancy May Have Been Caused
by a Specified Irradiation (1992)
8 The Application of ALARA for Occupational Exposures (1999)
9 Extension of the Skin Dose Limit for Hot Particles to Other External
Sources of Skin Irradiation (2001)
10 Recent Applications of the NCRP Public Dose Limit Recommendation
for Ionizing Radiation (2004)

Other Documents
The following documents were published outside of the NCRP report, com-
mentary and statement series:

Somatic Radiation Dose for the General Population, Report of the Ad Hoc
Committee of the National Council on Radiation Protection and
 NCRP PUBLICATIONS / 193

Measurements, 6 May 1959, Science 131 (3399), February 19,

482–486 (1960)
Dose Effect Modifying Factors in Radiation Protection, Report of
Subcommittee M-4 (Relative Biological Effectiveness) of the National
Council on Radiation Protection and Measurements, Report BNL
50073 (T-471) (1967) Brookhaven National Laboratory (National
Technical Information Service, Springfield, Virginia)
Residential Radon Exposure and Lung Cancer Risk: Commentary on
Cohen's County-Based Study, Health Phys. 87(6), 656–658 (2004)
INDEX

Index Terms Links

Acute radiation syndrome (ARS) 11 20 22 81

95
Advice to the public 124
air circulation (in-house) 125 128 131
announcements 126
children 125 131
clothing 125 130
evacuation 127 132
extent of incident 124 126
food 125 130
hair 125 130
pets 125
phones 125 127 129 133
potassium iodide 127 131
sheltering 127
showering 125 130
water 125 127 130
Aerosols 8 94
Alpha particles 6 16 45 85
100
Index Terms Links

Alternative medical treatment site (AMTS) 73 94

management of individuals 94
Ambulances 30 34 79
241
Americium-241 ( Am) 10 103 105 144
As low as reasonably achievable
(ALARA) principle 20 27 113 119
123 140
Assistance Convention (nuclear
accident or radiological emergency) 41 134 137

Ballistic fragment 8
Beta particles 6 10 13 16
45 52 85 100
Bioassays 102
children and pregnant women 104
during early phase 103 106
equipment 105
planning 104
resources 105
sharing information 106
sources of error 106
therapy decisions 106
uncertainties 106
urine samples 106
Index Terms Links

Biodosimetry 107
bone-marrow transplant 107
during early phase 107
limitations 108
methods 107
whole-body doses 107
Blast damage 33 51 53 55
58 60 69
Blood studies 8 11 13 22
85 107
Bone-marrow transplant 107
Building design and construction 23

Californium-252 (252Cf) 10
Cancer risk 11 14 21 53
110
137
Cesium-137 ( Cs) 10 105 144
Children 20 31 38 92
94 104 125 129
131
Clinical decision guide (CDG) 105
Cobalt-60 (60Co) 6 10
Cold zone 16 60 69 97
100
Colony stimulating factors 95
Comforters 18 119
Index Terms Links

Communications systems 25 31 55 58
68 76
Community reception centers (CRC) 48 73 93
external decontamination 93
internal contamination 93
management of individuals 93
Concerned citizens 47 75 78 83
88 91 93
Consequence Management Home
Team (CMHT) 44 150
Consumer products 141
Codex Alimentarius Commission 144
drinking water 145
edible products (except drinking water) 144
hot particles 147
international agreements 143
international trade 142
intervention exemption level 142
naturally-occurring radionuclides 141
nonedible products 143
protection strategy 146
radiation protection 141
radiological or nuclear terrorism 146
radionuclides in food 144
World Health Organization 145
Index Terms Links

Control zones 15
cold zone 16
dangerous-radiation zone 17
establishment 15
hot zone 16
Countermeasures 24 47 50 72
81 86 95 110
123
colony stimulating factors 95
decontamination and decorporation 50
diethylenetriamine pentaacetic
acid (DPTA) 96
evacuation and sheltering 72
for internal contamination 95
guidance 110
improvised respiratory protection 47
in vendor managed inventory 81 86
medical 123
potassium iodide 96
prussian blue 96
shutdown of air intake 24
Crime scene 17 36 50 80
115
Cytogenetic assays 94 107
Index Terms Links

Damage zones 36 55 63 71
83 87 93 109
light damage zone 36 55 71 83
87
moderate damage zone 36 55 71 87
severe damage zone 36 55 63 71
93 109
Dangerous-radiation zone 16 45 56 66
definition 17
Deceased persons 112
decontamination 113
disaster mortuary operational
response team 112
dose limits (for workers) 114
guidance 113
precautions 113
proper handling 114
Decision dose 6 18 21 25
34 59
Decontamination 96 153
at home 153
clothes 153
cuts and abrasions 154
deceased persons 102
domestic pets 98
dry techniques 97
Index Terms Links

Decontamination (Cont.)
farm animals 98
guidance on levels (skin and clothing) 100
hair 154
hospital reception and
decontamination centers 99
instructions for waiting public 101
major cities 99
priorities 96
radiation monitoring 100
removal of outer clothing 97
replacement clothing 99
scalable approach 97
screening 101 155
self-decontamination 98
showering 97 154
supplies 99
temporary decontamination
centers 98
valuables 154
while waiting at scene of incident 154
Decorporation therapy 8 50 85 103
Diethylenetriamine pentaacetic
acid (DTPA) 96
Disaster Mortuary Operational
Response Team (DMORT) 112
Index Terms Links

Dose limits 15 20 22 80
114 119 122
members of the public 119
occupational 15 20 22 80
114 119 122
Downwind populations 72
evacuation 72
sheltering 72
Drinking water 27 143 145

Early health effects 94

diagnosis 94
Early phase 3 27 29 55
66 103
bioassay 103
biodosimetry 107
federal assets 29
planning 55
population monitoring 109
priorities 66
quantities 5
Electromagnetic pulse (EMP) 14 54 58 70
Electronic surveillance system
(early notification of
community-based epidemics) 80
Index Terms Links

Emergency Management
Assistance Compact 40
Emergency Medical Services (EMS) 18 22 28 44
49 75 78 90
99
Emergency Operations Center (EOC) 32 61 67
Emergency phase (see early phase)
Emergency responders 20 34 48 60
65 67
ALARA principle 20
control of doses 34
informed consent 22
managing dose 20
personal protection equipment
(radiological terrorism) 48
planning (nuclear terrorism) 67
priority actions (blast damage area) 69
protective actions (nuclear terrorism) 69
radiation detection equipment
(radiological terrorism) 49
specific recommendations 20 49 60 65
67 71
Evacuation 20 46 58 61
63 65 72
routes 65
Index Terms Links

Family-assistance centers 86
Federal assets 29
Advisory Team for Environment,
Food, and Health 29
Federal Radiological Monitoring
and Assessment Center (FRMAC) 29
Interagency Modeling and
Atmospheric Assessment
Center (IMAAC) 29
Radiological Assistance Program (RAP) 29
Federal guidance 25
Federal Radiological Monitoring
and Assessment Center (FRMAC) 29 32 44 61
151
Field exercise 5 28 45
Fires 13 17 33 52
57 70
Firestorm 52
First receivers 11 15 23 75
80 92 102 152
managing doses 23
Fission products 14 52
Flash blindness 58
Food and water (contamination) 12
Index Terms Links

Glass breakage 13 33 51 61
Ground zero 51 53 55 109

Hazard evaluation 32 55
Hazardous material (HAZMAT) 8 12 16 23
29 31 44 52
airborne 29 52
evaluation 32
transportation accident 12
Hazard zones 45 55
radiological terrorism incident 45
Hospital emergency department 8 48 91
Hospital preparedness 76
concerned citizens 78
contact information 76
contamination 79
dangerous-radiation zone 77
disease outbreaks 80
handling victims 77
hospital reception and
decontamination center 78
hospital staff 80
hot zone 76
medical treatment 77
Index Terms Links

Hospital preparedness (Cont.)

nuclear medicine 77
outside expertise 81
outside resources 81
recovery personnel 80
regional plan 77
security precautions 78
shrapnel 80
surge capability 77
training 81
triage 78
Hospital reception (triage) and
decontamination center (HRDC) 73
Hot particles 147
Hot zone 16

Improvised nuclear device (IND) 12

characteristics and consequences 12
Incident Command System 28 35 77 82
116
Informed consent 22 114
Inhaled radionuclides 11 46 49 85
94 98 101 103
105
triage 49
Index Terms Links

Inter-Agency Committee on the

Response to Nuclear and
Radiological Accidents 41
Interagency Modeling and
Atmospheric Assessment Center
(IMAAC) 29 32 44 61
152
Intermediate phase 3 26 47
Protective Action Guides 26 47
Internal contamination
(assessment) 94
International agreements 40
International Atomic Energy
Agency (IAEA) 7
radionuclides used in
radiological terrorism 7
International conventions and
agreements 134
applicability 135 139
assistance 137
International Atomic Energy
Agency 136
notification 135
radioactive waste 138
transboundary release 135
World Health Organization 135
International System (quantities and units) 6
Intervention exemption levels 142
Index Terms Links

Iodine-131 (131I) 85 106 144

Iridium-192 (192Ir) 10

Joint Convention (spent fuel and

radioactive waste) 134 138
Joint information center (JIC) 39

Late phase 3 26 67
Lethal dose 50% deaths (LD50) 107
Lifesaving 4 17 19 30
34 43 65 71
100 110 122
dangerous radiation zone 17
decision dose 21
emergency responders 20
priority 43 71
shelter 65
victims 100
Lung counting 85 94 103

Medical follow-up 96
Medical Reserve Corps (MRC) 80 84 116
Index Terms Links

Medical treatment 90
crisis standards of care 91
definitive care 90
emergency care 90
number of victims 91
on-scene triage 90
Members of the general public 19 34 36 46
62 65
decontamination 34
evacuation 20
improvised respiratory
protection (radiological terrorism) 47
postemergency-phase
(radiological terrorism) 46
post-incident information 38
preincident information 37
protective action 19
sheltering 20
sheltering versus evacuation
(radiological terrorism) 46
specific recommendations 37 47 62 65
Mutual-aid agreements 40

National disaster medical system 80 84 112 116

National Incident Management
System (NIMS) 26 28 36 40
Index Terms Links

National Response Framework

(NRF) 4 26 47 150
National Response Team 32
Neutrons 6 13 53 57
activation 53 57
capture 53
Notification Convention (nuclear accident) 41 134 135
Nuclear blast 6 13 23 33
51 58 60 65
68 87 91
effects 13 23 33 58
60
injuries 13 87 91
neutrons 6
response 68
survivors 65
Nuclear facilities 7 12 31 105
Nuclear medicine 77 81 105 115
Nuclear/Radiological Incident
Annex (NRIA) 26 28 110 152
Nuclear terrorism 51
damage and fallout pattern 54
downwind population 72
emergency responders 67
hazard analysis 55
hazard zones 55
protective actions 63
Index Terms Links

Nuclear terrorism (Cont.)

public information 61
response plan 57
Nuclear yield 10 51 63

Optimization (of radiological protection) 4 18 26 115

143 146
cleanup 26
consumer products 143 146
deceased persons 115
principles 18

Personal protective equipment (PPE) 20 25 32 48

85 111 123
Plutonium 53 103 105
Plutonium-238 (238Pu) 10
239
Plutonium-239 ( Pu) 10 13 144
Population monitoring 108
action steps 108
downwind exposure 109
implementation 109
individuals monitored 109
lead agency 110
on-scene evaluation 108
survey equipment 109
Index Terms Links

Populations 66 72 109
downwind 72 109
priorities for response 66
Post-incident messages 38 62
Post-incident planning 62
Potassium iodide 96 103 127 131
Pregnant women 39 92 94 104
122 131
emergency responders 122
Preincident planning 2 15 34 36
43 61 87 90
control zones 15
medical treatment 90
public information 36 61
triage 87
Preincident public information 37
Prompt radiation 52
Protection factors (PF) 46 64
building types and locations 64
Protective Action Guides (PAGs) 19 26
Protective actions 3 8 15 18
26 35 44 46
52 61 72 150
consequence management 150
control zones 15
downwind population 72
members of the general public 18
nuclear terrorism 63
Index Terms Links

Protective actions (Cont.)

Protective Action Guides 19 26
public information 36 61
sheltering versus evacuation 46
training 35
Prussian blue 96 106
Psychosocial issues 10 36 83 88
Public health and medical
emergency-response system 73
alternative medical treatment
sites (AMTS) 73
community reception centers (CRC) 73
hospital reception (triage) and
decontamination center (HRDC) 73
temporary decontamination
center (TDC) 73
Public health and medical personnel 11 15 23 75
80 92 102 115
152
accrediting organizations 116
credentially process 116
first receivers 11 15 23 75
80 92 102 152
medical rescue corps 116
national network to facilitate use 116
recruitment and credentialing 115
state licensure 117
training 116
Index Terms Links

Public health and medical personnel (Cont.)

Uniform Emergency Volunteer
Health Practitioners Act 117
volunteers 117
Public information 61 124
nuclear terrorism incident 61
post-incident 62
preincident 61
sample statements (improvised
nuclear device) 128
sample statements (radiological
dispersal device) 124
Public information officer 39

Radiation casualties 95
acute radiation syndrome 95
hospital management 95
mass-casualty situation 95
palliative care 95
specialty care 95
Radiation Emergency Assistance
Center/Training Site (REAC/TS) 52 89 92 95
Radiation exposure device (RED) 11
characteristics and consequences 11
deliberate contamination 12
Index Terms Links

Radiation exposure device (RED) (Cont.)

fixed facilities 12
material in transit 12
Radiation monitoring 43 49 67
Radiation protection responsibilities 119
ALARA principle 123
emergency responders 122
employers 119
extreme situations 123
pregnancy 122
Radioactive waste 110 138
packaging 111
regulatory structure 111
Radiological assessment 92
decision tree 93
on-scene 92
Radiological Assistance Program (RAP) 29 32 44 61
149
Radiological dispersal device (RDD) 9
characteristics and consequences 9
Radiological terrorism 43
concerned citizens 47
crime scene 50
emergency responders 48
evacuation 46
hazard zones 45
members of the general public 46
protective actions 46
Index Terms Links

Radiological terrorism (Cont.)

respiratory protection 47
response plan 43
sheltering 46
triage (inhalation) 49
226
Radium-226 ( Ra) 10
Reception centers (nonhospital) 82
activation 82 86
alternative medical treatment
sites (AMTS) 82
co-location with AMTS 84
community reception centers (CRC) 82
family-assistance centers 86
functions (AMTS) 84
functions (CRC) 82
medical supplies 86
medical triage 83
messages 86
planning 83
psychosocial issues 84
radiation monitoring 85
radiological assessment of victims 85
registry medical records 85
special-needs shelters 86
staffing 84 86
training 86
Recovery and restoration 3 21 26 31
59 111 117
Index Terms Links

Regulations 15 22 27 41
113 115 120 122
135 142 144 145
consumer products 142 144
drinking water 145
emergency procedures 122
human remains 113
interstate commerce 27
notification of emergency 41 135
occupational 15 22 120
staff qualifications 115
Resources (U.S. Department of Energy) 149
aerial monitoring 152
asset timeline 149
Consequence Management
Home Team 150
Consequence Management
Response Team 150
Federal Radiological Monitoring
and Assessment Center 151
National Atmospheric Release
Advisory Center 152
Radiation Emergency Assistance
Center/Training Site 152
Radiological Assistance Program 149
Respiratory protection 7 47 93
Index Terms Links

Response plans 25 57
decontamination 34
emergency responders 34
federal guidelines 25
hazard evaluation 32
international agreements 40
mutual-aid agreements 40
nuclear terrorism incident 57
providing information
(post-incident) 38
providing information
(preincident) 37
radiological terrorism incident 43
requirements 30
roles and responsibilities 27
training and exercises 34
Roles and responsibilities (local,
state, tribal and federal agencies) 27

Screening 8 78 83 93
101 155
contamination 8 79 83 93
101 155
medical triage 78
Sheltering 20 24 46 60
72
Index Terms Links

Shelter-in-place 58
Shelters 65
adequate 65
inadequate 65
optimum time in 66
Shrapnel 80 102 110 112
Situational assessment 32 60 69
Skin 8 11 13 52
60 81 97 100
113 153 155
contamination 60 97 100 113
153 155
injury 8 11 13 52
81
Special-needs shelters 79 86
Strategic national stockpile (SNS) 81 86
90
Strontium-90 ( Sr) 10 144

Tabletop exercise 5 28 39 45
Temporary decontamination center (TDC) 73
Thermal effects 13 52
Thyroid 85 94 105 131
counting 85 94 105
potassium iodide 131
Time-to-vomiting 12 94 107
Index Terms Links

Training and exercises 34

programs 35
Transportation accident 12 31 33 113
Triage 87
categories 88
decision tree 89
hierarchy 89
implementation 89
improvised nuclear device 87
life-threatening injuries 87
on-scene triage 88
preincident planning 87
primary 89
priorities 87
radiation exposure device 87
radiological dispersal device 87
secondary 89
tertiary 90
victims 87

Uniform Emergency Volunteer

Health Practitioners Act 117
Uranium 10 13 53
235
Uranium-235 ( U) 13
Urine bioassay 83 85 93 104
106
Index Terms Links

Vendor managed inventory (VMI) 81 86 95

Ventilation systems 24
Volunteers 69 75

Whole body 7 94 103 107

countermeasures 95
counting 94 103
doses 7 94 107