Developing a Nuclear Global Health Workforce Amid the Increasing Threat of a Nuclear Crisis

A comprehensive review of dose limits, triage systems and measurement tools for consequence management of nuclear and radiological emergencies

During a radiological or nuclear emergency, occupational workers, members of the public, and emergency responders may be exposed to radionuclides, whether external or internal, through inhalation, ingestion, or wounds. In the case of internalized radiation exposure, prompt assessment of contamination is necessary to inform subsequent medical interventions. This review assembles the constituent considerations for managing nuclear and radiological incidents, focused on a parallel analysis of the evolution of radiation dose limits - notably in the emergency preparedness and response realm - alongside a discussion of triage systems and in vivo radionuclide detection tools. The review maps the development of international and national standards and regulations concerning radiation dose limits, illuminating how past incidents and accumulated knowledge have informed present emergency preparedness and response practices, specifically for internalized radiation. Additionally, the objectives and levels of radiation triage systems are explored in-depth, along with a global survey of practices and protocols. Finally, this review also focuses on in vivo detection systems and their capacities for radionuclide identification, prioritizing internalized gamma-emitting isotopes due to their broader relevance. Collectively, this study comprehensively addresses the intricacies of triage management following radiation emergencies, emphasizing the imperative for enhanced standardization and continued research in this critical domain.

Serum miRNA-based signature indicates radiation exposure and dose in humans: A multicenter diagnostic biomarker study

PURPOSE

Mouse and non-human primate models showed that serum miRNAs may be used to predict the biological impact of radiation doses. We hypothesized that these results can be translated to humans treated with total body irradiation (TBI), and that miRNAs may be used as clinically feasible biodosimeters.

METHODS

To test this hypothesis, serial serum samples were obtained from 25 patients (pediatric and adults) who underwent allogeneic stem-cell transplantation and profiled for miRNA expression using next-generation sequencing. miRNAs with diagnostic potential were quantified with qPCR and used to build logistic regression models with lasso penalty to reduce overfitting, identifying samples drawn from patients who underwent total body irradiation to a potentially lethal dose.

RESULTS

Differential expression results were consistent with previous studies in mice and non-human primates. miRNAs with detectable expression in this and two prior animal sets allowed for distinction of the irradiated from non-irradiated samples in mice, macaques and humans, validating the miRNAs as radiation-responsive through evolutionarily conserved transcriptional regulation mechanisms. Finally, we created a model based on the expression of miR-150-5p, miR-30b-5p and miR-320c normalized to two references and adjusted for patient age with an AUC of 0.9 (95%CI:0.83-0.97) for identifying samples drawn after irradiation; a separate model differentiating between high and low radiation dose achieved AUC of 0.85 (95%CI: 0.74-0.96).

CONCLUSIONS

We conclude that serum miRNAs reflect radiation exposure and dose for humans undergoing TBI and may be used as functional biodosimeters for precise identification of people exposed to clinically significant radiation doses.

Human Consequences of Multiple Nuclear Detonations in New Delhi (India): Interdisciplinary Requirements in Triage Management

The human casualties from simulated nuclear detonation scenarios in New Delhi, India are analyzed, with a focus on the distribution of casualties in urban environments and the theoretical application of a nuclear-specific triage system with significant innovation in interdisciplinary disaster management applicable generally to urban nuclear detonation medical response. Model estimates of nuclear war casualties employed ESRI’s ArcGIS 9.3, blast and prompt radiation were calculated using the Defense Nuclear Agency’s WE program, and fallout radiation was calculated using the Defense Threat Reduction Agency’s (DTRA’s) Hazard Prediction and Assessment Capability (HPAC) V404SP4, as well as custom GIS and database software applications. ESRI ArcGISTM programs were used to calculate affected populations from the Oak Ridge National Laboratory’s LandScan^TM 2007 Global Population Dataset for areas affected by thermal, blast and radiation data. Trauma, thermal burn, and radiation casualties were thus estimated on a geographic basis for New Delhi, India for single and multiple (six) 25 kt detonations and a single 1 mt (1000 kt) detonation. Major issues related to the emergency management of a nuclear incident are discussed with specific recommendations for improvement. The consequences for health management of thermal burn and radiation patients is the worst, as burn patients require enormous resources to treat, and there will be little to no familiarity with the treatment of radiation victims. Of particular importance is the interdisciplinary cooperation necessary for such a large-scale emergency response event, which would be exemplified by efforts such as the application of a Nuclear Global Health Workforce.

Radiation Injury Treatment Network Medical and Nursing Workforce Radiation: Knowledge and Attitude Assessment

Objectives:

The Radiation Injury Treatment Network (RITN) is prepared to respond to a national disaster resulting in mass casualties with marrow toxic injuries. How effective existing RITN workforce education and training is, or whether health-care providers (HCPs) at these centers possess the knowledge and skills to care for patients following a radiation emergency is unclear. HCP knowledge regarding the medical effects and medical management of radiation-exposed patients, along with clinical competence and willingness to care for patients following a radiation emergency was assessed.

Methods:

An online survey was conducted to assess level of knowledge regarding the medical effects of radiation, medical/nursing management of patients, self-perception of clinical competence, and willingness to respond to radiation emergencies and nuclear events.

Results:

Attendance at previous radiation emergency management courses and overall knowledge scores were low for all respondents. The majority indicated they were willing to respond to a radiation event, but few believed they were clinically competent to do so.

Conclusions:

Despite willingness to respond, HCPs at RITN centers may not possess adequate knowledge of medical management of radiation patients, and appropriate response actions during a radiation emergency. RITN should increase the awareness of the importance of radiation education and training.

Pillars of Hospital Preparedness in Radiation Emergency Management

Human beings have always suffered and have incurred irreparable damages from different disasters. The most logical way to deal with disaster is to be comprehensively prepared. In line with this, the readiness of hospitals in the vicinity of nuclear centers is of great importance, as this could lead to reduced injuries and damage. In this study, we aimed to develop a model by which hospitals could effectively react to nuclear incidents. This is a comparative study using library studies, including examining existing patterns, recommended policies and instructions of WHO and IEAE, and articles and documents of selected countries that have models for radiation disaster management. The primary developed model was discussed in expert panels and, ultimately, with some modifications, was finalized. The findings of the research indicated that the most important factors in the success of crisis management are skill in predicting a crisis and having a preparation plan for necessary measures at the time of an incident. Different countries have developed various approaches toward radiation incident management that are mostly focused on human resources, medical equipment, and physical space. The model plan developed here includes a two-part foundation with seven pillars. Intra- and intersectorial arrangements are considered as the foundation, and the pillars are physical structure, medical equipment, human resources, process and instructions, intra- and intrasectorial coordination, information systems, and organizational structure. Having an appropriate model for coping with radiation incidents is pivotal for hospitals active in areas with nuclear centers. Undoubtedly, existence of an effective and comprehensive model could reduce the consequences of radiation crises.

National Health Preparedness and Response Centers: Revisiting the Increasingly Critical Need to Expand Cooperative Emergency Response Capabilities in the United States

In 1999, a robust National Health Preparedness and Response Center was conceptualized and piloted, but never fully operationalized. This study revisits the expansive, coordinated efforts invested in this concept, considered an overdue remedy for persistent shortfalls in medical Chemical, Biological, Radiological, Nuclear, and High Yield Explosives training, proficiency, and preparation. The concept defined a robust mission for longstanding, proven programs for prepositioning equipment and associated training of personnel. This study explores the reasons that ended military and governmental support, attendant funding, and operations of the created Joint/Interagency Civil Support Center, which ceased on September 30, 2006. Unfortunately, the concept remains relevant. Major gaps in disaster medical response capabilities have been recognized for decades. Experts from the Institute of Medicine, United States Northern Command, and multiple academic centers and professional organizations have identified these shortcomings, but the national response posture remains disjointed, under-resourced, and based upon obsolete planning premises. Given increasing threats, the authors recommend revisiting the collaboration of military, civilian, academic, and governmental resources that once established the Joint/Interagency Civil Support Center as a multidisciplinary and trans-disciplinary model for a new National Health Preparedness and Response Center coordinated framework for enhanced resilience and operational response capabilities on a national level.

Developing a Model for Hospitals' Emergency Department Preparedness in Radiation and Nuclear Incidents and Nuclear Terrorism in Iran

Objective

To develop a national model for hospitals' Emergency Department (ED) preparedness when facing radiation and nuclear incidents as well as nuclear terrorism in Iran.

Methods

This analytical study was carried out in 2019 via Delphi technique in two rounds and prioritization using a pairwise questionnaire. Using classic Delphi technique and pairwise comparison, the components were given to 32 specialists in emergency medicine, nuclear medicine, medical physics, nuclear physics, radiobiology and radiation protection, health in disaster and emergency, and passive defense. Finally, the national model was developed by holding two focus group sessions.

Results

The results from the two rounds of Delphi technique showed that 31 factors of preparedness were classified into three main classes, namely staff, stuff, and structure (system). Only three factors were excluded and the rest were agreed upon by the specialists. Given the weight of each class, it was found that staff preparedness and stuff preparedness had the highest and lowest priorities, respectively.

Conclusion

Comprehensive preparedness requires enhancing and promoting cultural, social, economic, and political levels. Indeed, all preparedness levels should be promoted in alignment with each other. Hence, governments should align their policies to manage such incidents.

National Assessment of Nursing Schools and Nurse Educators Readiness for Radiation Emergencies and Nuclear Events

Nurses will play a crucial role in responding to a public health emergency resulting from nuclear war or other large-scale release of radiation into the environment and in supporting the National Health Security Strategy. Schools of nursing are ultimately responsible for developing a competent nursing workforce prepared to assess a population’s public health emergency needs and respond to these low-frequency but high-impact events. This responsibility includes the provision of specific content and training regarding how to respond and care for patients and communities in the event of a nuclear or radiation emergency. To date, however, there has been a lack of empirical evidence focusing specifically on nursing schools’ capacity to prepare nurses for radiation emergencies and nuclear events, as well as perception of risk. This study employed a cross-sectional survey administered to a nationwide sample of nursing school administrators and faculty to assess content, faculty expertise, planning, and perception of risk related to radiation emergencies and nuclear events.

The nursing profession: a critical component of the growing need for a nuclear global health workforce

BACKGROUND

Instability in the global geopolitical climate and the continuing spread of nuclear weapons and increase in their lethality has made the exchange of nuclear weapons or a terrorist attack upon a nuclear power plant a serious issue that demands appropriate planning for response. In response to this threat, the development of a nuclear global health workforce under the technical expertise of the International Atomic Energy Agency and the World Health Organization Radiation Emergency Medical Preparedness and Assistance Network has been proposed.

MAIN BODY OF THE ABSTRACT

As the largest component of the global healthcare workforce, nurses will play a critical role in both the leadership and health care effectiveness of a response to any public health emergency of international concern (PHEIC) resulting from the unprecedented numbers of trauma, thermal burn, and radiation affected patients that will require extensive involvement of the nursing professional community.

SHORT CONCLUSION

Lives can and will be saved if nurses are present. The clinical care of radiation contaminated patients (e.g. radiation burns, fluid management, infection control), thermal burn patients, and other health system response activities such as community screening for radiation exposure, triage, decontamination, administration of medical countermeasures and the provision of supportive emotional and mental health care will be overwhelmingly nurse intensive.

Guidance, Training and Exercises for Responding to an Improvised Nuclear Device: First Receivers, Public Health

All large-scale emergencies and disaster incidents, including the detonation of an improvised nuclear device (IND), have life and death medical consequences. Responders must have realistic plans to save lives and reduce physical and psychological morbidity. Fifteen years after 9/11, considerable progress toward developing and implementing such plans has been made, but gaps in the management of response to an IND loom large. Another paper in this series reviewed gaps for first responders; this paper reviews gaps for first receivers and public health. Closing gaps requires the implementation of complex systems including.

Readiness for Radiological and Nuclear Events among Emergency Medical Personnel

Background

Among medical providers, even though radiological and nuclear events are recognized as credible threats, there is a lack of knowledge and fear about the medical consequences among medical personnel which could significantly affect the treatment of patients injured and/or contaminated in such scenarios. This study was conducted to evaluate the relative knowledge, willingness to respond, and familiarity with nuclear/radiological contamination risks among U.S. and Japanese emergency medical personnel.

Methods

An institutional review board-approved anonymous paper survey was distributed at various medical and disaster conferences and medicine courses in Japan and in the U.S. The surveys were written in Japanese and English and collected information on the following four categories: generalized demographics, willingness to manage, knowledge of disaster systems, and contamination risks.

Results

A total of 418 surveys were completed and collected. Demographics showed that physicians and prehospital responders were the prevalent survey responders. The majority of responders, despite self-professed disaster training, were still very uncomfortable with and unaware how to respond to a radiological/nuclear event.

Conclusion

Despite some educational coverage in courses and a limited number of disaster events, it is concluded that there is a lack of comfort and knowledge regarding nuclear and radiological events among the medical community. It is recommended that considerable development and subsequent distribution is needed to better educate and prepare the medical community for inevitable upcoming radiological/nuclear events.

Justification for a Nuclear Global Health Workforce: multidisciplinary analysis of risk, survivability & preparedness, with emphasis on the triage management of thermal burns

Major challenges and crises in global health will not be solved by health alone; requiring rather a multidisciplinary, evidence-based analytical approach to prevention, preparedness and response. One such potential crisis is the continued spread of nuclear weapons to more nations concurrent with the increased volatility of international relations that has significantly escalated the risk of a major nuclear weapon exchange. This study argues for the development of a multidisciplinary global health response agenda based on the reality of the current political analysis of nuclear risk, research evidence suggesting higher-than-expected survivability risk, and the potential for improved health outcomes based on medical advances. To date, the medical consequences of such an exchange are not credibly addressed by any nation at this time, despite recent advances. While no one country could mount such a response, an international body of responders organized in the same fashion as the current World Health Organization’s global health workforce initiative for large-scale natural and public health emergencies could enlist and train for just such an emergency. A Nuclear Global Health Workforce is described for addressing the unprecedented medical and public health needs to be expected in the event of a nuclear conflict or catastrophic accident. The example of addressing mass casualty nuclear thermal burns outlines the potential triage and clinical response management of survivors enabled by this global approach.

Triage and the Lost Art of Decoding Vital Signs: Restoring Physiologically Based Triage Skills in Complex Humanitarian Emergencies

Triage management remains a major challenge, especially in resource-poor settings such as war, complex humanitarian emergencies, and public health emergencies in developing countries. In triage it is often the disruption of physiology, not anatomy, that is critical, supporting triage methodology based on clinician-assessed physiological parameters as well as anatomy and mechanism of injury. In recent times, too many clinicians from developed countries have deployed to humanitarian emergencies without the physical exam skills needed to assess patients without the benefit of remotely fed electronic monitoring, laboratory, and imaging studies. In triage, inclusion of the once-widely accepted and collectively taught “art of decoding vital signs” with attention to their character and meaning may provide clues to a patient’s physiological state, improving triage sensitivity. Attention to decoding vital signs is not a triage methodology of its own or a scoring system, but rather a skill set that supports existing triage methodologies. With unique triage management challenges being raised by an ever-changing variety of humanitarian crises, these once useful skill sets need to be revisited, understood, taught, and utilized by triage planners, triage officers, and teams as a necessary adjunct to physiologically based triage decision-making. (Disaster Med Public Health Preparedness. 2018;12:76–85)

The World Health Organization Global Health Emergency Workforce: What Role Will the United States Play?

During the May 2016 World Health Assembly of 194 member states, the World Health Organization (WHO) announced the process of developing and launching emergency medical teams as a critical component of the global health workforce concept. Over 64 countries have either launched or are in the development stages of vetting accredited teams, both international and national, to provide surge support to national health systems through WHO Regional Organizations and the delivery of emergency clinical care to sudden-onset disasters and outbreak-affected populations. To date, the United States has not yet committed to adopting the emergency medical team concept in funding and registering an international field hospital level team. This article discusses future options available for health-related nongovernmental organizations and the required educational and training requirements for health care provider accreditation. (Disaster Med Public Health Preparedness. 2016;10:531-535).