Enhanced Understanding of CBRN Threat, Vulnerability Capability

1. Enhanced Understanding of CBRN Threat, Vulnerability & Capability LTC Debra Schnelle 24 Apr 02

2. 2 QUESTION TO THE BOARD Provide recommendations on vaccines & immunization protocols necessary to enhance protection against validated biological warfare threat agents.

3. 3 Agenda Where were we, when? Where are we, now? Where do we need to be? NATO Biological Medical Advisory Committee (BioMedAC) Smallpox Recommendations, 3 May 02

4. 4 Where Were We, When? 26 Nov 93: DODD 6205.3, �DOD Immunization Program for BW Defense� May 99: AFEB recommends a �medical risk assessment of BW threat list� May 00: Joint Staff directs DOD EA to conduct a medical risk assessment May 01: Medical Risk Assessment product briefed to AFEB Directs Chair, Joint Staff to �validate & prioritize the BW threats to DOD Personnel� AFEB reviews BW Threat List & identifies vaccines available to address the threat Directs Chair, Joint Staff to �validate & prioritize the BW threats to DOD Personnel� AFEB reviews BW Threat List & identifies vaccines available to address the threat

5. 5 Medical Risk Assessment Objective To develop a methodology that will integrate a medical risk assessment and the intelligence threat assessment of validated biowarfare agents. Will be used for making medical defense research, development, testing, acquisition and stockpiling decisions.

6. 6 Overview of OTSG Approach Step 1: Convene Oversight Committee Step 2: Develop & award contract Step 3: Convene Military Panel Step 4: Scientific Panel Step 5: Develop Medical Risk Conclusions for Validated Biowarfare Agents

7. 7 Study Design Military Medical Panel identified and weighted significant operational criteria These criteria (w/o weights), and the word pictures necessary to evaluate the individual BW agents, were given to the Scientific Panel Results of the two Panels will be brought together and applied to the threat list

11. 11 Status of Med Risk Assessment Product Endorsed by AFEB, Sep 01 Widely applied & received (informally) Presented: NATO NBC/Medical WG, Jan 01 NATO BioMedical Advisory Committee, Jun 01 National Defense University, Jul 01 CANUKUS MOU Mtg, Sep 01

12. 12 Where Are We, Now? Summer 01: QDR directs a shift toward �capability based planning� 11 Sep 01 Dec 01: GAO report recommendation �that DOD address the gap between the stated CB threat and the current level of medical readiness� DOD response stated that OTSG would perform a �CBRN hazard analysis� by May 02 Briefing, W. Seth Carus & Mr. Read Hanmer, NDU/CCR, �The Validated BW Agent Threat Conundrum� Report, May 01, CBIAC, Medical Risk Assessment of the Biological Threat �Guidelines for Health Disaster Mgmt,� Mar 01, World Association for Disaster & Emergency Medicine, Briefing, W. Seth Carus & Mr. Read Hanmer, NDU/CCR, �The Validated BW Agent Threat Conundrum� Report, May 01, CBIAC, Medical Risk Assessment of the Biological Threat �Guidelines for Health Disaster Mgmt,� Mar 01, World Association for Disaster & Emergency Medicine,

13. Threat, Vulnerability & Capability

14. 14 What is the threat??? Diverse lists, approaches; purposes Diverse User Requirements CBRN scope too broad for conventional threat analysis Multiple agents; infinite scenarios Scenario impact largely unknown Fails to rule out threats Reinforces �threat-based� thinking

15. 15 Current NBC Threat Lists/Purposes Support acquisition �Chairman�s BW Threat List� System Threat Assessment Report (STAR) OTSG Medical Risk Assessment Prioritization for Response ITF6 Assessment (CANUKUS) CDC Critical Biological Agent List

16. 16 User Requirements Strategic: shape national military strategy Operational: What is the scope of the problems presented by the identified threats? How will I prepare, plan & prioritize? Tactical: What adaptations to my OPLAN must I be prepared to make, if the threat is realized? Technical: guide RDT&E

17. 17 Current Threat Definition Threat = Enemy Intent & Capability, based upon assessment of enemy: Doctrine Possession of agents Possession of delivery mechanisms Vulnerability of Friendly Forces

18. 18 Scope of CBRN Threat Multiple Possible Hazards (CBRN) Chemical: CWA/TIC Biological: BW/BT Nuclear/Radiological: weapon/improvised nuclear device Multiple Delivery Mechanisms Homeland & Deploying Forces

20. 20 Weaknesses of Current Lists All agents treated as equally dangerous Do not differentiate between hazards and potential events Focus on �known� threats Does not account for unknowns Omits agents that were once weaponized Ignores non-state users or transfers

21. Where Do We Need to BE????

22. 22 Objective The analysis of CBRN hazards, as they are realized along a broad spectrum of possible CBRN events, that allows a consistent assessment of vulnerability and defines the scope of capabilities required for an adequate medical response to a CBRN event.

23. Threat, Vulnerability & Capability

24. 24 Approach Consider diverse sources: OTSG Medical Risk Assessment NDU/CCR effort Env Risk Assessment methodologies Disaster & Emergency Medicine tenets Develop a framework that clarifies terms & concepts: Threat, vulnerability & capability Enemy intent & capability Hazard, event & damage Capability & medical response

25. 25 Approach Use current mod-sim tools & analytical methods to reveal subtle connections between concepts. NBC CREST NATO Publication �Medical Planning Guide for NBC Battle Casualties�

26. 26 What is Threat? Enemy intent & capability CBRN hazard realized as a CBRN event: Hazard: condition with the potential to cause injury, illness or death of personnel; damage to or loss of equipment or property; or mission degradation. Risk: probability of a particular hazard becoming realized as an event Event: an occurrence negatively influencing living beings and/or their environment

27. 27 What is �Vulnerability???� Damage: disruption of normal combat operations Impact: severity & extent of disruption, in terms of combat effectiveness

28. 28 What is Capability? The aggregate of facilities, expertise, personnel & resources� Encompasses �competency:� Know how to do the right procedures Possess the judgment on when, what, where, who & how For a specified course of action.

29. 29 Hazard Characteristics Persistence Communicability Infectivity/Effectivity/LD50/Activity Based upon work of Medical Risk Assessment Project

30. 30 Event Characteristics Specified event = scenario; includes: Delivery Mechanism Distribution System (as applicable) Target Vulnerability Characteristics (WADEM) Onset (sudden; gradual; slow) Duration (short or long) Scope (amplitude; intensity; magnitude)

31. 31 Damage Characteristics Defined elements of disruption to �normal operations;� Increased morbidity & mortality Compromised functions of: Facilities, Communication, Transportation Food & Water Supplies Power & Industrial Production

32. 32 Medical NBC Capabilities Hazard Analysis Early Detection/Monitoring & Warning Protection Medical Countermeasures Treatment Competency

33. 33 Medical Response The application of medical CBRN capabilities to prevent or mitigate the damage from a CBRN event. Includes: Planning Preventive Actions Mitigating Actions Recovery Actions

34. Initial Products from �Hazard Analysis�

35. Evaluation of BW Hazards

36. 36 Prioritization of CBRN Events BW Events Destruction of Toxic Industrial Facilities Destruction of US Army Chemical Warfare Agent Stockpiles Use of Chemical Warfare Agents PENDING: nuclear/radiological; covert use of TICs; contagious BW

37. Damage from BW Events(Increased Morbidity)

38. Damage from BW Events(Increased Morbidity/day) Anthrax release in LAAnthrax release in LA

39. Damage from BW Events(Increased Morbidity/day) Bot tox release in Washington, DCBot tox release in Washington, DC

40. Prediction of Magnitude of Damage on First Day(Increased Morbidity)

41. BW Event Damage: Medical Resources (Personnel & Beds)

42. CB Event Damage: Medical Supplies

43. 43 Emerging Insights: Onset & Duration Sudden, Short (SEB): WILL overwhelm medical response Slow & Short (Tularemia, Anthrax, Plague): initial window for medical response is 7 days Delayed & Long (Smallpox): �global mixing� assumption � ROM may not be effective in limiting spread

44. Scale of CBRN Events Aum Shinrikyo-Matsumoto Summary, 27 Jun 94. A group of cult members drove a converted refrigerator truck into a nondescript residential neighborhood in Matsumoto, a city of 300K people 322 km northwest of Tokyo. Parking in a secluded parking lot behind a stand of trees, they activated a computer-controlled system to release a cloud of sarin. The nerve agent floated toward a cluster of private homes, a mid-rise apartment building, town homes, and a small dormitory. A light breeze (3-5 knots); within a short time, 7 people were dead. 500 others were transported to local hospitals, where approximately 200 would require at least one night�s hospitalization. Aum Shinrikyo-Tokyo summary, 20 Mar 95. On the morning of 20 Mar 95, packages were placed on 5 different trains in the Tokyo subway system. The pkgs consisted of plastic basgs filled with a chemical mix and wrapped inside newspaters. Once placed on the floor of the subway car, each bag was punctured with a sharpened umbrella tip, and the material was allowed to spill onto the floor of the subway car. As the liquid spread out and evaporated, vaporous agent spread throughout the car. By the end of the day, 15 subway stations were affected; of these, stations along the Hibiya line were the most heavily affected, some with as many as 300-400 persons involved. The number injured in the attacks was just under 3,800. Of those, nearly 1,000 actually required hospitalization and 12 people were dead. Bhopal Industrial Chemical Accident Summary, 2 Dec 84. Late on the night of 2 Dec 84, a Union Carbide pesticide factory released 90K pounds of the chemical methyl isocyanate. Resulting toxic cloud caused the death of at least 6,500 people and an estimated 20,000-50,000 serious injuries. Aum Shinrikyo-Matsumoto Summary, 27 Jun 94. A group of cult members drove a converted refrigerator truck into a nondescript residential neighborhood in Matsumoto, a city of 300K people 322 km northwest of Tokyo. Parking in a secluded parking lot behind a stand of trees, they activated a computer-controlled system to release a cloud of sarin. The nerve agent floated toward a cluster of private homes, a mid-rise apartment building, town homes, and a small dormitory. A light breeze (3-5 knots); within a short time, 7 people were dead. 500 others were transported to local hospitals, where approximately 200 would require at least one night�s hospitalization. Aum Shinrikyo-Tokyo summary, 20 Mar 95. On the morning of 20 Mar 95, packages were placed on 5 different trains in the Tokyo subway system. The pkgs consisted of plastic basgs filled with a chemical mix and wrapped inside newspaters. Once placed on the floor of the subway car, each bag was punctured with a sharpened umbrella tip, and the material was allowed to spill onto the floor of the subway car. As the liquid spread out and evaporated, vaporous agent spread throughout the car. By the end of the day, 15 subway stations were affected; of these, stations along the Hibiya line were the most heavily affected, some with as many as 300-400 persons involved. The number injured in the attacks was just under 3,800. Of those, nearly 1,000 actually required hospitalization and 12 people were dead. Bhopal Industrial Chemical Accident Summary, 2 Dec 84. Late on the night of 2 Dec 84, a Union Carbide pesticide factory released 90K pounds of the chemical methyl isocyanate. Resulting toxic cloud caused the death of at least 6,500 people and an estimated 20,000-50,000 serious injuries.

45. CBRN Events, Medical Capabilities & Medical Response Strategies

46. Competency: Medical Surveillance & Medical Countermeasures Three points from this slide: decisions will need to be made on the basis of operational parameters (detector alert; med surveillance alert; clinical diagnosis alert) and NOT on the basis of attack characteristics (what agent was delivered when & how) Decisions will need to be made much EARLIER than is generally expected Highlights the necessity for the following med response capabilities: Medical surveillance is VITAL � not all agents will be delivered in a way that will allow them to be detected! Lab analysis is essential � provides confirmation/screening for both detectors & clinical diagnoses BW antibiotics are essential; if they can�t be distributed promptly, people will die It models the percent casualties avoided IF decision makers are able to recognize key operational triggers and act promptly. The three operational triggers for a covert BW agent attack are: detection at the moment of exposure; a medical surveillance alert; and a clinical diagnosis. #1. If you recognize that an exposure has occurred through detection & issue antibiotics immediately, you can avoid 100% casualties. If you wait an additional three days, you avoid only 71% casualties. If you then wait another 2 days, you avoid only 12% casualties. #2. If you do NOT have a detection, the next operational trigger is an alert from your medical surveillance system. Again, if you act immediately, you save only 71% of your exposed population. If you wait another 2 days, you save only 12% of your exposed population. #3. Finally, the last operational trigger is a clinical diagnosis, but if you act immediately, you avoid only 12% of your exposed population. The pink & green lines on the earlier chart showed the impact of delay (24 & 48 hrs) overlaid on top of the original event chronology in order to show the significance of those delays. Perhaps this version explains it more clearly.Three points from this slide: decisions will need to be made on the basis of operational parameters (detector alert; med surveillance alert; clinical diagnosis alert) and NOT on the basis of attack characteristics (what agent was delivered when & how) Decisions will need to be made much EARLIER than is generally expected Highlights the necessity for the following med response capabilities: Medical surveillance is VITAL � not all agents will be delivered in a way that will allow them to be detected! Lab analysis is essential � provides confirmation/screening for both detectors & clinical diagnoses BW antibiotics are essential; if they can�t be distributed promptly, people will die It models the percent casualties avoided IF decision makers are able to recognize key operational triggers and act promptly. The three operational triggers for a covert BW agent attack are: detection at the moment of exposure; a medical surveillance alert; and a clinical diagnosis. #1. If you recognize that an exposure has occurred through detection & issue antibiotics immediately, you can avoid 100% casualties. If you wait an additional three days, you avoid only 71% casualties. If you then wait another 2 days, you avoid only 12% casualties. #2. If you do NOT have a detection, the next operational trigger is an alert from your medical surveillance system. Again, if you act immediately, you save only 71% of your exposed population. If you wait another 2 days, you save only 12% of your exposed population. #3. Finally, the last operational trigger is a clinical diagnosis, but if you act immediately, you avoid only 12% of your exposed population. The pink & green lines on the earlier chart showed the impact of delay (24 & 48 hrs) overlaid on top of the original event chronology in order to show the significance of those delays. Perhaps this version explains it more clearly.

47. 47 In Summary�. Evaluate BW agents as hazards Define broad range of potential BW events Assess & prioritize damage from BW event spectrum

48. 48 BioMedAC, May 02 Statement #1: Potential for terrorist use implies military planning must be integrated with civil defense planning. Statement #2: Appearance of smallpox case most likely the result of an illegal (hostile) act Most likely scenario: large number of index cases in many different locations BioMedAC recommends that all NATO allies have the capability for immediate, widespread smallpox vaccination at the first appearance of a confirmed smallpox case �STATEMENT #1. The BioMedAC recognizes that the most likely use of a BW agent against NATO forces is a terrorist attack upon a NATO homeland. However, NATO BW defense must address battlespace concerns which requires the integration of civil and military efforts; policy and operational doctrine. �STATEMENT #2. Smallpox is a unique problem to nations and NATO, since it represents an adversarial use of a contagious disease of global impact. The appearance of one case of definitively confirmed smallpox (other than an accidental exposure in one of the two internationally approved storage facilities) indicates probable use of smallpox as a BW agent. The asymmetric nature of this use means that the resulting smallpox pandemic may begin with index cases in many nations. �The BioMedAC recommends that NATO vaccination policy for the military has the capability to ensure rapid, widespread protection at the appearance of the first confirmed case of smallpox anywhere in the world. This NATO policy must also recognize and address the risks of current available vaccines. �STATEMENT #1. The BioMedAC recognizes that the most likely use of a BW agent against NATO forces is a terrorist attack upon a NATO homeland. However, NATO BW defense must address battlespace concerns which requires the integration of civil and military efforts; policy and operational doctrine. �STATEMENT #2. Smallpox is a unique problem to nations and NATO, since it represents an adversarial use of a contagious disease of global impact. The appearance of one case of definitively confirmed smallpox (other than an accidental exposure in one of the two internationally approved storage facilities) indicates probable use of smallpox as a BW agent. The asymmetric nature of this use means that the resulting smallpox pandemic may begin with index cases in many nations. �The BioMedAC recommends that NATO vaccination policy for the military has the capability to ensure rapid, widespread protection at the appearance of the first confirmed case of smallpox anywhere in the world. This NATO policy must also recognize and address the risks of current available vaccines.