The morning session on the opening day focused on providing a common basis of understanding of CBRNE risks and vulnerabilities; a dialogue on possible NGO roles in a CBRNE event as well as a USG panel discussion on current CBRNE related initiatives and programs. Whether an industrial accident like that in Bhopal, India or the intentional use of a dirty bomb or radiological dispersal device (RDD) like that allegedly planned by accused Al Qaeda suspect Jose Padilla, or the contamination of food and water sources, the impact on populations, relief operations and personnel can be devastating.

It was noted that the risk equation - defined as potential hazard multiplied by the probability of occurrence - had dramatically changed in the post 9/11 world: a CBRNE event was no longer low probability/high consequence, but increasingly high probability and incredible consequence. As the probability of specific contaminants varies with time and place, an "all hazards approach" was adopted to more comprehensively discuss ways to reduce organizational vulnerability, without becoming overwhelmed by technical detail. While it is beneficial to focus on the commonalities of these unfamiliar hazards, there is still a need to identify unique characteristics in each event to be able to best define the needs and best response options.

To better understand the overall environment in which NGOs may find themselves operating, participants suggested three strategic scenarios be applied to put CBRNE events into context. As in any crisis, the stability, capability and infrastructure of the affected nation play critical roles. Each scenario outline below has associated issues that will influence response options, as well as levels and types of coordination, particularly in a civil-military framework.

1) A "one off" CBRNE event which occurs in relative isolation (e.g., Bhopal, Chernobyl)

2) The CBNRE event occurs during an ongoing humanitarian response requested operations in a stable host-nation (whether event is intentional or unintentional)

3) The CBRNE event occurs during a complex emergency with ongoing conflict, an incapacitated government and a recurring threat of terrorist attacks

Using matrices like the one below, past events and present potential hazards from Iraq to the Pacific to Latin America were highlighted.

Discussion on ways to reduce vulnerability of humanitarian organizations for a broad range of contingencies focused on several main themes:

i. Technical Capacity Building and Preparedness: NGOs have extensive knowledge and experience in disaster settings, even in situations of fluid security, but they have little to no experience in handling effects of most CBRNE hazards. However, building on existing capacities already inherent in the NGO community, such as disease reporting/surveillance and established medical logistics pipelines, can be critical to managing and containing the effects of a biological incident. In these areas the NGO community has many experiences such as this that can serve as a foundation from which they can build (see Emergency Management: CBRNE by Jeff Lewis).

Capacities of NGOs in CBRNE Incidents (adapted from "CBRNE Events in Humanitarian Settings" presentation by Rick Brennan, IRC) Incident Capacity Chemical incident Zero (little to none) Biological incident Some Nuclear incident Zero (little to none) Population Displacement Well equipped

A cursory look at an assessment of current NGO capabilities in the table above points to a clear need for development and enhancement of partnerships - with environmental organizations, the private sector and a broader cross-section of government agencies, to include the military, though there are obvious difficulties for the NGO community with this relationship, particularly where the military may be active combatants.

Effectiveness of NGO response to, and internal management of, the consequences of a CBRNE event will first and foremost require executive level management support. It may (particularly regarding equipment) necessitate that organizations acquire new skills, equipment and training and develop new policies.

Preparedness won't require that NGOs completely 're-create the wheel.' Great benefit can be derived from applying basic disaster management principles and other strategies with which NGOs are familiar, and have often pioneered and advocated. Inclusion of CBRN contaminants in disaster plans and education; creation of public awareness and education campaigns; training of first responders and medical staff; and integration of signs of these 'new threats' into existing surveillance programs are all examples of useful preparedness activities.

ii. Threat Assessments: Security and safety of staff is the overriding concern. Case-by-case decisions on evacuation or relocation may entail difficult choices over potentially leaving contaminated staff, people and patients behind. Though this is obviously not an easy decision, it may be a necessary - albeit ugly - reality that may face NGO leaders in order to continue to provide services to survivors fleeing a hot zone (or to preserve the safety of the uncontaminated staff).

Dialogue over how NGOs will both access and contribute to the critical, credible and timely data flow that responders will need to make informed decisions permeated the three days of discussion. In some instances, NGOs may be on the ground and able providing first hand information, while others may be completely overwhelmed and unable to operate.

There are obvious sensitivities about the flow of information that may be considered intelligence gathering that need to be taken into account. These and other complexities surrounding creation of NGO capacity to intervene and assist in the conduct of an independent, neutral assessment to provide first hand data on the needs in a contaminated area - - as proposed in the MERLIN/LSTHM report titled "Hope for the Best, Prepare for the Worst" - - were discussed and debated.

At a minimum, NGOs require pre-identified, reliable and credible information sources, with clear modalities for accessing or 'reaching back' to these experts on a continual basis. It is recommended that NGOs consider hiring resident CBRNE experts with the technical expertise, knowledge and networks to assist in assessing and analyzing CBRNE threats and data with a view to recommending policies and procedures for their organization where CBRNE is concerned.

Recommendation: NGOs should consider hiring resident CBRNE experts and include CBRNE as a "specialized threat" when conducting routine security assessments. Partnerships are key. At a minimum, NGOs should identify and partner with other organizations that have expertise in this field.

Some NGOs have already begun looking at internal policies on CBRNE issues and are willing to share their templates with others through the InterAction CBRNE Working Group. In addition, the United Nations Security Coordinator (UNSECOORD) has both created an internal policy for staff safety in contaminated environments, and has circulated a November 2002 document entitled "Safety Considerations in a Nuclear, Biological or Chemical (NBC) Warfare Environment" to all designated security officials, managers, officers and focal points in the UN system.

Though its current classification restricts direct access by NGOs, one resource with information that can assist NGOs in CBRNE risk assessment in areas of potential operations or programs is the "USAID/OFDA Foreign Disasters and Hazardous Substances Database," which contains information on chemical plants worldwide as well as information on specific medical management for thousands of different chemicals plus response and treatment information.

Recommendation: Devise transparent modalities for the NGO community to request information contained in the "USAID/OFDA Foreign Disasters and Hazardous Substances Database."

There are numerous other existing resources for NGOs on CBRNE. Please see below for a summary of selected resources.

Not everyone can or needs to be a technical expert on CBRNE events, but it is useful to understand certain important terms (and basic concepts such as decon and PPE). A suggested resource for terms associated with CBRNE is the Glossary of Terms compiled by the Agency for Toxic Substances & Disease Registry (ATSDR). A common understanding of basic vocabulary will also assist in coordination between different organizations.

iii. Defining Missions and Coordinating Response: As one participant put it: "Uncertainty is the only certainty." One key variable is the technical knowledge and capacity of the host and assisting governments and other responding organizations. What expectations exist in the NGO community, for instance, about the US military's response to an incident that may or may not be accurate?

Though improving, much work remains to be done to create a common baseline of understanding of the roles, mandates, capabilities and constraints of the abundance of actors with pieces of the 'consequent management pie' in a CBRNE contingency - some whom the NGO community may have not worked with in the past. Even within the humanitarian community, different NGOs will have different policies affecting operations in and around a CBRNE event, as well as varying response capabilities, assuming they choose to operate at all.

A lesson identified repeatedly from past international responses to disaster applies in the CBRNE context as well: it is imperative to establish early on (ideally in a pre-crisis setting) who is going to do what, where and under what circumstances. Such a determination - or at least initial discussions over where there is potential overlap, which organizations have the comparative advantage in certain given situations and what issues comprise are not-negotiable - can go a long way to reduce friction and strengthen coordinated response to benefit those affected.

As is the case in other civil-military environments, it is important for NGOs to ensure that the humanitarian community leads the relief effort, not the military or a belligerent government. An important distinction in a disaster with CBRNE contaminants - particularly for government response agencies that support NGO partners as the primary first responders in any relief operation - is the knowledge of which organizations can and are willing to operate in these environments.

iv. Defining Needs: Victims, staff, equipment and the environment can be contaminated in a CBRNE event. Many NGOs have begun thinking about how the needs of the affected populations may vary from traditional disasters, due to exposure to different contaminants. Apart from NGO capacity to treat victims - burn victims or those with ailments perhaps not seen before - other questions were raised, such as, what effect would a CBRNE event have on procurement of supplies and logistics chains? What, if any, new stocks should be pre-positioned? How can NGOs best adapt existing programs and potentially divert scarce resources to meet both the short term and long-term challenges?

Several information sources exist which can help NGOs research and prepare for potential needs and health consequences in populations affected by various specific contaminants:

• The World Health Organization (WHO) Guidance on Public Health response to biological and chemical weapons (2nd edition, 2001) which is currently in revision.
  • Creation of a CBRNE Health Kit was suggested.
• Centers for Disease Control and Prevention Agent List, CDC also provides information on different personal protection strategies such as sheltering in place.
• An analytical model developed by the Department of Defense (DoD) on the concept of and the procedures for "Medical CBRN Planning & Response," which includes the following products:
  • CBRN Defense operational concept
  • Medical CBRN planning procedures and factors
  • Medical CBRN response operational "rules of thumb"
  • Medical CBRN operational template

v. Training: It is recognized that the military is the most prepared and trained overall for response to CBRNE event. There was overwhelming consensus that NGOs needed to include CBRNE awareness as part of pre-deployment training. But what do NGOs need to know?

Training: What do NGOs need to know? (click here to see full "Personal Protection and Staff Health Issues" presentation by Mark Stinson, RI) - Range of threats in particular theater, their treatments and all necessary protective measures - Prophylactic immunization and pretreatment recommendations - Mass casualty strategies - Sources of technical assistance - Supplies/knowledge of operation of all relevant material and equipment (and fit testing of all various types of PPE) - Improvisation knowledge for the unexpected exposure (i.e. use of rainsuits, ponchos, etc) - Construction of safe rooms/shelter in place techniques - Civil-military liaison channels of communication - Practical personal protection strategies - Decontamination techniques (individual and mass)

There are current programs, like the OFDA/ATSDR Tier 1 and Tier 2 training an OFDA staff training activity which NGOs will be invited to attend on a space-available basis, the American Red Cross training for domestic preparedness at the Clara Barton Center in Arkansas, Federal Emergency Management Agency training, to name a few that NGOs have access to. The US Army Soldier and Biological Chemical Command (SBCCOM), and other military commands and units like the US Marine Corps Chemical-Biological Incident Response Force (CBRIF) may have knowledge, lessons and training with application for NGOs. Also, the US Department of Justice, which runs programs on domestic preparedness (including the Program on Domestic Preparedness formerly run by SBCCOM) and other training which may be relevant to NGOs. Synergy between all interested actors in terms of training should be pursued.

Chris Piper at TorqAid in Australia has compiled a useful summary of predominantly private sector trainings and other resources, and is moderating an online forum on CBRNE issues on the Aid Workers Network. There are also several planned initiatives, such as Relief International's planned Tier 2 training, and RedR courses, that focus on the training needs of the NGO community related to CBRNE.

Another such initiative highlighted by conference participants is a CD-ROM-based training tool entitled Chemical, Biological and Radiological Threats, A Guide for Aid Workers, now posted on the International Medical Corps (IMC) web site. The tool was produced by the IMC and the UCLA Center for International Emergency Medicine (CIEM), with support from USAID's Office of U.S. Foreign Disaster Assistance (OFDA). Based on the Mass Casualty Incident Responder program, the broad educational objectives of this MCI training CD-ROM are:

1. To ensure that field-staff are familiar with the acute consequences of a CBRNE incident;
2. To protect the health of field-staff in the event of a CBRNE incident;
3. To review field triage principles in the context of a CBRNE incident;
4. To review the initial management of CBRNE victims;
5. To delineate the ways in which a CBRNE incident impacts traditional NGO operational priorities;
6. To ensure adequate understanding of the role humanitarian agencies can play in their response to a CBRNE attack, along with those of other agencies.
7. To stimulate contingency planning and coordination of interagency responses to a CBRNE incident

Send requests for the CD-ROM to cd@imcworldwide.org. Dr. Eric Savitsky at UCLA's CIEM (esavitsk@ucla.edu) will gratefully receive comments and contributions regarding content.

b. Move 1: Chemical
Lead Subject Matter Expert: Mr. Joe Hughart, Agency for Toxic Substances & Disease Registry (See also Chemical Agent Fact Sheets)

Background: A release of some 10,000 liters of ammonia due to previously undetected structural damage to chemical storage apparatus caused by an earlier earthquake. The toxic cloud killed many in their sleep and sent thousands fleeing the area. In addition, due to an undetected crack in the facility floor, thousands of liters of the contaminant also seeped into the ground in an area with a very high water table. Those fleeing complained of burning eyes and throat, and many were coughing.

Discussion: The first instinct of many NGO workers faced with this situation may be to head in the direction from where people are fleeing to determine what is wrong. But CBRNE situation requires a different strategy. Being able to recognize general symptoms of chemical exposure, such as ammonia, is key and indicates that the landmine strategy be used: if someone has stepped on a landmine, you don't rush in to help, instead you trace your steps backward to remove yourself from danger.

While in certain circumstances becoming a victim may be an unavoidable reality, relief workers need to rethink their initial impulses in a CBRNE event. Triage becomes a central theme, and the hard choice of leaving someone behind may have to be made in order to maintain capacity to respond to the larger crisis. Recognizing this possibility, other factors related to protection and safety include:

i. Identifying and ensuring a safe distance from the current and potential hot zone: There are many factors that will affect the determination of the boundaries of a contaminated area or hot zone. Wind conditions for one can cause the danger zone to shift. While the determination of the distance needed to move will likely be a technical determination, NGO workers have critical knowledge - - 'eyes and ears' - - on the ground that can assist experts in analyzing the patterns of the event. This again highlights the need for pre-existing procedures for the timely and constant flow of credible information, both vertically within the organization as well as laterally to partners and technical experts.

It is important to note that organizations may not have the choice of where to evacuate or withdraw their staff. Quarantines, both local and international, may be in place and need to be taken into account.

ii. Maintaining the integrity of the cold zone: Once the hotline, or demarcation between the hot and cold zones, is well defined, it is critical to ensure that key decontamination and health facilities in unexposed areas remain uncompromised. This will require some form of population management or control, and will need to be closely coordinated (see Figure 1 below). Given that the hot-zone is not static (i.e. the plume shifts or contaminated persons, vehicles or equipment compromise the cold zone) and that displaced populations may re-displace, humanitarian organizations may need to examine the types of equipment used in potential hot spots, i.e. tents that are easily collapsible and more portable. The flow of accurate information will be critical for the safety of staff and beneficiaries.

Figure 1: Source ATSDR Medical Management Guidelines for Acute Chemical Exposure

iii. Managing Fear: Local populations will logically look to representatives of humanitarian agencies for assistance, particularly if they have been working and living in the community for a long period of time. A public information strategy on how to manage public panic, and provide accurate, timely information on whether people should shelter in place, the most effective measures of personal decontamination and other critical information on the situation need to be devised in advance. Such a strategy needs to be well coordinated with host nation, UN Agencies and other partners operating in the crisis area.

The need for training on dealing with the press or employment of a senior press person in these situations was highlighted. The reliability and credibility of the information organizations release may directly impact their ability to continue operations. Media outlets may have biases, and misinformation, once disseminated, becomes a part of the public record. (See Managing Fear: the Role of the Press, TV and Radio in a CBRNE Event by Richard Halloran).

iv. Decontamination: NGOs admittedly do not have the capacity for mass decontamination of civilian populations and will look to other partners that have this resident expertise and capacity, such as the military. There are legal obligations under the Geneva Conventions incumbent upon the occupying nation for the welfare of both the civilian population and prisoners of war, but the extent of the capacity for large-scale decontamination remains unclear.

Participants who observed Weapons of Mass Destruction (WMD) training of the 93rd Civil Support Detachment of the Hawaii National Guard were given a guided tour of a decontamination zone (see Figure 2 below) and were able to asked in depth questions on their basic set up and operation.

Figure 2: Source ATSDR Medical Management Guidelines for Acute Chemical Exposure

The Office for the Prohibition of Chemical Weapons (OPCW), an inter-governmental organization founded to implement the provisions of the Chemical Weapons Convention, has produced an introduction to methods and chemicals for decontamination, which includes information on personal and equipment decontamination. There was some limited discussion of OPCW's capacity and potential role in a response, as well as the Joint UN Environment Programme (UNEP)/Office for the Coordination of Humanitarian Affairs (OCHA) Environment Unit. It was suggested that more detailed coordination be conducted with both organizations.

v. Liability: As with media relations, the legal issues associated with CBRNE require the use of legal expertise. It is critical to recognize legal requirements of organizations to their staff and to operate within local laws. They face potential liability with 3rd party beneficiary populations.

At a minimum, as with current practice to minimize liability, organizations should have staff members sign waivers that they are freely and voluntary undertaking their assignment, with all associated risks. There would likely arise a need to separate repetitive and preventable risks from risks due to unforeseeable events. There was also discussion about the responsibility of the organization to adequately inform staff members of the potential risks to the best of their knowledge. (See Legal Briefing on Response to CBRNE Event by Raymond Heddings, Defense Threat Reduction Agency.)

The question arose as to whether there is potential for "hold harmless" clauses, such as in Articles 8 through 10 of the Convention on Emergency Response to a Nuclear Accident, to be a model for response to other hazards. The clause proscribes that if you were asked to respond, you cannot be held responsible and no third party claim can be filed against you. Further investigation may be warranted.

Recommendation: Explore whether "hold harmless" clauses can be used for the variety of possible CBRNE scenarios.

vi. Crime Scene: NGOs have some experience with conducting operations around crime scenes, such as those of mass graves during war crimes investigations, but an intentional attack using chemical, biological, radiological or nuclear devices would certainly prompt a full-scale investigation that can effect NGO operations and coordination issues, as the investigation may include organizations with which the humanitarian community has not traditionally worked.

vii. Non-Medical priorities: While medical and public health issues are key in managing consequences of a CBRNE event, they are by far not the only concern. Shelter and water in contaminated environments are critical. Further exploration and determination of what resources exist to deal with these other issues may be overlooked as a medical focus takes precedence.

c. Move 2: Biological

Lead Subject Matter Experts:
Mr. Scott Lillibridge, Center for Biosecurity & Public Health Preparedness, Univ. of Texas
Mr. Arnold Kaufman, Centers for Disease Control and Prevention
(See Biological Agent Fact Sheets)

Background: During ongoing NGO relief operations in response to an earthquake in a conflict-prone area, reports indicate sporadic and then increasing numbers of people dying of respiratory disease. Other reports indicate many dead rats are found littering the streets. It is soon determined that the victims are dying of the pneumonic form of Plague and a local terrorist outfit claims responsibility for it's release, threatening more in the future, particularly against expatriates. (See Arnold Kaufman's presentation Plague: Basic Concepts for background information on the disease)

Discussion: Perhaps the most important distinction between a chemical and biologic contaminant is the warning time and signs. In bio situation, it may take several days to recognize that an outbreak has occurred, versus the more immediate signs of chemical exposure.

NGO health surveillance systems may in fact detect the initial problem, but independent verification of the outbreak is critical, particularly in a terror-charged environment. Epidemiologists and other investigative teams will be busy determining source and spread of the disease (see "Principles of Epidemiology" presentation by Doug Hamilton). Symptoms of the pneumonic form of plague will include fever, headache, weakness, and rapidly developing pneumonia with shortness of breath, chest pain, cough, and sometimes bloody or watery sputum. Though diagnosis of the disease may not be difficult (gram stains feasible for the plague, if used to looking at them), the role of the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) were discussed in the independent confirmation of pathogen and possible lab support were raised, particularly to determine if the pathogen is an anti-biotic resistant strain.

Recommendation: Pre-identify lab facilities with which NGOs may have working relationships in high-risk areas, particularly for independent confirmation of pathogen as well as possible determination of anti-biotic resistant strains.

The biggest risk of contraction of the disease is face-to-face exposure with coughing infected individual. Secondary side effects very rapidly onset and require acute monitoring. Extreme humidity and close quarters can increase rates of exposure.

Isolation of pneumonic plague patients is extremely important as it can be spread person to person through the air. Breaking the cycle of transmission, i.e. airborne contact, blood, contaminated needles or vectors is critical to containment of any disease. Early treatment is essential to reduce risk of death. Antibiotic treatments are critical within twenty-four hours of presentation of symptoms.

There will inevitably be difficulties when large populations are affected. NGO emergency kits are not set up for a mass biological events and staff are not currently trained for Category A agents (see CDC's agent list for more details on the different categories). Organizations may consider taking extra doxycycline, for instance, instead of breaking open lots of kits. If not, begin treatment with in stock supply, and re-supply through the medical pipeline. There may be an urgent need for meds and a great need for international logistical assistance to bring medical supplies to the site of the outbreak and facilitate containment.

Preparation is key. Stockpiles of medication and equipment should be propositioned (to the extend possible with meds) and NGOs should pre-arranged authority to access them. Health workers should be given prophylaxis and a gauze mask. Gauze masks serve as good protection for secondary infection only and are NOT sufficient to protect workers at the source of an outbreak. Other preventive measures include standards of minimizing rodents in camp areas by removing food sources and other methods with which the NGOs are familiar.

It is critical that the medical NGO community share the information of their findings as widely as possible. Information on prevention, symptoms, etc, should be passed through diverse means, including through local hires, drivers, etc. The public information campaign should be well coordinated to avoid panic and fear, and should advise people of the best forms of prevention and protection.

Cause and risk factors are important. NGOs themselves will be on hyper-alert while the determination of whether the event was a natural or non-natural occurrence is taking place, given that the initial release may not be an isolated attack. Safety and communication precautions are critical. NGO staff must "be aware and share." In this environment, organizations need to be prepared for the potential of a second release. It was pointed out that information flow might be compromised due to political implications of a terror threat (or political embarrassment). Building confidence that "specific" threat information will be shared with NGOs under these circumstances is important.

As in the chemical scenario, there was issue of whether evacuation was even a possibility, due to quarantine issues, particularly if staff has been exposed. Again, the question of who will declare and enforce any imposed quarantine, and maintain order at treatment facilities remained a variable, depending on the host nation capacity and other partners that may be on the ground and capable of this role. In addition, if responders factor into the outbreak, then NGO operations will be hampered, as they will not be functioning at full strength.

The need to do something will be great, particularly if large populations are exposed, but the military role more limited in this case. They do not have the capacity, or the mandate, to treat large civilian populations. CDC may not be on the ground until asked by the host nation to provide support, but will be available by satellite phone, if needed. However, CDC's International Emergency and Refugee Health Branch may be tapped by NGOs directly.

The local population typically provides immediate assistance before internationals arrive on the scene, but it may be more difficult for them to respond due to the technical nature of a biological event. In addition, local NGO staff, which is relied on heavily in most humanitarian organizations, may need to be with their families, as they may too be affected.

As in other emergency situations, NGO staff has right to refuse to work in dangerous areas. Ethnicity of staff may come into play and riots and looting are possible. As discussed in the chemical scenario, most organizations already have a policy of informed consent that should be adapted to cover CBRNE, however, acts of terrorism will change NGO insurance.

In terms of staff mental health, CBRNE can be considered another stress factor. Burnout occurs due to background stress of situation coupled with physical security and emotional distress. Medical staff may feel extremely committed to patients and will not wish to abandon them, if necessary. It is important to have daily debriefings. R&R policy needs to be enforced. Support networks for staff are critical (see Mental Health Issues in CBRNE Events presentation by Barbara Lopes Cardozo).

From a security perspective, coordination is key: coordination of health information, a credible public message, protection and other security information. There is a need to see "the big picture". Standardization of data becomes more critical in a terror event. Universals on geographic information may affect maps and other security analysis tools. While information is often competitive and data gathering sensitive, efforts towards it's systematic collection during other emergencies through vehicles like the Humanitarian Information Center, though not perfect, has proved beneficial. This data can also help to transition from relief phase onward (see "Common Operational Picture" presentation by Shawn Messick).

There was general agreement that the Plague scenario was more manageable than the chemical one. NGOs should be able to function in this type of bio-environment and be effective. Employment of disease control and surveillance measures, vector control, and other functions NGOs perform on a routine basis, will help effectively manage the initial outbreak. Still, worker safety is key to staying in business. Concerns over staff protection will drive the decision to evacuate or not, and information, or lack thereof, will play heavily into this decision process. Smaller NGOs may make more conservative decisions than those with more resources.

The playing field would change if the agent were smallpox, however. The issue of availability of smallpox vaccine for NGOs is under development.

d. Move 3: Radiological/Explosive

Lead Subject Matter Experts: Mr. Joe Hughart, ATSDR and Mr. Arnold Kaufman, CDC
(See Radiological Agent Fact Sheets)

Due to time constraints and richness of other discussions, Move 3 was not executed. Click here for an informational description of the move. The World Health Organization (WHO) has developed a concise information sheet on the effects of a dirty bomb or radiological dispersion device (RDD).

e. Personal Protective Equipment (PPE) and Personal Protection/Staff Safety

Lead Subject Matter Experts: Mr. Joe Hughart, ATSDR and Dr. Mark Stinson, Relief International

There is an apparent desire to improve NGO capacity and preparedness for CBRNE events, where in the past, evacuation was considered the best strategy. NGOs preparedness planning in CBRNE environments suffers from both a lack experience in dealing with many of these issues but also a lack of clarity in government and military partners they can rely on for technical support. Despite current challenges in ensuring staff safety and defining specific roles, some NGOs intend to operate in potentially hazardous environments, such as the Iraqi theatre.

Training and other preparedness activities are now beginning to be looked at by a number of agencies, but there is a fear that many of these initiatives are being done in a silo or stove-piped fashion. It is important to avoid isolation, and coordinate to enhance effectiveness of programs and pool resources. Mainstreaming and institutionalizing CBRNE in organizational policy is crucial for the NGOs to build capacity and confidence in their ability to protect staff and civilian populations.

There is the inherent risk of overestimating NGO capacity in a large scale or prolonged CBRNE event. There is currently a lack of training relevant to NGOs, and a very steep learning curve should something happen in Iraq. Inadequate funding for relevant equipment and supplies and staff concerns of risks over vaccinations and other pretreatments are just some of the difficulties facing organizations.

In order to get a better feel for various types of Personal Protective Equipment (PPE), a hands-on demonstration afforded participants the opportunity to try on equipment and ask questions about different models.

"Technique before technology" is the main message. At this point in time, it is almost inconceivable that an NGO would need top of the line level-A suits to go into a hot zone, but NGO staffers may require escape hoods, etc., to evacuate to a cold zone. Individual organizations will need to determine their own requirement and investigate the simple solutions that may apply: soap, water; trash bags and duct tape could be all that is required.

A.P.E.

The following is a recommendation for NGO preparedness:

Avoid: Conduct a thorough threat assessment (databases, visual, discussions with host nation). Identify potential harmful agents and avoid areas where they may be encountered.

Prevent: Maintain vaccinations. Use insect repellents (skin and clothing) and good sanitation practices in areas where vector-borne agent threats exist. Locate camps away from or upwind from potential plume areas. Secure hazardous materials that could be used as weapons.

Escape: Personal protective clothing and equipment needed to escape from hazardous materials is often lighter, simpler and less expensive than equipment needed to enter into, fight in, or remain in contaminated environments. Buy accordingly. Identify potential escape routes and procedures. Identify locations for alternate operation centers and rally points. Establish communication procedures. Identify evacuation priorities (e.g., patients, equipment). And most importantly, TRAIN.

If organizations decide to provide PPE for their staff, fairly extensive research is advised before purchasing. Some homework and consultation with experts can save money. Technical experts should be able to advise you of "the best fit" for different needs of different organizations.

Given the potential long-term health consequences, a critical staff-protection measure, already in place in some organizations, are pre- and post-deployment medical monitoring programs.

Recommendation: Though domestically focused, the Occupational Safety and Health Administration (OSHA) was suggested as a useful template for safety standards and development of medical monitoring programs (See OSHA standard 1910.120: Hazardous waste operations and emergency response and "A Model Medical Surveillance Program For Persons in Hazardous Waste Operations" by Phil Jones, Peter P. Greaney, Marion J. Fedoruk.

There are organizations, such as People in Aid, which look at human resource management issues that could be of assistance to some NGOs. In addition, there is discussion of incorporation of staff health into the Sphere Standards.