On 11 March 2011, northern Japan was struck by first a magnitude 9.0 earthquake off the eastern coast and then by an ensuing tsunami. At the Fukushima Dai-ichi Nuclear Power Plant (NPP), these twin disasters initiated a cascade of events that led to radionuclide releases. Radioactive material from Japan was subsequently transported to locations around the globe, including the U.S. The levels of radioactive material that arrived in the U.S. were never large enough to cause health effects, but the presence of this material in the environment was enough to require a response from the public health community. Events during the response illustrated some U.S. preparedness challenges that previously had been anticipated and others that were newly identified. Some of these challenges include the following: (1) Capacity, including radiation health experts, for monitoring potentially exposed people for radioactive contamination are limited and may not be adequate at the time of a large-scale radiological incident; (2) there is no public health authority to detain people contaminated with radioactive materials; (3) public health and medical capacities for response to radiation emergencies are limited; (4) public health communications regarding radiation emergencies can be improved to enhance public health response; (5) national and international exposure standards for radiation measurements (and units) and protective action guides lack uniformity; (6) access to radiation emergency monitoring data can be limited; and (7) the Strategic National Stockpile may not be currently prepared to meet the public health need for KI in the case of a surge in demand from a large-scale radiation emergency. Members of the public health community can draw on this experience to improve public health preparedness.

Assumptions for public health emergency preparedness planning involving the detonation of an improvised nuclear device in a large metropolitan area include casualties in the hundreds of thousands, total infrastructure damage within a radius of 0.8–4.8 km (0.5–3 mi), and radioactive materials contaminating thousands of square kilometers (1). It is apparent that responding to an improvised nuclear device detonation would require an unprecedented national effort. Hundreds of thousands of people would require (and many others would likely desire) monitoring for external and internal contamination with radioactive materials. | Large numbers of people would need decontamination. Vast environmental areas would require surface monitoring for radioactive contamination and subsequent decontamination. The response and recovery efforts would take years. Although an improvised nuclear device scenario is the most extreme example, radiation public health emergencies can take many forms. Conversely, the key principles for responding to such events are similar.

The events surrounding the nuclear power plant accident in Fukushima, Japan, uncovered a number of questions and issues that need to be addressed in the United States (US) regarding the preparedness and response to similar potential incidents. A recent commentary discussed some of these issues, including the lack of a sufficient number of radiation subject matter experts that are needed to provide guidance to other public health planners and responders. 1 Indeed, although no health effects from the exposure to radiation were expected to occur in the US, the Emergency Operation Center at the Centers of Disease Control and Prevention (CDC) in Atlanta operated at full capacity to support the needs of State and Federal partners both at home and abroad, particularly in Japan. During such events, the public will seek answers to numerous questions that can overwhelm existing resources like the CDC Info Line and the Radiation Emergency Assistance Center/Training Site (REAC/TS) emergency line. 2 In March and April 2011, a number of CDC toxicologists participated in the Japan Earthquake response in various roles while poison centers provided public health partners with daily updates on radiation exposure and information based on queries relating to radiation exposure and the use of potassium iodide.3 | The role of poison centers in a nuclear power plant or other radiation emergency is well supported by a long and successful record of involvement during other public health incidents that range from infectious disease epidemics like West Nile virus to environmental disasters like the British Petroleum oil spill. In a radiation emergency, poison centers can educate callers about the proper use of medical countermeasures or antidotes, monitor for patterns of use and misuse of these therapies, and detect potential secondary adverse events from their use. Because of their existing technical resources and their experience in operating as a call center, they can assist in communicating important health messages and protective action measures to the public. Currently, the American Association of Poison Control Centers (AAPCC) collaborates closely with CDC in the area of surveillance and belongs to the recently formed National Alliance for Radiation Readiness whose mission is to enhance the Nation’s radiological preparedness. 4 Additionally, the AAPCC participated in the response to the Fukushima and the CardioGen Rubidium-82 contamination incidents. 5 Further steps need to be taken by poison centers and their local and state partners to establish or solidify collaborations and formalize the role of poison centers in radiation preparedness and response alongside other stakeholders like Radiation Control Programs and Emergency Management Agencies.

On November 23, 2006, former Russian military intelligence officer Alexander Litvinenko died in a London hospital. Authorities determined he was deliberately poisoned with the radionuclide Polonium-210 (210Po). Police subsequently discovered that those involved in this crime had--apparently inadvertently--spread 210Po over many locations in London. The United Kingdom Health Protection Agency (HPA) contacted many persons who might have been exposed to 210Po and provided voluntary urine testing. Some of those identified as potentially exposed were U.S. citizens, whom the HPA requested that the Centers for Disease Control and Prevention (CDC) assist in contacting. CDC also provided health care professionals and state and local public health officials with guidance as to how they might respond should a Litvinenko-like incident occur in the U.S. This guidance has resulted in the identification of a number of lessons that can be useful to public health and medical authorities in planning for radiological incidents. Eight such lessons are discussed in this article.

On 11 March 2011, northern Japan was rocked by first a magnitude 9.0 earthquake off the eastern coast and then an ensuing tsunami. The Fukushima Daiichi Nuclear Power Plant complex was hit by these twin disasters, and a cascade of events was initiated that led to radionuclide releases causing widespread radioactive contamination of residential areas, agricultural land, and coastal waters. Radioactive material from Japan was subsequently transmitted to locations around the globe, including the U.S. The levels of radioactive material that arrived in the U.S. were never large enough to be a concern for health effects, but the presence of this material in the environment was enough to create a public health emergency in the U.S. The radiation safety and public health communities in the U.S. are identifying challenges they faced in responding to this incident. This paper discusses three of those challenges: (1) The growing shortage of trained radiation subject matter experts in the field of environmental transport and dosimetry of radionuclides; (2) the need to begin expressing all radiation-related quantities in terms of the International System of Units; and (3) the need to define when a radiation dose is or is not one of "public health concern." This list represents only a small subset of the list of challenges being identified by public health agencies that responded to the Fukushima incident. However, these three challenges are fundamental to any radiological emergency response. Addressing them will have a significant positive impact on how the U.S. responds to the next radiological emergency.

The report by Dr. Takeo Ohnishi in this issue of Radiation Research (1) is a comprehensive detailing of the Fukushima-Daiichi nuclear power plant (NPP) disaster. We have chosen for the title of this commentary “combined disaster,” which is emphasized by both Dr. Ohnishi and Dr. Makoto Akashi from the National Institute of Radiological Sciences (2), who was involved in the management of the incident. Dr. Akashi and others emphasize the catastrophic loss of life and damage primarily from the earthquake and tsunami and that the NPP disaster was the consequence of the loss of infrastructure, including power supply and access to the facility. There are lessons observed regarding NPP issues, and there is now broad worldwide discussion on the future of energy sources. The consequences of the NPP disaster will take years to better understand as the Fukushima-Daiichi incident plays out. In addition, nuclear power issues will take decades to be addressed, given the complexity of worldwide energy needs, potential sources and suppliers of alternative forms of energy, and the environmental impact of the rising worldwide energy demand. Furthermore, energy policy complicates matters as decisions by one country can have an enormous impact on its neighbors and the entire world. | This commentary is from the personal and professional perspective of the four coauthors, who were directly involved in the response at the U.S. Embassy in Japan (CNC and MAN) and in the U.S. at the National Security Staff (CBM) at the White House and Centers for Disease Control and Prevention (RCW). In that the number of radiation experts within the U.S. government (USG) is small and there are many ongoing interagency collaborations [e.g., Planning Guidance (3)], the overall U.S. response involved people who worked tirelessly over the first month to provide their expertise and support for the international and domestic aspects of the response, including supporting the Japanese. This NPP disaster is unique in the enormity of the overall infrastructure damage, the sophisticated response and monitoring ability, the breadth of the media attention, the presence of multiple potential sources for radiation release, and the stepwise evolution with real-time monitoring of an environmental radionuclide release. While comparisons are made with Chernobyl, this incident was certainly different in terms of the type of reactor, character of radionuclide release, and timeliness of reporting in regard to the onset of the incident (2).

Federal agencies have a variety of roles and responsibilities related to communicating with the public before, during, and after a radiological emergency. To better understand the various efforts currently underway, the Radiation Studies Branch of the Centers for Disease Control and Prevention convened a roundtable of representatives from federal agencies with responsibility for communicating with the public about radiation emergencies. Roundtable participants shared valuable information about efforts underway to develop information and messages for a variety of audiences and agreed that continued interagency coordination and dialogue about communication before, during, and after an event are needed. The group suggested several strategies for future collaborative efforts and indicated a desire to continue working together to develop and assess messages for radiological emergency preparedness and response. The group also recommended that more work be done to determine whether messages need to be packaged or tailored for specific special populations and suggested that more research be conducted to answer questions about specific audience/cultural needs around communicating radiation risks. Since this roundtable, attendees have continued to work together to develop and test messages for the public.

The chair of this panel, Charles W. Miller [Centers for Disease Control and Prevention (CDC)], began the session with a report of a roundtable on communications related to radiological/nuclear emergencies that CDC convened in January 2009. This roundtable brought together representatives from many different agencies of the federal government to share their current efforts and to discuss coordinated planning of future efforts to develop communication materials for use in radiological/nuclear emergencies. Charles Miller noted several of the issues that the roundtable participants discussed, including: | The use of the intranet for information sharing and how it may be exclusionary for segments of the population that do not have internet access; | The need for federal agencies to share information and messages with state, local, and tribal partners; | The imperative to communicate with a diverse population (i.e., there is no single “general public”); | The challenge of educating people without needlessly scaring them; and | The selection of appropriate spokespersons to deliver potentially life-saving messages.

Following a radiation emergency, evacuated, sheltered or other members of the public would require monitoring for external and/or internal contamination and, if indicated, decontamination. In addition, the potentially-impacted population would be identified for biodosimetry/bioassay or needed medical treatment (chelation therapy, cytokine treatment, etc.) and prioritized for follow-up. Expeditious implementation of these activities presents many challenges, especially when a large population is affected. Furthermore, experience from previous radiation incidents has demonstrated that the number of people seeking monitoring for radioactive contamination (both external and internal) could be much higher than the actual number of contaminated individuals. In the United States, the Department of Health and Human Services is the lead agency to coordinate federal support for population monitoring activities. Population monitoring includes (1) monitoring people for external contamination; (2) monitoring people for internal contamination; (3) population decontamination; (4) collecting epidemiologic data regarding potentially exposed and/or contaminated individuals to prioritize the affected population for limited medical resources; (5) administering available pharmaceuticals for internal decontamination as deemed necessary by appropriate health officials; (6) performing dose reconstruction; and (7) establishing a registry to conduct long-term monitoring of this population for potential long-term health effects. This paper will focus on screening for internal contamination and will describe the use of early epidemiologic data as well as direct bioassay techniques to rapidly identify and prioritize the affected population for further analysis and medical attention.