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FM 4-02.7 MULTISERVICE TACTICS, TECHNIQUES, AND PROCEDURES FOR HEALTH SERVICE SUPPORT IN A CHEMICAL, BIOLOGICAL, RADIOLOGICAL, AND NUCLEAR ENVIRONMENT (JULY 2009) - page 1

 

 

*FM 4-02.7
MCRP 4-11.1F
NTTP 4-02.7
AFTTP 3-42.3
FM 4-02.7
Headquarters, Department of the Army
Washington, DC
MCRP 4-11.1F
Marine Corps Combat Development Command
Quantico, Virginia
NTTP 4-02.7
Navy Warfare Development Command
Newport, Rhode Island
AFTTP 3-42.3
Headquarters, Air Force Doctrine Center
Maxwell Air Force Base, Alabama
15 July 2009
MULTISERVICE TACTICS, TECHNIQUES, AND PROCEDURES
FOR
HEALTH SERVICE SUPPORT IN A CHEMICAL, BIOLOGICAL,
RADIOLOGICAL, AND NUCLEAR ENVIRONMENT
TABLE OF CONTENTS
Page
EXECUTIVE SUMMARY
xvi
CHAPTER I
CHEMICAL, BIOLOGICAL, RADIOLOGICAL, AND
NUCLEAR ASPECT OF HEALTH SERVICE SUPPORT
I-1
General
I-1
Health Threat
I-1
Management of Chemical, Biological, Radiological, and
Nuclear Casualties
I-5
Military Operations in a Chemical, Biological, Radiological,
and Nuclear Environment
I-13
Health Service Support Planning Considerations
I-16
Command, Control, Communications, Computers, and
Intelligence Systems in a Chemical, Biological,
Radiological, and Nuclear Environment
I-17
DISTRIBUTION RESTRICTION: Approved for public release; distribution is unlimited.
*This publication supersedes FM 4-02.7 (FM 8-10-7), 1 October 2002.
15 July 2009
FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
vii
Obtaining Medical Intelligence Information on Chemical,
Biological, Radiological, and Nuclear Threats
I-18
Joint Warning and Reporting Network
I-21
CHAPTER II
CASUALTY PREVENTION
II-1
General
II-1
Medical Surveillance and Occupational and Environmental
Health Surveillance Activities
II-2
Medical Countermeasures for Chemical, Biological,
Radiological, and Nuclear Casualty Prevention
II-2
Disease Incidence Following the Use of Chemical,
Biological, Radiological, and Nuclear Weapons
II-3
Sustainment of Health Service Support Operations in a
Chemical, Biological, Radiological, and Nuclear
Environment
II-5
Preparation and Training for Chemical, Biological,
Radiological, and Nuclear Defense
II-6
Predeployment Procedures
II-7
Predeployment Actions
II-8
Deployment Procedures
II-10
Deployment Actions
II-12
Actions Before a Chemical, Biological, Radiological, and
Nuclear Attack
II-13
Actions During a Chemical, Biological, Radiological, and
Nuclear Attack
II-14
Actions After a Chemical, Biological, Radiological, and
Nuclear Attack
II-15
Other Chemical, Biological, Radiological, and Nuclear
Defenses
II-16
Postdeployment Actions
II-16
CHAPTER III
CASUALTY CARE AND MANAGEMENT
III-1
General
III-1
Chemical, Biological, Radiological, and Nuclear Mass
Casualty
III-1
Triage
III-5
Mission-Oriented Protective Posture Levels
III-7
Civilian Casualties
III-7
Taxonomy of Care
III-7
Roles of Care
III-9
Role 1 Health Service Support in a Chemical, Biological,
Radiological, and Nuclear Environment
III-10
Role 2 Health Service Support in a Chemical, Biological,
Radiological, and Nuclear Environment
III-11
Role 3 Health Service Support in a Chemical, Biological,
Radiological, and Nuclear Environment
III-12
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15 July 2009
Management of Chemical, Biological, Radiological, and
Nuclear Casualties in a Medical Treatment Facility
III-13
United States Marine Corps Operations Casualty
Management
III-14
Protection of Medical Treatment Facilities
III-15
Chemical Environment
III-16
Biological Environment
III-18
Nuclear Environment
III-20
Medical Treatment Facility Contamination Control
III-21
Medical Treatment Facility Decontamination
III-25
Training and Exercises
III-27
Restriction of Movement, Isolation, and Quarantine
III-28
Worried Well
III-28
CHAPTER IV
PATIENT MOVEMENT
IV-1
General
IV-1
Medical Evacuation in a Chemical, Biological, Radiological,
and Nuclear Environment
IV-1
Medical Air Evacuation Under High Level Biosafety
Containment
IV-4
Aeromedical Evacuation Process
IV-5
Patient Isolation Unit
IV-6
CHAPTER V
PATIENT DECONTAMINATION
V-1
General
V-1
Levels of Decontamination
V-2
The Importance of Early Contaminant Removal and Medical
Monitoring of Patients
V-3
Zones of Contamination
V-6
Personal Protective Equipment Worn by Decontamination
Operators
V-7
Decontamination Materials
V-9
Detection Devices Used During Patient Decontamination
V-13
Safety, Heat Injury Prevention, and Water Consumption
V-14
Heat Injury
V-15
Core Components of the Patient Decontamination Site and
Patient Flow
V-17
Collocating a Land-Based Patient Decontamination
Operation with Troop Decontamination Operations
V-22
Litter Patient Mask, Protective Ensemble, and Clothing
Removal Procedures
V-23
Ambulatory Patient Mask, Protective Ensemble, and
Clothing Removal Procedures
V-30
Wound Decontamination and Trauma Management
Procedures
V-34
Establishing a Patient Decontamination Site
V-35
Actions to Take Upon Notification of Patient Arrival
V-44
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ix
Actions to Take When Contaminated Patients Arrive
V-44
Moving a Litter Patient Through a Patient Decontamination
Site
V-45
Clothing Removal Station
V-48
Decontaminate the Patient
V-49
Check Patient for Completeness of Decontamination
V-51
Movement of the Patient to the Hot Line
V-51
Movement of the Patient on the Clean Side of the Hot Line
V-53
Moving an Ambulatory Patient Through Patient
Decontamination
V-53
Processing Through the Ambulatory Decontamination Line
V-55
Procedures for Closing Down a Patient Decontamination
Site
V-57
Equipment and Supply Recovery
V-58
Decontamination Team Personnel Recovery (Technical
Decontamination)
V-59
Establishing a Patient Decontamination Station on a Water
Vessel
V-60
Actions to Take Prior to Arrival of Patients
V-61
Procedures to be Performed on the Flight Deck
V-64
Moving a Litter Patient Through a Patient Decontamination
Station on a Water Vessel
V-66
Procedures to be Performed in First Compartment
V-67
Procedures to be Performed in Second (Monitoring)
Compartment
V-68
Procedures for Decontaminating the Facility and the
Decontamination Team
V-70
Moving an Ambulatory Patient Through a Patient
Decontamination Station on a Water Vessel
V-72
Procedures For Closing Down the Patient Decontamination
Station on Board a Water Vessel
V-74
Night Operations
V-75
Activities during Night Operations
V-76
Cold Weather Operations
V-78
CHAPTER VI
VETERINARY SERVICE SUPPORT AND FOOD AND
WATER SAFETY
VI-1
General
VI-1
Veterinary Service Support
VI-1
Food Safety and Security and Quality Assurance
VI-2
Veterinary Medical Care
VI-3
Veterinary Preventive Medicine
VI-3
Veterinary Unit Operations in a CBRN Environment
VI-4
Veterinary Support for Subsistence
VI-5
Veterinary Survey of Storage Facilities and Subsistence
VI-5
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15 July 2009
Testing, Screening, and Collecting Food Samples in the
Field
VI-6
Subsistence Decontamination
VI-7
Treatment of Military Working Dogs Exposed to a Chemical,
Biological, Radiological, and Nuclear Environment
VI-8
Protection Against Nerve Agents
VI-10
Signs of Nerve Agent Intoxication in Military Working Dogs
VI-10
Nerve Agent Decontamination Procedures
VI-11
Treatment of Military Working Dog Casualties of Nerve
Agents
VI-12
Protection Against Incapacitating Agents (BZ Type)
VI-14
Protection Against Blister Agents
VI-15
Lung-Damaging Agents (Choking Agents)
VI-18
Cyanide Compounds (Blood Agents)
VI-18
Biological Warfare Agents
VI-19
Nuclear and Radiological Weapons
VI-20
Water Safety and Management
VI-20
Detection of Contaminated Water
VI-21
Treatment of Contaminated Water
VI-22
Engineer Support
VI-22
CHAPTER VII
MEDICAL LABORATORY SUPPORT
VII-1
General
VII-1
Samples/Specimen Collection and Management of
Chemical, Biological, Radiological, and Nuclear
Contaminants
VII-2
Handling and Storage of Samples Within the Laboratory
VII-5
Confidence Levels of Laboratory Analysis
VII-6
Joint Biological Agent Identification and Diagnostic System
VII-7
Operational Employment
VII-9
Nationally Recognized Reference Laboratories (Definitive)
VII-10
Other Department of Defense Laboratories
VII-11
Laboratory Response Network
VII-12
CHAPTER VIII
COMBAT AND OPERATIONAL STRESS CONTROL
VIII-1
General
VIII-1
Combat and Operational Stress Reaction
VIII-1
Combat and Operational Stress Control Under Reactions
VIII-3
Combat and Operational Stress Reaction Leader Risks
VIII-3
Combat and Operational Stress Reaction Leadership
Actions
VIII-3
Individual Responsibilities
VIII-5
Behavioral Health Personnel Responsibilities
VIII-5
Conducting Combat and Operational Stress Control in a
CBRN Environment
VIII-5
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xi
CHAPTER IX
HEALTH SERVICE LOGISTICS SUPPORT
IX-1
General
IX-1
Logistics Support in a Chemical, Biological, Radiological,
and Nuclear Environment
IX-1
Health Service Logistics Support Considerations in a
Chemical, Biological, Radiological, and Nuclear
Environment
IX-2
Protecting Supplies in Storage
IX-3
Protecting Supplies During Shipment
IX-3
Movement Control
IX-3
CHAPTER X
HOMELAND DEFENSE
X-1
General
X-1
Homeland Defense Chemical, Biological, Radiological, and
Nuclear Response
X-1
United States Army Role in Homeland Defense
X-3
United States Army National Guard Role
X-3
United States Army Reserve Role
X-5
United States Coast Guard National Strike Force Role
X-6
United States Navy Medicine Role
X-7
United States Marine Corps Role
X-7
United States Air Force Role
X-8
Other Department of Defense Response Assets (Not
Inclusive)
X-8
CHAPTER XI
INDIVIDUAL AND COLLECTIVE PROTECTION
SYSTEMS
XI-1
General
XI-1
Types of Collective Protection Systems
XI-2
Collectively Protected Field Hospital
XI-4
The Joint Expeditionary Collective Protection Program
XI-6
Employment of the Chemical Biological Protective Shelter
System
XI-7
Brigade Support Medical Company Role 2 Medical
Treatment Facility in a Chemical Biological Protective
Shelter
XI-9
Forward Surgical Team in a Chemical Biological Protective
Shelter
XI-10
Employment of the Chemically Protected Deployable
Medical Systems and Simplified Collective Protection
Systems
XI-12
Chemically/Biologically Protecting the International
Organization for Standardization Shelter
XI-17
Chemically/Biologically Protecting the Vestibules
XI-17
Chemically/Biologically Protecting Air Handler Equipment
XI-17
Establish Collective Protection Shelter Using the M20
Simplified Collective Protection System
XI-17
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15 July 2009
Patient Decontamination
XI-18
Operations, Entry, and Exit Guidelines
XI-18
Decontamination of Entrance Area
XI-18
Entry/Exit for the Collective Protection Shelter System
XI-19
APPENDIX A
CHEMICAL, BIOLOGICAL, RADIOLOGICAL, AND
NUCLEAR CASUALTY ESTIMATION
A-1
Decision Support Tool
A-1
Casualty Estimates
A-1
Joint Effects Model
A-1
Joint Operational Effects Federation Model
A-2
APPENDIX B
HEALTH SERVICE SUPPORT CHEMICAL,
BIOLOGICAL, RADIOLOGICAL, AND NUCLEAR
ANNEX TO AN OPERATION PLAN/OPERATION
ORDER
B-1
Medical Chemical, Biological, Radiological, and Nuclear
Staff Officer Planning for Health Service Support in a
Chemical, Biological, Radiological, and Nuclear
Environment
B-1
Sample Format for the Health Service Support Plan for
Chemical, Biological, Radiological, and Nuclear
Operations
B-2
APPENDIX C
SERVICE-SPECIFIC TASKS LIST
C-1
United States Army Tasks List
C-1
United States Air Force Tasks List
C-4
United States Navy Tasks List
C-8
United States Marine Corps Tasks List
C-9
APPENDIX D
SERVICE-SPECIFIC CHEMICAL, BIOLOGICAL,
RADIOLOGICAL, AND NUCLEAR DEFENSE
CAPABILITIES
D-1
Service-Specific Chemical, Biological, Radiological, and
Nuclear Defense Capabilities Descriptions
D-1
United States Army Chemical, Biological, Radiological, and
Nuclear Defense Capabilities
D-1
United States Marine Corps Chemical, Biological,
Radiological, and Nuclear Defense Capabilities
D-4
United States Navy Chemical, Biological, Radiological, and
Nuclear Defense Capabilities
D-6
United States Air Force Deployable Teams Related to the
Medical Chemical, Biological, Radiological, and
Nuclear Defense
D-7
Technical Reachback
D-10
REFERENCES
..........................................................................................References-1
GLOSSARY
..............................................................................................Glossary-1
INDEX
.................................................................................................... Index-1
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xiii
FIGURES
Figure IV-1. Patient Isolation Unit Roles of Care
Operational Concept
IV-7
Figure V-1. Patient Decontamination Site Layout
V-6
Figure V-2. Cutline for Hoods Integral to Overgarments
V-24
Figure V-3. Cutline for Hoods Attached to Mask
V-24
Figure V-4. Cutline for Overgarment Jacket
V-26
Figure V-5. Cutline for Overgarment Trousers
V-27
Figure V-6. Outer Gloves Removal
V-28
Figure VII-1. Levels of Identification Confidence
VII-7
Figure VII-2. The “New” Laboratory Reference Network
Designation
VII-13
Figure XI-1. Chemical Biological Protective Shelter System
XI-7
Figure XI-2. Battalion Aid Station Using the Chemical
Biological Protective Shelter
XI-9
Figure XI-3. Chemical Biological Protective Shelter
Configuration as a Brigade Support Medical Company
Role 2 Medical Treatment Facility
XI-10
Figure XI-4. Forward Surgical Team Configuration for
Operations in Conventional Mode
XI-11
Figure XI-5. Forward Surgical Team and Brigade Support
Medical Company Role 2 Medical Treatment Facility
Configuration for Operations in a Chemical, Biological,
Radiological, and Nuclear Environment
XI-12
Figure XI-6. Sample Layout of a Medical Force 2000
Combat Support Hospital (Unit Base) Employing
Chemically Protected Deployable Medical System
XI-14
Figure XI-7. Sample Layout of an 84-Bed Medical
Reengineering Initiative Hospital Employing Chemically
Protected Deployable Medical System
XI-15
Figure XI-8. Sample Layout of a 164-Bed Medical
Reengineering Hospital Employing Chemically
Protected Deployable Medical System
XI-16
TABLES
Table I-1. Nations Known or Suspected of Possessing
Chemical Weapons
I-2
Table I-2. Chemical Warfare Agents
I-2
Table I-3. Examples of Known or Suspected Biological
Warfare Agents
I-3
Table I-4. The Future of Biological Warfare Agents
I-3
Table I-5. Countries Possessing or Suspected of
Possessing Nuclear Weapons
I-4
Table III-1. Troop Decontamination Levels and
Responsible Unit
III-4
Table III-2. Patient Decontamination Levels and
Responsible Element
III-5
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15 July 2009
Table IV-1. Contagious Diseases
IV-8
Table V-1. General Recommended Decontamination
Actions by Type and Category of Agent
V-5
Table V-2. General Chemical, Biological, Radiological,
and Nuclear Decontaminants/Hazard Mitigation
Techniques and Applications
V-8
Table V-3. Summary of Appropriate Uses for Decontaminants
V-12
Table V-4. Work/Rest Cycles and Water Consumption
(Without Protective Ensemble)
V-16
Table V-5. Suggested Minimal Staffing for One Work
Cycle
V-37
Table V-6. Equipment and Supplies Needed for a
Decontamination Lane
V-43
Table V-7. Equipment and Supplies Required for the
Contamination Check Area at a Patient
Decontamination Site With Minimal Equipment
V-43
Table V-8. Equipment and Supplies Required for the Hot
Line at a Patient Decontamination Site With Minimal
Equipment
V-44
Table V-9. Equipment and Supplies Required for the
Closure/Disestablishment of a Patient Decontamination
Site
.....................................................................................V-58
Table V-10. Minimal Staffing for One Work Cycle at a
Patient Decontamination Site on a Water Vessel
V-64
Table V-11. Equipment and Supplies Required for Patient
Decontamination Procedures Conducted on the Flight
Deck
V-65
Table V-12. Equipment and Supplies Required for Patient
Decontamination Procedures Conducted in First
Compartment
V-65
Table V-13. Stages and Symptoms of Hypothermia
V-80
Table V-14. Decontamination Methods Based on Ambient
Temperature
V-81
Table VI-1. Environmental Factors—Temperate Regions
VI-23
Table VI-2. Environmental Factors—Tropical Regions
VI-24
Table VI-3. Environmental Factors—Frigid Climates
VI-24
Table VI-4. Environmental Factors—Arid Regions
VI-24
Table D-1. Technical Reachback Points of Contact
D-11
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xv
EXECUTIVE SUMMARY
Multiservice Tactics, Techniques, and Procedures for
Health Service Support in a Chemical, Biological, Radiological, and
Nuclear Environment
Chapter I
Chemical, Biological, Radiological, and Nuclear Aspect of Health
Service Support
Chapter I discusses the current policy, health threat, and HSS planning considerations in a
CBRN environment.
Chapter II
Casualty Prevention
Chapter II discusses medical surveillance and occupational and environmental health
surveillance activities and predeployment, deployment, and postdeployment activities.
Chapter III
Casualty Care and Management
Chapter III discusses CBRN mass casualty, triage, taxonomy of care, roles of care, and
medical treatment facility (MTF) activities.
Chapter IV
Patient Movement
Chapter IV discusses medical evacuation in CBRN environment, medical evacuation under
high level biosafety containment, patient isolation unit, and medical evacuation capabilities.
Chapter V
Patient Decontamination
Chapter V discusses levels of decontamination, zones of contamination, safety, and the
patient decontamination process.
Chapter VI
Veterinary Service Support and Food and Water Safety
Chapter VI discusses food protection, food defense, support for subsistence, medical and
treatment care for government-owned animals/military working dogs (MWDs), and water
safety and management.
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15 July 2009
Chapter VII
Medical Laboratory Support
Chapter VII discusses samples/specimen collection and management of CBRN
contaminants, handling and storage of sample within the laboratory, confidence levels of
laboratory analysis, joint biological agent identification and diagnostic system, definitive
laboratories, other DOD laboratories and the laboratory response network.
Chapter VIII
Combat and Operational Stress Control
Chapter VIII discusses combat and operational stress reaction, combat and operational
stress control under reactions, combat and operational stress reaction leader risks and
actions, individual responsibilities, behavioral health personnel responsibilities, and
conducting combat and operational stress control in a CBRN environment.
Chapter IX
Health Service Logistics Support
Chapter IX discusses logistics support in a CBRN environment, HSLS considerations in a
CBRN environment, protecting supplies in storage and during shipment, and movement
control.
Chapter X
Homeland Defense
Chapter X discusses homeland defense CBRN response, US Army role, US Coast Guard
role, US Navy role, US Marine Corps role, US Air Force role, and other DOD response
assets.
Chapter XI
Individual and Collective Protection Systems
Chapter XI discusses types of collective protection systems, collectively protected field
hospital, joint expeditionary collective protection
(JECP), employment of the chemical
biological protective shelter system, brigade support medical company Role 2 MTF in a
chemical biological protective shelter, forward surgical team in a chemical biological
protective shelter, the employment of the chemically protected deployable medical system
(CPDEPMEDS), chemically/biologically protecting the International Organization for
Standardization (ISO) shelter, and establish collective protection shelter using the M20
simplified collective protection system.
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xvii
PROGRAM PARTICIPANTS
The following commands and agencies participated in the development of this publication:
Army
United States Army Office of The Surgeon General, 5111 Leesburg Pike, Ste. 401,
Falls Church, VA 22041-3258
United States Army Center for Health Promotion & Preventive Medicine, 5158
Blackhawk Road, Aberdeen Proving Ground, MD 21010-5403
United States Army Medical Research Institute of Infectious Diseases, 1425 Porter
Street, Frederick, MD 21702-5011
United States Army Medical Research Institute of Chemical Defense, 3100 Ricketts
Point Road, Aberdeen Proving Ground, MD 21010-5400
Marine Corps
United States Marine Corps Combat Development Command, ATTN: C42 (Director)
3300 Russell Road, Quantico, VA 22134-5021
Navy
United States Navy Warfare Development Command, ATTN: N5, 686 Cushing
Road, Newport, RI 02841-1207
Air Force
Headquarters Air Force Doctrine Center, ATTN: DR, 155 North Twining Street,
Maxwell AFB, AL 36112-6112
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Chapter I
CHEMICAL, BIOLOGICAL, RADIOLOGICAL, AND NUCLEAR
ASPECT OF HEALTH SERVICE SUPPORT
1. General
a. Planning for military operations at all levels inherently includes provisions for
adequate FHP and HSS. Commanders are responsible for the maintenance of the health of
their commands to ensure mission accomplishment in the event of CBRN attacks.
Maintaining the physiological and psychological health of military forces is a basic
requirement for combat effectiveness. The JFC at all levels is faced with the possibility that
any operation may have to be conducted in a CBRN environment.
b. The term CBRN environment includes the deliberate or accidental employment or
threat of CBRN weapons and attacks with TIM. The employment or threat of CBRN
weapons and other toxic materials pose challenges to US military operations worldwide.
Responsibility for operations in any theater involves peacetime preparations and transition
to operations with forces from areas outside the theater, including other theaters and the
US, and inherently involves joint, multinational, and interagency dimensions. Medical forces
including Table of Distribution and Allowance (TDA) fixed facilities and teams as well as
table of organization and equipment (TOE) units may be required to operate in a CBRN
environment.
c. The JFC must plan and integrate US and multinational force capabilities to sustain
the operational tempo in all mediums (air, sea, land, and space). The component command
surgeons, working with the appointed joint force surgeon (JFS), are responsible for guiding
and integrating all HSS capabilities available to the command to support mission
accomplishment in a CBRN environment. In planning for FHP and HSS in potential CBRN
environments, preparations should include preexposure immunizations, pretreatments,
prophylaxis, and medical barrier materials applicable to the entire force, including
multinational, interagency, and civilian participants. Basic doctrine for joint HSS operations
is contained in JP 4-02 and JP 3-11.
2. Health Threat
a. Agents, Weapons, and Devices that Produce Health Threats. The health threat is a
composite of ongoing or potential enemy actions; adverse environmental, occupational, and
geographic and meteorological conditions; endemic diseases; and employment of nuclear,
biological, and chemical weapons (to include weapons of mass destruction) that have the
potential to affect the short- or long-term health
(including psychological impact) of
personnel. Service members are the targets of these threats. Weapons or environmental
conditions that will generate wounded, injured, and sick Service members beyond the
capability of the HSS system to provide timely medical care from available resources, are
considered major health threats. Weapons or environmental conditions that produce
qualitatively different wound or disease processes are also considered major health threats.
Added to the combat and operational, environmental, disease and nonbattle injury (DNBI),
and stress health threats are the adversary use of the following types of weapons, agents,
and devices—
(1) Chemical warfare (CW) agents.
(2) Biological warfare (BW) agents.
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I-1
(3) Radiological dispersal devices.
(4) Nuclear weapons.
(5) Toxic industrial materials.
(6) Directed-energy (DE) devices/weapons.
b. Chemical Warfare.
(1) Many nations view an offensive CW capability as a reasonable and affordable
deterrent to the military advantage of a potential adversary. Table I-1 lists those countries
known or suspected of having offensive chemical weapons.
Table I-1. Nations Known or Suspected of Possessing Chemical Weapons
Known to Possess
Suspected of Possessing
United States of America
People’s Republic of China
Russia
North Korea
India
Egypt
Iraq
Israel
Iran
Ethiopia
Syria
Taiwan
Yugoslavia (Serbia & Montenegro)
Burma
Libya
Algeria
South Korea
South Africa
Kazakhstan
Pakistan
(2) The Russian Republic has the most extensive CW capability in Europe.
Chemical strikes can be delivered with almost any type of conventional fire support
weapons systems (from mortars to long-range tactical missiles). Agents known to be
available in the Russian inventory include nerve agents (O-ethyl S-[2-diisopropylaminoethyl]
methylphosphonothiolate [VX], thickened VX, sarin
[GB], and thickened soman [GD]);
vesicants (thickened Lewisite [L] and mustard-Lewisite mixture [HL]); and choking agent
(phosgene [CG]). Although not considered CW agents, riot control agents are also in the
Russian inventory. Table I-2 provides a list of known CW agents.
Table I-2. Chemical Warfare Agents
Nerve
Vesicant
Incapacitating
Choking
Blood
Tabun (GA)
Sulfur Mustard (HD)
3-quinuclidinyl benzilate (BZ)
Phosgene (CG)
Hydrogen Cyanide (AC)
Sarin (GB)
Mustard-Lewisite mixture (HL)
Chloropicrin (PS)
Diphosgene (DP)
Cyanogen Chloride (CK)
Soman (GD)
Lewisite (L)
D-Lysergic Acid Diethylamide
Chlorine (Cl)
(LSD)
Cyclosarin (GF)
Phosgene Oxime (CX)
O-ethyl S-(2-
diisopropylaminoethyl)
methylphosphonothiolate
(VX)
(3) The US and various other countries noted in Table I-1 are in the process of
destroying their stockpiles of CW weapons. Many weapons have already been destroyed
and the storage facilities have been rendered safe of all CW agent residues.
I-2
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c. Biological Warfare.
(1) Biological warfare is defined by the US intelligence community as the
intentional use of disease-causing organisms
(pathogens), toxins, or other agents of
biological origin (ABOs) to incapacitate, injure, or kill humans and animals; to destroy crops;
to weaken resistance to attack; and to reduce the will to fight. Historically, BW has primarily
involved the use of pathogens in assassinations or as sabotage agents in food and water
supplies to spread disease among target populations.
(2) For purposes of health threat assessment, we are interested only in those BW
agents that incapacitate, injure, or kill humans or animals.
(3) Known or suspected BW agents and ABOs can generally be categorized as
naturally occurring, unmodified infectious agents (pathogens); toxins, venoms, and their
biologically active fractions; modified infectious agents; and bioregulators. See Table I-3 for
examples of known or suspected BW agents. Table I-4 also presents possible
developmental BW agents.
Table I-3. Examples of Known or Suspected Biological Warfare Agents
Pathogens
Toxins
Bacillus anthracis (Anthrax)
Botulinum Toxin
Francisella tularensis (Tularemia)
Mycotoxins
Yersinia pestis (Plague)
Enterotoxins
Brucella species (Brucellosis)
Ricin
Vibrio cholerae (Cholera)
Variola species (Smallpox)
Viral Hemorrhagic Fevers
(4) Many governments recognize the industrial and economic potential of
advanced biotechnology and bioengineering.
The same knowledge, skills, and
methodologies can be applied to the production of second and third generation BW agents.
Naturally occurring infectious organisms can be made more virulent and antibiotic resistant
and manipulated to render protective vaccines ineffective. These developments complicate
the ability to detect and identify BW agents and to operate in areas contaminated by the BW
agents. The first indication that a BW agent release/attack has occurred may be casualties
presenting at an MTF with symptoms not fitting the mold for endemic diseases in the area of
operations
(AO). See Chapter VII for sampling requirements, sampling procedures,
packaging and shipping, and chain of custody requirements.
Table I-4. The Future of Biological Warfare Agents
Current Threat
Future
Pathogens
Modified Pathogens
Limited number of Toxins
Expanded Range of Toxins (Organo-Toxins)
Agents of Biological Origin
Protein Fractions
Agents of Biological Origin
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d. Nuclear Weapons and Radiological Dispersal Device Threats.
(1) Available information suggests that a number of countries in the Middle East,
Asia, and Africa have or may have nuclear weapons capability within the next decade.
Table I-5 lists those countries known to have or are suspected of possessing and/or seeking
nuclear weapons.
(2) Medical planners can expect, as a minimum, 10 to 20 percent casualties within
a division-sized force that has experienced a nuclear strike. In addition to the casualties, a
nuclear weapon detonation can generate an electromagnetic pulse (EMP) that will cause
catastrophic failures of electronic equipment components. Radiological dispersal devices
are comprised of an explosive device with radioactive material which can be detonated
without the need for the components of a nuclear weapon. The RDD can disperse
radioactive material over an area of the battlefield causing effects from nuisance levels of
radioactive material to life-threatening levels without the thermal and, in most cases, the
blast effects of a nuclear detonation.
Table I-5. Countries Possessing or Suspected of Possessing Nuclear Weapons
Known to Possess
Suspect or Seeking
United States of America
Libya
Russia
North Korea
Israel
People’s Republic of China
France
United Kingdom
Pakistan
India
Iran
e. Toxic Industrial Materials.
(1) Toxic industrial materials can present a health threat to deployed forces. Toxic
industrial materials is a broad term used to refer to hazardous commercial materials or
substances to include TICs as well as commercially generated/used biological and
radiological materials and or wastes. These materials are found throughout the world and
are used on a daily basis for commercial and private purposes. Large storage facilities,
transportation tankers
(over the road and railcars), as well as smaller containers of
materials, pose a danger to the health of civilians and military personnel.
(2) Accidental spills or releases and terrorist actions can all lead to the release of
these materials into the environment causing potential casualty-producing effects. Medical
treatment facilities and nuclear power plants use radioactive materials that can pose a
health hazard if accidentally released or used by hostile forces, terrorists, or others to
contaminate an area. Biological materials used in medical research and pharmaceutical
manufacturing may also be used to produce casualties.
(3) Toxic industrial chemicals of particular concern to the military are common
commercially produced chemicals that pose a risk of severe and immediate (acute) adverse
health effects from a single release event. The degree of risk is dependent on the severity
of effects and the probability that the TIC may be obtained and/or released in large
quantities. Over the last few years various military efforts have identified the most critical
TICs of concern; examples include chlorine, ammonia, sulfur dioxide, as well as chemicals
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that have also been classified and warfare agents such as hydrogen cyanide and
phosgene. Ongoing efforts continue to improve military materiel and procedural defensive
measures against these TIC threats. However, it is acknowledged that the current
detection, protection, and medical equipment and procedures for TICs are still inadequate.
For current doctrine regarding these threats see FM 3-11.21/Marine Corps Reference
Publication (MCRP) 3-37.2C/Navy Tactics, Techniques, and Procedures (NTTP) 3-11.24/Air
Force Tactics, Techniques, and Procedures (Interservice) (AFTTP[I]) 3-2.37 and FM 3-11-4
(FM 3-4)/Marine Corps Warfighting Publication (MCWP) 3-37.2/NTTP 3-11.27/AFTTP (I)
3-2.46. For additional specific guidance and references contact United States Army Center
for Health Promotion and Preventive Medicine
(USACHPPM) or see USACHPPM
Deployment Health Guide: Toxic Industrial Chemicals
(TIC) Release Response
f. Directed-Energy Devices/Weapons.
(1) Directed-energy weapons are weapons that direct energy by means other than
a projectile in a particular direction. It transfers energy to a target for a desired effect and
take the form of lasers, high-powered microwaves, and particle beams.
(2) In recent events, laser pointers have come to the public’s attention since the
Federal Aviation Administration reported more than 150 incidents in which aircrafts were
illuminated by lasers. The likelihood of lasers being pointed at commercial and military
airline pilots during takeoff and landing has raised concerns that this may be an inexpensive
form of device which could be used by terrorists.
3. Management of Chemical, Biological, Radiological, and Nuclear Casualties
a. Chemical Warfare Agent. Health service support operations in a CW environment
are complex. In addition to providing care in protected environments or while dressed in
protective clothing, medical personnel will have to treat chemically injured and contaminated
casualties in large numbers. Types of injuries associated with CW are—
(1) Nerve agent injury. Nerve agent injuries are classified as mild and severe.
Classification is based on the signs and symptoms presented by the individual. The
individual may only be having minor problems (such as miosis) or may be convulsing and
exhibiting severe respiratory distress. Some individuals can return to duty (RTD) after
receiving a single injection of the Mark I/antidote treatment-nerve agent, autoinjector
(ATNAA); others may require three doses of the Mark I/ATNAA followed by convulsant
antidote for nerve agent (diazepam) (CANA) and assisted ventilation. Additionally, some
individuals may require more doses of atropine once they reach an MTF. For more
information on nerve agent antidote, see FM 4-02.285 (FM 8-285)/MCRP 4-11.1A/Navy
Tactics, Techniques, and procedures (NTRP) 4-02.22/AFTTP (I) 3-2.69.
(2) Blister agent injury. Individuals exposed to blister agents may not know that
they have been exposed to the agent for hours or days later. The first indication of
exposure may be small blisters on the skin. Others will have immediate burning because of
a high level of exposure. The individual with a few small blisters or reddening of the skin
can continue the mission. An individual suffering mild injuries may require admission to an
MTF for treatment, then RTD; whereas, the individual with severe injuries may have to be
evacuated from the theater.
(3) Incapacitating agent injury. Incapacitating agents produce injury by depressing
or stimulating the central nervous system
(CNS). These agents affect the CNS by
disrupting the high integrative functions of memory, problem solving, attention, and
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comprehension. Relatively high doses produce toxic delirium, which destroys the ability to
perform any task.
(4) Cyanogen (blood) agent injury. Cyanogen agents produce their effects by
interfering with oxygen use at the cellular level. The agent prevents the oxidative process
within cells. In high concentrations, there is an increase in the depth of respiration within a
few seconds. The casualty cannot voluntarily hold his breath. Violent convulsions occur
after 20 to 30 seconds with cessation of respiration within 1 minute. Cardiac failure follows
within a few minutes. Inhalation is the usual route of entry.
(5) Lung-damaging agent injury. Lung-damaging (choking) agents attack lung
tissue, primarily causing pulmonary edema. The principle agents in this group are
phosgene (CG), diphosgene (DP), chlorine (Cl), and chloropicrin (PS).
b. Management of Chemical Agent Casualties. Movement of CW agent casualties can
spread the contamination to clean areas. All casualties are decontaminated as far forward
as the situation permits. All casualties must be decontaminated before they are admitted
into a clean MTF. The admission of one contaminated casualty into an MTF will
contaminate the facility; thereby, reducing treatment capabilities in the facility.
(1) Mass Casualty. As with other CBRN weapons, a mass casualty situation may
result when CW agents are employed. Additional HSS personnel and equipment must be
provided quickly if the level of care is to be maintained. Treatment at far forward MTFs is
limited to life- or limb-saving care. Casualties that can survive evacuation to the next role of
care are not treated at the forward facility. This provides time for treating those casualties
that cannot survive the evacuation. Refer to Appendix A for CBRN casualty estimation.
(2) Decontamination. Decontamination of chemically contaminated casualties
requires the removal of their contaminated clothing and the use of a variety of
decontamination kits and solutions. See Chapter V for details on patient decontamination.
(3) Treatment. Field Manual
4-02.285
(FM 8-285)/MCRP
4-11.1A/NTRP
4-
02.22/AFTTP (I) 3-2.69 provides additional information on treatment procedures for CW
agent casualties.
c. Biological Warfare Agent. The impact of BW on HSS may be as simple as a few
casualties with diarrhea or as complex as a mass casualty situation. Biological warfare
agents are most likely to be delivered covertly and by aerosol. Most BW agents have a long
incubation period from onset to clinical symptoms compared with CW agents. For these
reasons, the first indication of a BW attack will most likely be casualties arriving at an MTF
with an illness. The primary route of entry for BW agents is by inhalation. However, other
routes include ingestion and percutaneous inoculation.
(1) Aerosol.
(a) Inhalation. Inhalation of agent aerosols, with resultant deposition of
infectious or toxic particles within alveoli, provides a direct pathway to the systemic
circulation. The process of breathing causes a continuing flux of BW agent to exposed
individuals. The major risk is pulmonary retention of inhaled particles. Droplets as large as
20 microns can infect the upper respiratory tract; however, natural anatomic and
physiological processes generally filter these relatively large particles and only much
smaller particles (ranging from 0.5 to 5 microns) reach the alveoli efficiently.
(b) Ingestion. Food and water supplies may be contaminated during an
aerosol BW attack. Unwary consumption of such contaminated materials could result
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in disease. Inhaled aerosols also lead to agent being ingested as particles trapped in the
respiratory tract and will eventually be swallowed.
(c) Percutaneous. Intact skin provides an excellent barrier for most, but not
all, BW agents. However, mucous membranes and damaged skin constitute breaches in
this normal barrier through which BW agents may readily pass.
(2) Contamination of food and water. Direct contamination of food and water could
be used as a means to disseminate infectious agents or toxins. This method of attack is
most suitable for sabotage activities and might be used against limited targets such as
water supplies or food supplies of a specific unit or base.
(3) Other considerations.
(a) Arthropodborne. The spread of diseases may be accomplished by
releasing infected arthropods such as mosquitoes, ticks, or fleas. These live vectors can be
produced in large numbers and infected by allowing them to feed on infected animals,
infected blood reservoirs, or artificially produced sources of a BW agent.
(b) Long-term survival of infectious agents. Preservation of toxins for
extended periods and the protective influence of dust particles onto which microorganisms
adsorb when spread by aerosols have been documented. Therefore, the potential exists for
the delayed generation of secondary aerosols from contaminated surfaces. To a lesser
extent, particles may adhere to an individual or to clothing, creating additional exposure
hazards.
(c) Person-to-person contact. The spread of potential BW agents by person-
to-person contact has been documented. Man, as an unaware and highly effective carrier
of a communicable agent, could readily become a source of dissemination (for example,
plague or smallpox).
d. Management of Biological Warfare Casualties. Biologically contaminated casualties
require decontamination before admission into an MTF. Casualties suspected of suffering
from exposure to BW agents may require isolation or quarantine to reduce the possibility of
spreading the disease to health care providers and other casualties. Specimens must be
collected and submitted to the designated supporting laboratory for identification to
determine if infectious disease isolation precautions are necessary.
(1) Mass casualty. A BW agent attack can produce a mass casualty situation at all
roles of care. Therefore, HSS planners must ensure that mass casualty situations are
included in HSS plans.
(2) Decontamination. Majority of casualties presenting to the MTF with symptoms
or disease due to BW agent exposure will not require decontamination; during the delay
between BW agent exposure and onset of symptoms external contamination would likely
have dissipated to a large degree. Contamination can be removed by use of soap and
water, which is the most preferred method. See Chapter V for details on patient
decontamination.
(3) Treatment. Treatment is dependent upon the BW agent used. Casualties are
treated as described in FM 8-284/NTRP 4-02.23 (Navy Medical [NAVMED] P-5042)/Air
Force Manual (Interservice) (AFMAN [I]) 44-156/MCRP 4-11.1C.
e. Radiologically Contaminated Casualties. Casualties from fallout areas may have
contamination on their skin and clothing. Removal of the contamination should be
accomplished as soon as possible, but definitely before admission into a clean treatment
area. The distinction must be made between radiation-injured casualties and those that are
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radiologically contaminated. Although casualties may have received substantial radiation
exposure, this exposure alone does not result in the individual being contaminated.
Normally, contaminated casualties do not pose a short-term hazard to the medical staff;
rather the contamination is a hazard to the casualty’s health. However, without casualty
decontamination, medical personnel may receive sufficient exposure to create beta burns,
especially with extended exposure. Certain isotopes emit gamma radiation which
penetrates any protective garment causing continued radiation exposure to the victim and
health care workers. This contamination also must be removed.
(1) Management. Radiologically contaminated casualties must be decontaminated
before admission to an MTF. Monitoring is conducted when potentially contaminated
casualties arrive at the MTF. This monitoring is conducted at the MTF’s receiving
point/entry control point
(ECP) before admitting the casualty. To properly handle
radiologically contaminated casualties, medical personnel must first detect the
contamination. Detectors that may be used to monitor casualties for contamination are the
AN/PDR 77, AN/VDR 2, and ADM 300. Generally, a reading on the meter twice the current
background reading indicates that the casualty is contaminated.
(2) Decontamination. Radioactive decontamination is simple; removing all outer
clothing and a brief washing or brushing of exposed skin will reduce
99 percent of
contamination; vigorous bathing or showering is unnecessary. Do not let radiological
contamination interfere with immediate lifesaving treatment or the best possible medical
care. See Chapter V for details on casualty decontamination.
(3) Treatment. Treatment procedures for radiation injuries are described in the
Emergency War Surgery handbook, Medical Management of Radiological Casualties
Handbook, and FM 4-02.283/NTRP 4-02.21/AFMAN 44-161(I)/MCRP 4-11.1B.
f.
Management of Casualties Injured by Nuclear Weapons. Management of casualties
injured by the immediate effects of nuclear weapons (flash, blast, and thermal) is the same
as for conventional battlefield injuries, although the injury severity may be increased. First
aid (self-aid, buddy aid, and combat lifesaver [CLS]) for lacerations, broken bones, and
burns are performed. Combat lifesavers in the US Army are Soldiers that have been trained
to conduct enhanced first aid. The following are types of injuries associated with nuclear
warfare:
• Flash injury. The intense light of a nuclear fireball can cause flash blindness. The
duration of blindness depends upon the length of exposure and the light
conditions. However, even at night it is unlikely that flash blindness will last more
than a few minutes. Most individuals can continue their mission after a short
recovery period. Severe cases may have retinal and optic nerve injuries that lead
to permanent blindness; these cases will require evacuation to an MTF.
• Blast injuries have three types of effects—
• Primary injuries are due to overpressure that is, eardrum rupture, lung injury,
and so forth.
• Secondary blast injury is due to flying debris that is, penetrating injury due to
shrapnel.
• Tertiary blast injury is due to translational injury that is, the victim is blown into
the air and suffers blunt trauma by deceleration.
• Thermal injury. Thermal injuries are generated by—
• Direct thermal radiation (flash burns and eye injuries).
• Indirect (flame) effects.
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• Radiation injury. Casualties produced by ionizing radiation alone or with other
injuries will be common. Due to the limitations inherent in field medical treatment
and mass casualty care, it will not be possible to determine the total radiation
exposure of most victims. Additionally, total exposure may not be received at one
time, but as the result of several incidents in contaminated regions.
g. Handling and Management of Toxic Industrial Materials Casualties. Although the
hazards of weaponized chemicals have long been recognized, the hazards of industrial
materials have only recently become more widely understood. Deliberate terrorist release
or inadvertent release of TIM significantly increases hazards to the indigenous population
and deployed US forces. While CW agents are highly toxic and lethal in small amounts, the
countries producing them are generally known and are few in number when compared with
the quantities and universal nature of TIM.
(1) Toxic industrial materials include chemicals manufactured for use in industrial,
commercial, or medical processes. Toxic industrial chemicals/TIMs can be in gas, liquid, or
solid form (include particles), though those of particular concern tend to be gases because
gas spreads easily. Some common TICs include: ammonia, chlorine, and hydrogen
cyanide.
(2) Exposures to TIMs can result from accidental releases, collateral damage from
explosions/attacks near stored chemicals, or intentional dispersion with explosives such as
improvised explosive devices (IEDs). Insurgents in Iraq have used chlorine gas tanks
packaged with IEDs. Toxic industrial materials of concern can be found almost anywhere,
but primarily in: chemical plants, industrial manufacturing facilities, wastewater treatment
plants, chemical/waste storage facilities/landfills, laboratory settings, large fuel storage
areas, and at major transportation centers including the vehicles (for example, trains,
barges).
(3) Health effects can vary and depend on the type of chemical/material, how it
enters the body, the amount, and how long personnel were exposed. Some bodies may
have unique reactions to certain TIMs and some may have no reaction at all. Potential
symptoms of exposure include immediate or short-term (acute) health effects: coughing,
difficulty breathing, and/or irritation of the nose, mouth, throat, eyes, or skin. Acute
exposure to certain TIMs at high dosage(s) can cause death. For more information on
diagnosis and treatment information refer to USACHPPM Technical Guide (TG) 273.
(4) While the acute toxicity and associated immediate severe health effects of TIMs
are often the primary concern, exposures to certain TIMs can potentially cause long-term or
permanent health effects. Industrial chemicals are often corrosive and can damage
equipment to include electronic equipment. Many TIMs are flammable, explosive, or react
violently with air or water and therefore present physical hazards which can be greater than
the immediate toxic effects from an industrial chemical release.
(5) Operational Planning for Toxic Industrial Material Hazards:
(a) Crisis Action Planning. In concurrence with deliberate and crisis action
planning, CCDRs, command surgeons, HSS planners, preventive medicine (PVNTMED)
personnel, bioenvironmental engineers, and public health personnel should develop an
understanding of the potential hazard from TIM in the AO. Information required to support
vulnerability analysis and assessment during the planning process include some of the
following key factors—
• Identifying all possible industrial plants, storage sites, and shipping
depots.
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Identifying TIM routinely produced, used, or processed in the area.
Knowledge of the manufacturing processes used at an industrial plant
is especially important as TIMs are often used as intermediates in the
production of plastics, pesticides, and herbicides or other products and
materials.
Assessing the effects of the release of TIM either as a result of
collateral damage or an accident.
Assessing whether the deliberate release of a TIM is realistic in a
particular situation.
Factors that should be considered in this
assessment are—
• Terrain and meteorological conditions.
• Political environment (serves as a bargaining chip).
• Military advantage or benefit to be gained.
• Psychological impact.
• Assessing the need for special detectors and/or modifications to
detectors.
• Assessing potential information items for the commander. These
items include—
- How does one determine if there is a potential threat?
- Is there a special way one needs to react to these chemicals
that is different from the way he has been trained?
- Where is it safe to be?
- How much exposure is safe?
- What decontamination equipment can be used or is needed?
- What are the short-term and long-term health effects?
- What are the effects on noncombatants?
- What are the effects on military equipment including individual
protective equipment (IPE)?
(b)
Hazard Level Zones Determination. Plans supporting determination of
hazards levels (hot, warm, and cold zones) for each hazard site and immediate evacuation
from the hazard’s path are the best defense against the TIM hazard. Commanders should
consult with the engineer officer, CBRN defense officer, legal officer, command surgeon,
intelligence officer, PVNTMED staff, meteorologists, fire and security personnel, emergency
response hazardous materials (HAZMATs) incidents team, civil military operations officer
and public affairs officer (PAO) when identifying hazard levels (zones). These staff officers
can provide guidance for hazard isolation, site entry control, decontamination, on-scene
medical treatment, evacuation, civilian populace, and in-place protection.
(c) When evacuating the hazard area, individuals should wear clothing that
prevents deposit of liquids and minimizes injury to exposed skin. Evacuees should not be
permitted to congregate except at established safe distances. Evacuation to established
safe distance does not guarantee complete safety for evacuated personnel. Evacuated
personnel should be moved to a designated location by a specific route and to a distance
where additional movement is not required following a radical wind shift. Refer to the
Department of Transportation
(DOT) Emergency Response Guidebook for hazardous
materials incidents and information on hazard level zones. This guidebook can be obtained
at http://hazmat.dot.gov/pubs/erg/gydebook.htm.
(6) Vulnerability Mitigation to Toxic Industrial Material Hazards.
(a) Each TIM incident has multiple considerations. When planning, ensure to
obtain key information regarding effects, toxicity, production, storage facilities, and
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transportation of TIM. This information can be acquired through companies that produce the
TIMs, experts (for example, scientific or civilian industrial personnel, CW treaty experts),
material safety data sheets, and local civilian authorities that have emergency response
procedures and resources.
(b) Refer to the National Center for Medical Intelligence (NCMI), Air Force
Institute
for
Operational
Health,
airforceinstituteforoperationalhealth/index.asp
and
USACHPPM,
www.apgea.army.mil/ for additional information.
Reachback information can be found in
Appendix D.
Note: Military CBRN protection, detection, and decontamination equipment were not
designed for handling TIM.
(c) In conducting detection procedures, some plants, facilities, storage
containers, or transport containers may be identified by markers. These could take the form
of international hazardous chemicals
(HAZCHEMs) markers that are diamond-shaped
(United Nations markers) and contain information that can be used to identify the exact
industrial chemical. When encountering a suspect industrial chemical, attempt to identify
the exact TIM and all possible information on the material. For proper handling, protection,
and hazard-management information, responders seek guidance from their command and
control (C2) element. Other sources for assistance include the Chemical Transportation
Emergency Center hot line, for emergency assistance within the US/Canada: 1-800-424-
9300 or outside the continental United States
(OCONUS): 1-202-483-7617 (toll free).
Commanders also identify the local civilian authorities that may have additional emergency
response procedures and resources.
(d) Mission-oriented protective posture (MOPP) ensemble, CBRN detection
equipment, and CBRN decontamination procedures are specifically designed for use and
tested against CW agents. Toxic industrial materials present hazards that may render
CBRN equipment and procedures ineffective. Each TIM should be evaluated individually to
establish protection and response procedures and to select associated equipment
requirements. The military protective mask may be used under emergency conditions to
protect against the immediate toxic effects of some TIMs and while evacuating from the
immediate hazard zone. However, the protective mask may or may not be effective in
protecting against high concentrations of TIMs over an extended period of time.
Commanders should consider the use of appropriate protective equipment such as self-
contained breathing apparatus
(SCBA), substance-specific cartridges or canisters, and
change-out requirements tailored to the TIM threat at each location.
(7) Precautions and Decontamination in Toxic Industrial Material Environment.
(a) Personnel or equipment that may have been contaminated with TIM can
usually be decontaminated by washing with large amounts of soapy water. Contaminated
clothing should be immediately removed and disposed of in a safe manner; however, when
no release has occurred, establish a minimum hazard level zone based on mission
requirements, surveys, and assessments of the TIM facility.
(b) If a TIM release occurs, evacuate beyond the established hazard level
zone. Reduce safety exclusion areas only after a detailed survey and assessment of the
extent of the probable hazard area. When friendly units are required to operate in an area
where a potential TIM facility exists, planners should—
• Coordinate with civilian or host nation emergency response teams.
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Identify the probable TIM, extent of possible contamination, minimum
protective equipment, and personnel safety considerations.
Coordinate with higher headquarters and the host nation to identify
support availability.
Develop an incident response plan. For detailed information and
procedures for response plans, refer to Service-specific publications
that provide templates for plan development
(for example, FM
3-
11.21/MCRP 3-37.2C/NTTP 3-11.24/AFTTP [I] 3-2.37; AFMAN 32-
4004; and AFMAN 32-4013).
Implement the TIM reconnaissance plan and assign units to prepare
and execute the reconnaissance missions.
Use commercial detectors which can provide confirmation of individual
TIM, if available.
Coordinate with decontamination elements for decontamination of
personnel and equipment.
Coordinate for transport and delivery of collected samples to the
supporting laboratory.
Avoid hazard areas as long as possible.
When conducting
reconnaissance or rescue operations near or within the hazard area,
equip ground survey teams with respiratory protection (for example,
SCBA) and skin protection certified for the TIM. Use aerial or visual
reconnaissance to help collect information to support C2 operations.
Coordinate with theater medical elements (for example, PVNTMED
teams) for follow-on industrial hygiene assessments, as dictated by
mission requirements.
(8)
Toxic Industrial Material Information Management Resources.
(a) The DOT Emergency Response Guidebook lists HAZMATs commonly
shipped in the US. This publication is primarily a guide to aid first responders in quickly
identifying the specific or generic hazards of the materials involved in the incident and
protecting themselves and the general public during the initial response phase of the
incident.
(b) The National Institute for Occupational Safety and Health (NIOSH) Pocket
Guide to Chemical Hazards (NPG) provides reference information in a table format, which
can be used for hazard assessment and management. The information includes chemical
names, synonyms, trade names, exposure limits, physical and chemical properties,
chemical incompatibilities and reactivities, personal protection measures, and health
hazards. The NPG can be obtained at http://www.cdc.gov/niosh/npg/npg.html.
(c) Field Manual 8-500 provides guidance on TIM hazards for first responders.
This manual details basic procedures to be accomplished with existing medical protocols.
(d) The USACHPPM Deployment Health Guide: Toxic Industrial Chemicals
(TIC)
Release Response
TICResponse2.pdf) identifies and defines TIC hazard categories and specific TICs of
concern and provides information that can help reduce risk of injury or disease during
continental United States (CONUS)/OCONUS military missions involving a hazardous or
TIC release. This guide addresses a variety of audiences but is primarily aimed at
PVNTMED assets who have key responsibilities to help ensure the health and safety of a
unit.
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(e) The USACHPPM Hazardous and Toxic Industrial Chemicals Tables;
vide chemical, physical, and health effect information for key TICs of military concern
(includes acutely toxic airborne hazards, example chemicals that are physical hazards, and
example chemicals that are acute ingestion hazards).
(f)
The USACHPPM TG 273 provides some basic principals regarding TICs,
toxidrome, health effect and treatment information for irritant gases, corrosives, organics,
asphyxiants, and cholinergics.
(g) The USACHPPM TG
230 provides military exposure guidelines for
chemicals in air, water, and soil for use during deployments. Specific information is
provided regarding the type and severity of health effects resulting from exposures to
varying chemical concentrations, the primary organs/systems affected, odor/taste threshold
information, and additional notes when available. This TG provides application guidance
describing how the military exposure guidelines can be used to characterize the level of
health and mission risks associated with identified or anticipated exposures to chemicals in
the deployment environment in a manner consistent with the existing military operational
risk management paradigm.
(h) The USACHPPM Chlorine and Improvised Explosive Devices factsheet
PVNTMED reference tool and checklist for predeployment and response actions. The IED
factsheet includes predeployment planning actions, chlorine physical and chemical
characteristics, exposure signs and symptoms, protection against exposures,
decontamination and treatment, response actions and considerations, and documentation
requirements.
(i)
The USACHPPM TG 244 addresses operational health concerns in
environments where CBRN threats exist. Potential CBRN threats range from weapons of
mass destruction (WMD) to contamination of the battlefield by hazardous material. Medical
personnel, in conjunction with chemical personnel, must be able to advise commanders on
a wide range of issues including the health effects of NBC threats, protective clothing and
measures, and management of NBC casualties. This manual is not an emergency
response book or treatment guide. It is intended to provide a quick reference for
decisionmaking as to whether to request expert consultation in a given area.
4. Military Operations in a Chemical, Biological, Radiological, and Nuclear
Environment
a. A number of potential adversaries have or are in the process of developing WMD.
Some terrorist groups and several countries designated as State Sponsors of Terrorism
have also shown an interest in pursuing a CBRN capability. Others are strongly engaged in
the sale or transfer of associated CBRN technology. Chemical, biological, radiological, and
nuclear weapons are considered asymmetric threats, since adversaries will seek an
advantage over the US by using unconventional approaches to circumvent or undermine our
strengths while exploiting our vulnerabilities. The potential for catastrophic use of WMD is
greater than it has been in many decades. Aimed at responding to the overwhelming power
and superiority of the military infrastructure of the US, either domestically or abroad, WMD
could seriously disrupt the execution and tempo of military operations. It is imperative that
FHP and HSS plans are prepared to reduce the effects that WMD has on the execution and
tempo of military operations.
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b. The medical commander must consider the nature of the environment. If the
immediate environment is vulnerable to CBRN attack, the commander should determine the
level of protection that would be needed, during, and after the attack. The mission of
medical units in a CBRN environment is to survive the attack and sustain the supported
force. In addition to providing medical care after the attack, the commander needs to know
whether to expect residual contamination to remain and how long it is likely to persist. The
commander needs to determine—
(1) Level of protection required. Is eye-respiratory protection sufficient or is full
body coverage required?
(2) When to increase the protective posture. Donning protective clothing too soon
can have an unwarranted negative impact on the Service member’s ability to perform
mission-related tasks. Donning it too late can result in casualties.
(3) Medical facility decontamination. Is facility decontamination required and, if so,
which option is best?
(4) When to relax the protective posture. When is it safe to remove protective
clothing to reduce heat stress and other restrictions on job performance? Is Split MOPP
operation applicable to the situation?
(5) In addition to these considerations, the commander must consider other
vulnerability reduction measures and be prepared to provide support to branches and
sequels of the supported commander’s operation. Refer to FM
3-11.14/MCRP
3-
37.1A/NTTP 3-11.28/AFTTP (I) 3-2.54 for more information.
c. Stability Operations.
(1) The US Armed Forces participate in full spectrum operations in an effort to deter
war, resolve conflict, promote peace, and support civil authorities in domestic and foreign
emergencies as permitted by law. Stability operations may be conducted as a precursor to
combat operations, in parallel with ongoing combat operations, or following the cessation of
combat activity.
(2) State-supported and nonstate terrorist groups may employ CBRN weapons, or
natural and man-made disasters may contaminate areas with toxic materials whose
mitigation will require the efforts of specialized military forces. The conduct of stability and
reconstruction operations in a CBRN environment may require coordination and cooperation
with agencies, organizations, and individuals, outside the military chain of command or
direct control. In many stability and reconstruction operations situations, the JFC may be in
a supporting role to civil authorities or to host nation authorities. Regardless of the role, the
JFC and joint force elements must be prepared for CBRN use and contamination with toxic
materials at any point, including the transition from noncombat to combat environments.
Additionally, Chairman of the Joint Chiefs of Staff Instruction (CJCSI) 3214.01 defines
responsibilities for planning and conducting military consequence management
(CM)
operations in response to incidents on foreign soil involving WMD (FM 3-11.21/MCRP 3-
37.2C/NTTP 3-11.24/AFTTP [I] 3-2.37).
(3) The HSS planning activities generally include hospitalization, PVNTMED,
veterinary services, HSL, and medical regulating and patient movement. Plans for
OCONUS and CONUS operations should include provision for surge medical requirements
using on-hand and rapidly deployable capabilities. Special consideration is required for
HSS to noncombatant evacuation operation evacuees who may have been exposed to
CBRN or other toxic agents. In the US, there may be a requirement to augment civilian
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medical capabilities in the handling of casualties resulting from CBRN attacks or other toxic
material contamination. The ability of domestic and host nation medical facilities to handle
mass casualties from CBRN effects should be assessed and factored into joint and
multinational HSS planning.
(4) Close coordination with HSS personnel and other public health providers in the
theater is a vital means of detecting BW and CW attacks, since casualties from such an
attack may appear initially in the civilian medical system.
d. Health Service Support in Multinational Operations.
(1) Language, values, religious systems, economics, and social outlooks can have
great impact on the delivery of FHP and HSS. Forces of member nations must be
supported either by national assets or through the alliance/coalition assets. Because
resource contributions will vary between nations, some may contribute logistically, while
others contribute military forces. Commanders of multinational forces should seek to ensure
that member forces are appropriately supplied consistent with their nation capabilities and
the terms established at the formation of the alliance and/or coalition.
(2) Plans in multinational operations should be coordinated with member forces.
(3) Health service logistics is a major challenge for multinational operations.
Planning issues to consider are—
(a) Health service logistics doctrine (JP 4-08).
(b) Stockage levels, logistics mobility, interoperability, infrastructure, national
resource limitation, and host nation and alliance/coalition support limitations/agreements.
Joint force commanders typically form multinational logistics staff sections early to facilitate
coordination and support of operations.
(c) Operations abroad may involve military support to other countries’ civil
authorities. This support is controlled by the US ambassador/country team or provided
directly by the JFC according to bilateral or multinational arrangements.
In all
circumstances, commanders must reduce the vulnerability to a CBRN attack and be
prepared to mitigate and recover from the consequences of a CBRN attack. Joint force
commanders and joint/multinational elements must be prepared for CBRN use and
contamination with TIMs at any point. For further guidance regarding stability operations,
refer to Department of Defense Directive (DODD) 3000.05.
e. Operations in Extreme Environments.
(1) Enemy employment of CBRN weapons or TIMs in the extremes of climate or
terrain warrants additional consideration. These considerations include the peculiarities of
urban terrain, mountains, snow and extreme cold, jungle, and desert operations in a CBRN
environment with the resultant CBRN-related effects upon medical treatment and medical
evacuation. For a more detailed discussion on CBRN aspects of urban terrain, mountain,
snow and extreme cold, jungle, and desert operations, see FMs 3-06; 3-06.11; 90-3/Fleet
Marine Force Manual (FMFM) 7-27; and 90-5.
(2) In mountain operations, passes and gorges may tend to channel the nuclear
blast and the movement of BW and CW agents. Ridges and steep slopes may offer some
shielding from thermal radiation effects. Close terrain may limit concentrations of troops
and fewer targets may exist; therefore, a lower patient workload may be anticipated.
However, the terrain will complicate medical evacuation operations and may require
patients to be decontaminated, treated, and held for longer periods than would be required
for other operational areas.
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(3) The effects of extreme cold weather combined with CBRN-produced injuries
have not been extensively studied. However, with traumatic injuries, cold hastens the
progress of shock, providing a less favorable prognosis. Thermal effects will tend to be
reinforced by reflection of thermal radiation from snow- and ice-covered areas. Care must
be exercised when moving chemically contaminated patients into a warm shelter. A CW
agent on the patient’s clothing may not be apparent. As the clothing warms to room
temperature, the CW agent will vaporize (off-gas), contaminating the shelter and exposing
the occupants to potentially hazardous levels of the agent. A three-tent system is
suggested for processing patients in extreme cold operations. The first tent (unheated) is
used to strip off potentially contaminated clothing. The second tent (heated) is used to
perform decontamination, perform emergency medical treatment (EMT), and detect off-
gassing. The third tent (heated) is used to provide the follow-on care and patient holding.
(4) In rain forests and other jungle environments, the overhead canopy will, to some
extent, shield personnel from thermal radiation. However, the canopy may ignite and create
forest fires and result in burn injuries. By reducing sunlight, the canopy may increase the
persistency effect of CW agents near ground level. The canopy also provides a favorable
environment for BW agent dispersion and survival.
(5) In desert operations, troops may be widely dispersed, presenting less profitable
targets. However, the lack of cover and concealment exposes troops to increased hazards.
Smooth sand is a good reflector of nuclear thermal and blast effects; generating an increase
in the number of injuries. High temperatures will increase the discomfort and debilitating
effects on personnel wearing MOPP, especially heat injuries.
5. Health Service Support Planning Considerations
a. Health service support is integral to theater strategic, deliberate, and crisis planning
and execution. To provide adequate FHP and HSS, definitive planning and coordination
with component/joint planning and intelligence staffs are required. The FHP and HSS
activities must ensure adequate preparations before and during the transition to these
operations in a joint environment. Additional guidance is provided in JP 3-0 and JP 4-02.
b. The CCDR establishes the command’s FHP and HSS requirements and uses
directive authority to ensure the proper coordination of all FHP and HSS capabilities in the
force. Planning for HSS must include all aspects of HSS requirements especially the unique
characteristics and effects of CBRN weapons and TIMs. Health service support planning
must begin simultaneously with the operational planning process to ensure its
synchronization with the campaign plan or operation plan (OPLAN). Timely, effective
planning and coordination are essential for ensuring HSS mission success. The health
threat, occupational and environmental health (OEH) threats, medical intelligence, patient
estimates, theater evacuation policy, hospitalization, patient movement, and available lift, all
play a significant part in supporting the theater mission. The medical planners must
consider the above listed factors in planning FHP and HSS in support of the CCDR. Joint
Publication
4-02 reflects more detail on FHP and HSS planning. Plans must include
PVNTMED, bioenvironmental engineering/public health, and veterinary support as part of
the early entry force to ensure DNBI prevention and food safety considerations begin as the
force enters the theater of operations (TO). Refer to JP 5-0 for additional information on
contingency and crisis action planning.
c. It is imperative that medical CBRN defense be fully integrated into the deliberate
planning process to maximize readiness. Key elements include patient estimates, medical
surveillance, OEH surveillance, prophylaxis (including immunizations), diagnostics, mass
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casualty management, evacuation, and casualty decontamination requirements. The
potential for high host nation casualties may make host nation medical facilities unavailable
to the joint force. Gaps in the medical CBRN defense capabilities of multinational forces
must be addressed in order to ensure multinational cohesion and effectiveness in both
planning and operations. Joint and multinational exercises must include realistic standards
for conducting HSS operations in a CBRN environment.
d. In addition, key staff elements must be closely coordinated with during the planning
process. The CBRN staff will have conducted the CBRN intelligence preparation of the
operational environment and development of CBRN aspects of courses of action (COAs). In
addition CBRN, operations, and intelligence staffs will require input during the planning
process in selection of decision points and trigger levels following biological attacks.
Medical input is key in developing biological surveillance plans which aid in the rapid
decisionmaking necessary to reduce the risk to the force. Additional information can be
found in FM 3-11.86/MCWP 3.37.1C/NTTP 3-11.31/AFTTP (I) 3-2.52. Planning must also
consider the use of all health service support capabilities to prevent, detect, respond, and
recover from CBRN attack. Each capability has a role to play to mitigate the effects of an
attack and each must be synchronized with both the medical and nonmedical capabilities.
e. The USAF theater medical system operates within the air and space expeditionary
task force (ASETF) and joint task force (JTF) structures to support CCDR’s objectives.
When the threat of CBRN use is high, a robust expeditionary CBRN structure is required to
support the mission. To assist operational planners and the Air Force forces (AFFOR) as
they develop concept of operations (CONOPS) in support of JFC deliberate and crisis action
plans, this section offers the following planning guidance for employment of Air Force
Medical Service
(AFMS) assets in CBRN environments. Planners must review and
understand the mission capability statements and CONOPS of the various AFMSs unit type
codes (UTCs) to fully understand how best to employ them.
f.
Planning the flow of resources into the theater and the continued sustainment of
those resources should involve input from the commander and his planning, operations, and
logistics staffs to ensure campaign objectives are met with minimal overall operational risk.
This must be considered during all phases of campaign planning and execution. Health
service support planners should provide the commander a risk analysis and
recommendations on COAs to support CBRN-related operations.
6. Command, Control, Communications, Computers, and Intelligence
Systems in a Chemical, Biological, Radiological, and Nuclear Environment
a. The JFC controls the C2 system to ensure that data and information get to the right
place on time and in a form that is quickly usable by its intended recipients. In this regard,
command, control, communications, computers, and intelligence
(C4I) systems play a
critical role in delivering this data throughout the joint force. These communications systems
permit the JFC to pass critical information at decisive times, to exploit tactical success, and
to facilitate future operations. Logistics, operations, and intelligence functions all depend on
responsive C4I systems. The C4I systems are the central system tying together all aspects
of joint operations and allowing commanders and their staffs to initiate, direct, monitor,
question, and react.
b. In a CBRN environment an unbroken chain of communications must extend from the
CCDRs, commanders of Service components, and all subordinate commanders. The C4I
systems must provide this chain of rapid, reliable, and secure flow and processing of data to
ensure continuous information exchange throughout the force. To ensure the continuous
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and uninterrupted flow and processing of information, joint warfighters must have C4I
systems that are interoperable, flexible, responsive, mobile, disciplined, survivable, and
sustainable.
c. In a high threat CBRN environment, it is imperative that the communications
architecture includes lines of communication among deployed combat units, medical units
tasked with providing medical care, and specialized units providing CBRN detection,
warning, and decontamination functions. To provide adequate defense, the Marine air-
ground task force commander organizes CBRN defense assets. Units at all levels must be
capable of detecting and identifying CBRN agents, warning of and reporting CBRN attacks,
performing individual and collective protection measures, decontaminating personnel,
equipment, and terrain, and administering first aid according to unit medical operations and
exposure guidance. For more information on HSS C2 see FM 4-02 (Army), Air Force
Doctrine Document (AFDD) 2 (USAF), MCWP 3-37.1 (USMC).
d. Operational Communications.
(1) The Annex K of the OPLAN details the communications architecture between
echelons of command and between supported and supporting units and provides security
procedures and frequencies. Refer to Appendix B for more information and sample of a
medical annex. In cases where no OPLAN is published, the tasking order should provide
communications details or is determined in predeployment planning between the medical
commander and the supported command surgeon for medical communications and within
the deploying medical forces for internal communications. It is critical to ensure that
communications assets and systems are compatible with systems used in the TO.
(2) National policy dictates the survivability of C4I systems through which decisions
are transmitted to the command forces. It is not practical or economically feasible to make
all C4I systems or elements of a system equally survivable. The degree of survivability for
C4I systems supporting the function of C2 should be commensurate with the survival
potential of the associated command centers. (Refer to JP 6-0.)
7. Obtaining Medical Intelligence Information on Chemical, Biological,
Radiological, and Nuclear Threats
a. Operations in a CBRN environment place a great need for HSS demands on the
intelligence system. A clear and commonly shared assessment of adversary CBRN
capabilities and US, multinational, and host nations HSS capabilities and limitations in
countering adversary CBRN use are of great importance. The CBRN threat information
gathered by the component/joint intelligence staff is used by the deployed HSS staff for
planning and the employment of HSS assets. Threat assessments should include the
identification of industrial sites in the theater that use, produce or store large quantities of
TICs. Toxic industrial materials could become a health hazard to deployed forces if these
sites are accidentally or intentionally destroyed or left in normal operation. Threat
information is also used to prepare the health threat and update environmental health and
industrial facility databases.
The NCMI produces all-source medical intelligence
assessments for HSS functions.
b. The NCMI responds to requests from the Armed Forces for emergency, up-to-date
medical intelligence assessments. The NCMI is the nation’s premier producer and
coordinator of all-source medical intelligence. The NCMI produces intelligence for global
force protection and homeland health protection to safeguard US interests worldwide. The
NCMI remains an integral part of the Defense Intelligence Agency (DIA).
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c. The NCMI predecessor, the Armed Forces Medical Intelligence Center, focused on
force protection for deploying DOD military personnel. The NCMI is integrating foreign
intelligence and partnering with domestic agencies to share health information to protect the
health and welfare of US military forces and citizens, at home and abroad. The NCMI’s
growing partnerships include the Department of Homeland Security and other domestic
agencies, and coalition and foreign partners. The NCMI partners with other intelligence
agencies to provide critical information on countries that do not report openly share health
information with international health agencies such as the World Health Organization
(WHO). For these countries, medical intelligence may be the only source of information on
health threats.
d. Some of the functions of NCMI are to—
• Assess potential health threats to foreign populations and medical capabilities to
respond to these threats in support of US health diplomacy missions in
developing countries.
• Assess foreign intelligence on veterinary disease threats and capabilities to
assist in decisions on preventing and controlling these diseases overseas before
they impact the homeland.
• Monitor the threat of global outbreaks of diseases such as anthrax and of terrorist
or criminal use of TICs.
e. The NCMI partners with other intelligence community and nonintelligence community
agencies within the federal government and with US allies to provide intelligence in three
critical ways—
(1) Provide earliest possible warning on foreign health threats to prevent serious
illness and/or mitigate potential impacts.
• Identify, assess, and prepare reports on naturally occurring outbreaks of
diseases such as an avian influenza, anthrax, plague, or West Nile virus.
• Evaluate a wide range of TICs to identify potential environmental hazards
and model health impacts.
• Assess health events such as disease outbreaks and chemical releases to
identify and warn on possible indicators of terrorism and/or intentional use
of biological or chemical agents.
(2) Develop and disseminate intelligence reports and forecasts on the following
health threats and issues:
• Foreign health systems’ capabilities to support and sustain forces in the
field, and medical response capabilities to naturally occurring bio-threats
and CBRN events.
• Foreign environmental health risks, including TICs.
• Foreign infectious disease threats, including baseline intelligence on the
natural distribution of known BW agents such as anthrax and plague.
• Foreign applications of biotechnology such as vaccines and therapeutics for
avian influenza and CBRN medical defense.
(3) The NCMI fosters information-sharing partnerships with academia, industry,
other federal agencies, and foreign nations.
• The NCMI leads intelligence community outreach efforts on health threats
and issues to collaborate and consult with academia and industry to
understand such diverse topics as newly emerging dangerous pathogens,
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modeling of the dispersion of chemical hazards, and trends in development
of future medical therapeutics and vaccines.
• The NCMI collaborates with federal agencies to share health information
and analytic methodologies to bolster the capabilities of the US government
to warn of foreign and domestic health threats and to model possible
intervention scenarios to assist decisions on countermeasures to prevent
serious illness and/or mitigate health impacts.
f.
Accurate and timely medical intelligence is a critical HSS tool for planning, executing,
and sustaining all military operations. A supporting intelligence element should exist at
some point in the medical unit’s chain of command. This element, whether military or
civilian, should be the primary source for the HSS planner to access the necessary
intelligence for the execution of HSS operations. The HSS personnel must develop a
feedback system with the supporting intelligence element to provide and receive intelligence
updates.
g. When obtaining intelligence to meet specific medical requirements, first determine if
local intelligence data or NCMI publications can satisfy requirements. If significant
requirements remain unanswered then submit a formal request for information through
intelligence channels. The request will be reviewed by the component/joint intelligence
officer, Joint Staff Operations Directorate (JSOD) (J-3), or up or down to the level where the
desired information is available. These requests could conceivably be passed up to the
primary source of the DOD strategic intelligence, the DIA. In this case, DIA may validate the
requirements and submit them to the NCMI for completion. The requirements become tasks
for NCMI to respond to the requester.
h. Accurate and timely medical intelligence is a critical HSS tool for planning, executing,
and sustaining all military operations. A supporting intelligence element should exist at
some point in the medical unit’s chain of command. This element, whether military or
civilian, should be the primary source for the HSS planner to access the necessary
intelligence for the execution of HSS operations. The HSS personnel must develop a
feedback system with the supporting intelligence element to provide and receive intelligence
updates.
i.
There are other specialized organizations that provide expert information resources
on medical aspects of CBRN threats, casualty prevention, CBRN agent sample and
specimen collection, and medical care and management of casualties. These include the
Defense Threat Reduction Agency (DTRA), the Armed Forces Radiobiology Research
Institute
(AFRRI), the Naval Medical Research Center (NMRC), the US Army Medical
Research Institute of Infectious Diseases (USAMRIID), the US Army Medical Research
Institute of Chemical Defense (USAMRICD), USACHPPM, and the US Army Nuclear and
Chemical Agency (USANCA). See Appendix D for more information on technical reachback
points of contact.
j.
United States Air Force HSS in a CBRN environment reflects the Air Force ground
support operational environment. Air bases are lucrative targets for attack. The USAF
deployed medical facilities may be located near active airfields that are likely targets for
military or terrorist CBRN attack. The AFMS assets support the passive defense component
of USAF operational counter CBRN doctrine (refer to AFDD 2-1.8), as well as the tactical
surveillance and identification components of the crosscutting element of command, control,
communications, computers, intelligence, surveillance, and reconnaissance (C4ISR).
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(1) Medical assets and information can save lives and maximize combat
effectiveness by providing critical components of the air base “passive defense,” conducting
tactical CBRN surveillance and identification missions, and by properly treating, stabilizing,
and processing CBRN casualties.
(2) The deployed medical commander (DMC) has a need-to-know and must be
cognizant of operational intelligence pertaining to the CBRN threat. The DMC and key staff
must have appropriate security clearances for access to this information. The DMC and his
key CBRN staff must be integrated into the ASETF battle staff and CBRN cell, as tactically
and situationally appropriate.
8. Joint Warning and Reporting Network
a. The Marine Corps is the lead Service for implementation of the Joint Warning and
Reporting Network (JWARN) program. The JWARN will provide joint forces with an
integrated comprehensive analysis and response capability to minimize the effects of hostile
CBRN attacks or accident/incidents, environmental hazards, or hazards from TIM. The
system will consist of hardware, software, and connectivity with command, control,
communications, computers, intelligence, and information
(C4I2) systems and remote
detectors/sensors. The JWARN will be compatible and integrated with Joint/Service C4I2
systems, the Defense Medical Surveillance System (DMSS), and networks/broadcasts.
b. The JWARN is an acquisition category (ACAT) III (Sentinel and Oversight Program)
information system that networks CBRN sensors, mission application software tools, and
C4ISR systems. The JWARN builds on Block I capabilities by fully integrating with common
operating environment-based and tactical C4ISR systems automatically generates alerts for
warning and dewarning affected forces automatically generates hazard area plots.
c. The JWARN provides the JFC with the capability to—
• Report CBRN and TIM hazard detection.
• Analyze the detections to enable identification of the hazard and the affected
locations and units.
• Disseminate warning information to affected units in near real time.
• Control and configure a local sensor network.
• Generate and display hazard areas Interconnected to weather and medical
databases.
• Retrieve and archive automatically event data to enable postoperations forensic
evaluation.
d. The JWARN Block 1 (JWARN 1E/Signal Fire) enables an immediate and integrated
response to threats of contamination through rapid warning and dissemination of CBRN
information—
• Collect and consolidate sensor information manually.
• Report CBRN and TIM hazard detection.
• Generate hazard area plot Allied Tactical Publication
(ATP)-45(C), hazard
prediction and assessment capability (HPAC), and joint effects model (JEM).
• Display hazard warning area on common operational picture (COP) networked to
C2 personal computer and Maneuver Control System.
• Generate warning and dewarning (CBRN) messages to affected forces.
e. The JWARN provides benefits to the warfighter—
• Automates the current largely manual, error-prone process.
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• Minimizes time from detection to warning (less than 2 minutes).
• Provides timely warning and dewarning of affected units to maximize combat
effectiveness.
• Automates recording and archiving of exposure data which will enable more
effective forensic analysis.
• Integrates with current and future C4I2 systems.
f.
The JWARN is designed to—
• Integrate and be compatible with Joint Service C4I2 systems located in C2
centers at the appropriate level, defined by Service specific annexes, and
employed by CBRN defense specialists and other designated personnel.
• Disseminate warnings and transfer data for decisions down to the lowest level on
the battlefield.
• Provide additional data processing, production of plans and reports, and access
to specific CBRN information to improve the efficiency of limited CBRN defense
personnel assets.
• Accelerate the warfighter’s response to an enemy CBRN attack.
g. Medical units and staffs must be integrated into the COP provided by JWARN. The
information contained in the system includes NBC-1 through 5 reports as well as NBC
situation reports (SITREPs). These reports quickly allow the medical staffs and units to gain
situational awareness to anticipate the locations, timing, and magnitude of required medical
asset support requirements. Additionally, NBC reports (NBC-4 or NBC SITREP) may be
submitted by medical units or staffs upon diagnosis of a disease or injury of interest such as
anthrax or chlorine exposure, both of which may occur clandestinely with the first indication
being presentation at an MTF.
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Chapter II
CASUALTY PREVENTION
1. General
a. Casualty prevention, a force multiplier, is essential throughout the health life cycle of
Service members. Before deployment, good health requires control of environmental (to
include disease and stress) and occupational threats to prevent casualties and to maintain a
healthy and fit force. During deployment, the enemy and the total environment present a
health threat to the forces. The enemy threat produces most combat-related casualties
commonly called battle injuries, while disease, environmental injuries (such as heat and
cold), and stress threats produce DNBI casualties. Implementation of casualty prevention
management limits casualties from environmental, occupational, operational, and CBRN
warfare threats.
b. Casualty prevention is a CBRN passive defense force multiplier focusing on threats
posed by enemy forces and complex endemic and environmental health threats. Failure to
counter these threats jeopardizes mission accomplishment.
Casualty prevention
concentrates on countering two types of threats: health threat and enemy threat. The health
threat is composed of a complex set of environmental and operational factors that combine
to produce DNBI which, historically, creates the largest number of military casualties. The
enemy threat usually produces smaller numbers of more seriously injured casualties. The
enemy threat depends on the enemy’s willingness and ability to use conventional and
nonconventional weapons systems, munitions, and CBRN agents. Failure to counter either
threat jeopardizes mission accomplishment and ultimately impacts achieving operational
objectives. Medical readiness provides the means to mitigate these threats. Information
provided by ongoing health surveillance and DNBI reporting is critical to counter CBRN
operations and are used as passive defenses and medical surveillance for casualty
prevention.
c. Passive defense protects personnel from the effects of a CBRN attack and improves
the capability of personnel to survive and sustain operations in a CBRN environment.
Passive defense includes FHP and HSS measures, a process that begins before
deployment, and encompasses the entire deployment scenario. The elements of passive
defense measures against a CBRN attack consist of: contamination avoidance, protection,
and contamination control. For more information on passive defense, see FM 3-11 (FM 3-
100)/MCWP 3-37.1/NWP 3-11/AFTTP (I) 3-2.42 and FM 3-11.34/MCWP 3-37.5/NTTP 3-
11.23/AFTTP(I) 3-2.33. Preparations for operations in potential CBRN environments begin
early in predeployment and include threat assessments, medical screening, preexposure
immunizations, pretreatments, prophylaxis, quantitative fit testing and risk-based training on
the ability to survive and operate (ATSO) in CBRN environments, training for HSS personnel
in the use of protective equipment, and training of medical personnel in the specifics of
CBRN casualty care.
d. Casualty prevention seeks to provide the line commander the best available health-
based risk assessment of the tactical situation improving his situational awareness and
enabling the warfighter to perform the mission. It becomes imperative that passive defenses
be aggressively pursued and institutionalized throughout the deployment process. By using
chemoprophylaxis early on, as indicated through health surveillance, we can secure and
sustain an effective force.
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e. Prevention of DNBI casualties requires the full commitment of individual Service
members and unit commanders. Health service support actions required to prevent and/or
mitigate DNBIs include—
• Implementing and refining medical and OEH surveillance activities.
• Collecting and analyzing specimens and samples.
• Developing objective exposure measurements to identify DNBI threats.
• Determining effective methods of assessment.
• Developing countermeasures to mitigate actual and potential health threats.
f.
Geographic dispersion of forces and improved personal protective systems will
reduce injuries.
g. Prevention of CBRN casualties requires full use of detection capabilities, timely
reporting, and use of protective measures.
2. Medical Surveillance and Occupational and Environmental Health
Surveillance Activities
a. Medical surveillance is the ongoing, systematic collection, analysis, and
interpretation of data derived from instances of medical care or medical evaluation, and the
reporting of population-based information for characterizing and countering threats to a
population’s health, well-being, and performance.
b. Occupational and environmental health surveillance is the regular or repeated
collection, analysis, archiving, interpretation, and dissemination of OEH-related data for
monitoring the health of, or potential health hazard impact on, a population and individual
personnel, and for intervening in a timely manner to prevent, treat, or control the occurrence
of disease or injury when determined necessary. For more information on medical
surveillance and OEH surveillance, see DODD
6490.02E, Department of Defense
Instruction (DODI) 6490.03, and Memorandum for the Chairman (MCM) -0028-07.
c. The determination of unit-specific rates of illness and injuries
(including related
CBRN/TIM casualties) of public health significance is the foundation of these programs.
Surveillance is closely integrated with the timely dissemination of data to those responsible
for the prevention and control of DNBI. Implementing guidance is found in DODI 6490.03.
The establishment of uniform and standardized health surveillance and readiness
procedures for all deployments is contained in DODD 6490.02E, and DODI 6055.1.
d. Surveillance forms a basis for medical resource allocation, refines knowledge of the
health threat, and permits continual assessment of the effectiveness of measures used to
prevent and control DNBI. The surveillance teams gather, analyze, and submit this
information to commanders, command surgeons, medical planners, and others that require
this information.
3. Medical Countermeasures for Chemical, Biological, Radiological, and
Nuclear Casualty Prevention
a. Combatant commanders must ensure PVNTMED supplies and equipment are
provided and maintained to support implementation of their prevention responsibilities.
Additionally, they should maximize the use of joint training to exploit existing Tri-Service
PVNTMED expertise. Preventive medicine training is essential for DNBI prevention and
should become an integral part of predeployment preparation.
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15 July 2009
b. The spectrum of FHP and HSS capabilities must include the ability to prevent and
mitigate the effects of CBRN casualties and conventional injuries. Health service support
includes a combination of preventive and curative measures that are effective in a CBRN
environment. Therefore, commanders must ensure that all personnel are in a constant state
of readiness to survive and accomplish their missions in CBRN environments. In addition to
ensuring that immunizations are kept current, commanders must ensure that personnel are
fully trained in the techniques and procedures for CBRN survival. This includes regularly
scheduled training and instruction in the use of all available IPE and available medications
(such as chemoprophylaxis, pretreatments, and barrier creams).
c. Endemic disease and BW agent threats in the joint operational area (JOA) must be
identified during the predeployment period. It is important to monitor the health of the force
to gauge the predeployment health status of units and to identify preexisting (baseline)
health characteristics of an individual. Infectious diseases in the AO should be prioritized
and monitored according to the threat each poses to the force and the achievement of the
mission. Appropriate medical countermeasures must be implemented, particularly in the
areas of food and water vulnerability, waste disposal, and personal protective measures
(such as immunizations, prophylaxis, insect repellents, and insect netting).
d. Preventive measures in FHP and HSS planning for CBRN environments include—
(1) Development of the body’s natural defenses through individual and unit health
and fitness programs.
(2) Integration of military PVNTMED and civilian public health preventive
capabilities to the extent feasible.
(3) Protection of medical supplies and equipment by using CW agent-resistant
coatings and covers.
(4) Frequent testing of all food and water sources and supplies for CBRN
contamination.
(5) Force protection measures extended to HSS organizations and facilities to
ensure HSS availability in the event of adversary CBRN attacks.
(6) Integration of HSS units and facilities into joint force plans and activities to limit
CBRN exposure and contamination following a CBRN attack, through application of CBRN
defense principles.
e. During deployment, vigilant monitoring of DNBI rates (sick call, outpatient treatment,
and hospital admissions) in relation to the numbers of disease vectors and local pathogens
is required for effective planning and refinement of appropriate countermeasures to
infectious disease. Information drawn from historical data, type of deployment, duration of
the deployment, and the level of support needed can be used to create a predictive DNBI
model.
4. Disease Incidence Following the Use of Chemical, Biological, Radiological
and Nuclear Weapons
a. Factors of prime importance in determining the nature and severity of the disease
effects are—
• Immunization status of personnel.
• Underlying health status of the population.
• Population density.
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
II-3
• Degree of industrialization in the AO.
• Availability of health services.
• Availability of sanitation facilities.
• Availability of food supplies.
• Availability of water and ice.
• Climate.
b. The manner and situation in which nuclear weapons are used is important. A single
weapon detonated in a socially stable area will have less serious effects than a detonation in
an area where combat has already disrupted the social stability. At Hiroshima and
Nagasaki, Japan (excellent examples of the first type of situation), the survivors who could
get away were able to obtain food, shelter, and care from surrounding intact areas. With
prolonged combat operations, such intact areas would not be available, resulting in no food,
shelter, or care for survivors. There will be a breakdown in social order and there will be a
lack of effective medical support (including PVNTMED functions and facilities).
c. Without PVNTMED capabilities, increased incidence and morbidity from diseases will
follow. Some diseases will predominate in incidence, depending upon the geographical
areas involved and the endemic diseases present.
(1) In urban areas with temperate climates, several diseases are epidemic threats.
These epidemic threats may include—
• Dysentery (due to a variety of pathogens).
• Rickettsial diseases, particularly typhus and scrub typhus.
• Hepatitis.
• Tuberculosis.
• Malaria and cholera (in many parts of the world).
(2) There are several reasons for the increased risk of disease including, but not
limited to—
• Crowding of surviving populations with limited sanitary facilities as was seen
during the flight of Rwandan refugees into the North Kivu region of Zaire and
in Europe at the end of World War II.
• A lack of prophylaxis and immunizations with resultant increases in the
susceptibility factor of a given population.
• A lack of pest management activities.
• With the high levels of fallout covering wide areas, a large number of people
will sustain sublethal whole-body doses of radiation. The interaction of
irradiation with infections is not clear; but it may be the result of latent
infections manifesting and decreased resistance to infection. The result is
an increased incidence of disease.
• Each class and order of animals has marked differences in sensitivity to
irradiation.
Arthropods, for example, are much more resistant than
vertebrates. The normal balance between arthropods and birds that prey
upon them in a given area may be severely upset, producing a marked
overgrowth of arthropods. If the arthropods include vectors of disease there
would be a serious increase in disease hazards. If there is an increase in
arthropods that destroy vegetation there would be a serious destruction of
food crops.
• The introduction of a BW agent in an AO in which the disease organism is
endemic or epidemic can increase the risk level for exposed personnel.
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
15 July 2009
d. This risk can be mitigated by the rapid diagnosis of BW infection. Medical units
including PVNTMED, veterinary detachments and field hospitals now have the capability to
identify BW agents in specimens and samples. The Joint Biological Agent Identification and
Diagnostic System
(JBAIDS) uses polymerase chain reaction
(PCR) to identify the
deoxyribonucleic acid (DNA) of threat agents. For more information on JBAIDS, refer to
Chapter VII.
e. Routine disease surveillance information may be the sentinel indication of BW agent
use. Early disease recognition enables effective intervention. A BW attack may create a
disease mass casualty situation in the area of operation. The medical commanders have
the core knowledge and competency for many BW passive defense actions. The medical
commander fields deployable and forward-deployed assets that employ biotechnology to
rapidly and accurately identify specific pathogens of military concern. This capability,
coupled with health surveillance systems built on advanced information technology and
management architecture can provide early recognition of a covert BW attack and rapid
identification of agents, vastly improving commander situational awareness and enabling
early and appropriate intervention.
5. Sustainment of Health Service Support Operations in a Chemical,
Biological, Radiological, and Nuclear Environment
a. Planning for and maintaining a sound medical and OEH surveillance program for all
operations can maximize force effectiveness by eliminating or reducing the effects of CBRN
threats. Health service support personnel must include the unique characteristics and
effects of CBRN weapons/agents in their FHP and HSS plans. Although most essential
care is rendered outside the area of immediate combat in a nontactical environment, triage,
patient decontamination, and initial resuscitative care are necessary in the combat area.
Medical commanders must ensure that MTFs can locate clean areas to establish operations
or employ collective protection shelter (CPS) systems in areas that have the potential for
being contaminated.
b. The CCDR and his medical planners establish the command’s HSS requirements
and ensure the proper coordination of all HSS capabilities. Medical plans must account for
the possible disruption of supply lines, contamination or destruction of medical units, and the
contamination of medical evacuation assets. Resupply of units in the downwind hazard
area or on the far side of a contaminated area must account for the need to protect both the
Class VIII supplies, the platform used to conduct the resupply, and the personnel conducting
resupply. Prior coordination for thorough or operational decon must be made with the
CBRN staff. Medical Chemical Defense Materiel (MCDM) will be in demand post CBRN
attack. The MCDM must be pushed to locations near to the units attacked to allow resupply
of nerve agent antidotes, antibiotics, or skin decon kits to both Service members as well as
for medical equipment set (MES) potency and dated (P&D) items. The CBRN casualty
estimation during the planning process will give medical planners and logisticians an
approximate demand for MCDM following a CBRN attack. Casualty estimation both aids in
risk assessment, course of action analysis, and medical force planning.
c. Adversary use of CBRN weapons/agents can cause large numbers of casualties in a
short period of time. In addition to agent-related casualties, planning should include a
means to manage/triage nonagent harmed personnel/psychological casualties who may
overwhelm medical/triage or other health monitoring assets in an event involving CBRN
agents. This has been borne out in real life incidents such as the Tokyo subway sarin gas
release and the radiological accident in Goiania, Brazil; where the number of nonagent
harmed persons reporting to be monitored/addressed through health assessment far exceed
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