Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
L  P H
OCAL  UBLIC  EALTH 
 
P
  REPAREDNESS FOR 
 
R
  ADIOLOGICAL AND 
N I  
UCLEAR  NCIDENTS
 
Daniel R. Levinson  
Inspector General 
 
January 2012 
OEI-04-10-00250   
   
Local Public Health Preparedness for Radiological and Nuclear Incidents 
OEI-04-10-00250 
 
WHY WE DID THIS STUDY  
 
According to the 2010 National Security Strategy, the American people face no greater or 
more urgent danger than a terrorist attack with a nuclear weapon.  If State and local 
public health officials do not plan for such incidents, local public health departments will 
not be adequately prepared to quickly respond and protect the public.  Although the 
Nuclear Regulatory Commission requires nuclear powerplants to have emergency plans 
for their facilities and the immediate surrounding area, no Federal entity requires States 
or localities to have public health emergency plans for nonpowerplant radiological and/or 
nuclear (RN) incidents, such as a terrorist attack. 
 
HOW WE DID THIS STUDY 
 
Using information requests and conducting document reviews, we determined the extent 
to which 40 localities from the Nations most populous metropolitan statistical areas 
(referred to as the selected localities) used local risk assessments to prioritize planning 
for RN incidents.  We also determined whether the selected localities planned for RN 
incidents by engaging in five RN-specific public health planning areas; coordinating with 
Federal, State, and local partners; and using Federal guidance sources. 
 
WHAT WE FOUND 
 
Thirty-six of the forty selected localities had conducted risk assessments, but RN-specific 
public health planning did not always correspond to localities prioritized threats.  For 
example, of the four localities that categorized RN incidents as a high-priority threat, 
only one had RN-specific plans.  Twenty-one of the forty selected localities conducted 
RN-specific public health planning in at least one of the five public health areas of 
responsibility we examined, but planning in the five areas varied.  Localities also varied 
in the extent to which they coordinated with Federal, State, and local partners for RN-
specific public health planning.  Most State and local officials were aware of Federal 
guidance sources available to aid RN-specific public health planning, but requested more 
comprehensive and specific planning tools.   
 
WHAT WE RECOMMEND 
 
Our report made four recommendations to the Centers for Disease Control and 
Prevention (CDC).  First, work with selected localities to more closely align their 
incident-specific planning with risk assessments.  Second, provide more specific 
guidance outlining the public health areas of responsibility to include in RN-incident 
planning.  Third, provide more guidance on coordination with other entities for RN-
incident planning.  Finally, provide more training to selected localities about the unique 
aspects of an RN incident not addressed in all-hazards planning.  CDC agreed with all 
four of our recommendations.   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ..............................................................................................12 
Findings......................................................................................................18 
Thirty-six of the forty selected localities had conducted risk 
assessments, but RN-specific public health planning did not always 
correspond to localities prioritized threats ....................................18 
Twenty-one of the forty selected localities conducted RN-specific 
public health planning ....................................................................19 
Localities varied in the extent to which they coordinated with 
Federal, State, and local partners for RN-specific public health 
planning..........................................................................................22 
Most State and local officials are aware of Federal guidance 
sources available to aid RN-specific public health planning but 
requested more comprehensive and specific planning tools ..........24 
Recommendations ......................................................................................27 
Agency Comments and Office of Inspector General Response .....29 
Appendixes ................................................................................................31 
A:  Forty Most Populous Metropolitan Statistical Areas and the 
Selected Localities .........................................................................31 
B:  Planning for 5 Radiological/Nuclear-Specific Public Health 
Areas Among the 21 Localities With Radiological/Nuclear-
Specific Planning and Proximity to Nuclear Powerplants .............32 
C:  Localities Planning for Key Components for Each of the Five 
Radiological/Nuclear-Specific Public Health Areas of 
Responsibility ................................................................................33 
D:  List of Abbreviations and Acronyms .......................................35 
E:  Agency Comments ...................................................................36 
Acknowledgments......................................................................................40 
   
   
OBJECTIVES 
To determine the extent to which selected localities prepared for a public 
health response to a radiological and/or nuclear (RN) incident by: 
1.  using their risk assessments to prioritize planning; 
2.  engaging in planning activities for five public health areas of 
responsibility; 
3.  coordinating with Federal, State, and local partners; and  
4.  using Federal guidance sources. 
BACKGROUND 
According to the 2010 National Security Strategy, the American people face 
no greater or more urgent danger than a terrorist attack with a nuclear 
weapon.1  An attack, or RN incident, may come in several forms:  a dirty 
bomb, detonation of an improvised nuclear device (IND; nuclear weapon), 
a radioactive source placed in a public place, or contamination of the food 
and water supply with radioactive materials.2, 3   
In March 2011, an earthquake and a tsunami caused the release of radiation 
from the Fukushima Daiichi nuclear powerplant in Japan.  The public health 
concerns resulting from this incident emphasize the importance of 
emergency planning for all types of RN incidents. 
Without planning for such incidents, including how to monitor radiological 
contamination, identify and treat contaminated patients, and disseminate 
critical public health information, public health officials will not be 
adequately prepared to quickly respond to an RN incident and protect the 
public.  The Department of Homeland Security (DHS), the lead Federal 
department for emergency preparedness and response, notes that proper 
planning for RN incidents can save tens of thousands of lives.4  DHS also 
states that while Federal assistance may be needed in an emergency, the 
initial response will come from the local level.5   Therefore, localities need 
to be prepared to respond quickly to various emergency scenarios.   
 
1 National Security Strategy (May 2010), p. 4.   Accessed at 
http://www.whitehouse.gov/sites/default/files/rss_viewer/national_security_strategy.pdf  on October 17, 2011.  
2 A dirty bomb is an explosive device that uses conventional explosives, such as dynamite, to spread radioactive 
material into the environment. The Centers for Disease Control and Prevention (CDC), Types of Radiation 
Emergencies.  Accessed at http://www.bt.cdc.gov/radiation/typesofemergencies.asp on October 17, 2011. 
3 A list of acronyms used in this report can be found in Appendix E. 
4 DHS, IND Response Strategy (March 2010), p. 3.  Accessed at http://publicintelligence.info/DHS-
INDResponse.pdf on October 17, 2011.  
5 DHS, National Response Framework (January 2008), which superseded the National Response Plan, 2004.  
Accessed at http://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf on October 17, 2011. 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  1   
   
Nuclear Powerplant Incidents Versus Other Types of RN 
Incidents 
In the United States, the Nuclear Regulatory Commission (NRC) regulates 
all persons and organizations that receive a license to use nuclear materials 
or operate nuclear facilities.6  The NRC requires that nuclear powerplants 
have emergency plans for their facilities and the area within a 50-mile 
radius.  These emergency plans include coordinating medical and public 
health support from State and local entities.7  However, neither NRC nor any 
other Federal entity requires States or localities to have public health 
emergency plans for nonpowerplant RN incidents, such as a terrorist attack 
with a dirty bomb or an IND. 
Emergency planning for nuclear powerplants differs from emergency 
planning for other types of RN incidents.  For example, in a nuclear 
powerplant incident, there is usually leadtime before radioactive release 
occurs (e.g., personnel can detect a reactor getting too hot).  Further, there 
are known factors in a nuclear powerplant emergency, such as the type of 
isotopes involved, the number and identity of people present at the facility, 
the areas that will likely be affected, and facility personnel awareness of 
emergency response procedures.  Additionally, nuclear powerplants must 
develop emergency response plans and must exercise these plans with 
Federal, State, and local authorities once every 2 years.8  NRC and the 
Federal Emergency Management Agency (FEMA) oversee and evaluate 
these exercises.9   
A nonpowerplant RN incident is unexpected and almost all circumstances 
are unknown.  For example, the isotope is unknown until samples are 
collected and analyzed, the population and area affected are initially 
unknown, and the affected population may not know how to respond.  
Nuclear powerplant emergency plans do not address these unique 
circumstances that characterize nonpowerplant RN incidents.   
The National Response Framework 
In 2003, Homeland Security Presidential Directive-8 was issued to 
strengthen the preparedness of the United States to prevent and respond to 
threatened or actual domestic terrorist attacks, major disasters, and other 
 
6 10 CFR pts. 1199. 
7 NRC, Fact Sheet on Emergency Planning and Preparedness (March 2002).  Accessed at 
http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/emer-plan-prep.html on October 17, 2011. 
8 NRC, Fact Sheet on Emergency Planning and Preparedness, loc. cit. 
9 NRC, Frequently Asked Questions About Emergency Preparedness and Response.  Accessed at 
http://www.nrc.gov/about-nrc/emerg-preparedness/faq.html#3 on October 17, 2011. 
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emergencies ...10  From this directive, DHS developed planning guidance 
to assist in preparing the Nation for potential threats.  The National 
Preparedness Guidelines provide an overarching guide to national 
emergency preparedness.11  In addition, the National Response Framework 
(NRF) provides more specific guidance regarding various responsibilities 
and incident-specific planning.  The NRF is designed to be flexible and 
scalable so that it can be applied to Federal, State, and local planning and to 
allow coordination among the various levels.12   
Specifically, the NRF outlines each Federal departments responsibilities 
during an incident through its 15 Emergency Support Functions (ESF).13  
ESF #8 (Public Health and Medical Services) outlines public health roles 
and responsibilities, ranging from public health and medical needs 
assessment to mass fatality management.14  Although HHSs Office of the 
Assistant Secretary for Preparedness and Response (ASPR) is designated as 
the lead Federal agency for ESF #8, the initial public health response will be 
at the local level, with HHS supporting the local response as needed.15 
The NRF also includes annexes to aid planning for specific types of 
incidents.  The Nuclear/Radiological Incident Annex outlines the various 
roles of the Federal departments and agencies involved in the response to an 
RN incident.16  Additionally, the Nuclear/Radiological Incident Annex 
emphasizes that specific planning for an RN incident is necessary to 
supplement all-hazards planning because of the unique challenges this type 
of incident poses.     
All-Hazards and Risk-Based Planning 
Both the National Preparedness Guidelines and the NRF support the 
development of all-hazards emergency response planning.17  All-hazards 
 
10 Homeland Security Presidential Directive/HSPD-8 (December 2003).  HSPD-8 was rescinded and replaced 
by Presidential Policy Directive/PPD-8:  National Preparedness on March 30, 2011.  However, the 
preparedness guidance from HSPD-8 remained in effect.  
11 DHS, National Preparedness Guidelines (September 2007).  Accessed at 
http://www.dhs.gov/xlibrary/assets/National_Preparedness_Guidelines.pdf on October 17, 2011. 
12 DHS, NRF, loc. cit. 
13 Section 2801(a) of the Public Health Service Act (PHSA) (42 U.S.C.  300hh(a)) provides that the Secretary 
of the Department of Health and Human Services (HHS) lead all Federal public health and medical response to 
public health emergencies and incidents covered by the National Response Plan or any successor plan.  In 
addition, section 2802(b)(5) of the PHSA (42 U.S.C.  300hh-1(b)(5)) states that planning should minimize 
duplication and ensure coordination between Federal, State, local, and tribal governments.  These all-hazards 
planning and response activities must also be consistent with the NRF. 
14 DHS, National Response Framework:  Emergency Support Functions #8 Annex (January 2008).  Accessed at 
http://www.fema.gov/pdf/emergency/nrf/nrf-esf-08.pdf on October 17, 2011. 
15 Ibid. 
16 DHS, Nuclear/Radiological Incident Annex (June 2008).   Accessed at  
http://www.fema.gov/pdf/emergency/nrf/nrf_nuclearradiologicalincidentannex.pdf on October 17, 2011.  
17 DHS, National Preparedness Guidelines, loc. cit.; DHS, NRF, loc. cit.  
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planning focuses on developing certain general emergency response 
capabilities that can be applied to a variety of emergency scenarios.18  These 
capabilities cover broad areas of preparedness, such as mass medical care or 
emergency public safety, which apply to a variety of incidents.   
In addition to supporting all-hazards planning, the National Preparedness 
Guidelines establish a risk-based approach to planning.19  The National 
Preparedness Guidelines recommend, but do not require, that local incident-
specific planning supplement all-hazards planning according to each 
jurisdictions risk assessment.  This allows emergency planning to be 
tailored to a jurisdictions specific needs and identified risks.20  Using risk 
assessments to determine planning priorities also allows States and localities 
to focus their limited resources on the risks that are of greatest concern to 
them instead of incidents that may be low-priority threats to their areas.  
Once risks are identified, Federal, State, and local governments can use 
documents such as the NRFs incident-specific annexes to develop plans for 
these risks.  
Public Health Emergency Preparedness Cooperative 
Agreements 
HHS is authorized to award cooperative agreements to States, territories, and 
selected localities (grantees) to enhance the security of the United States 
with respect to public health emergencies.21  Through CDC and pursuant to 
this authority, HHS awards Public Health Emergency Preparedness (PHEP) 
cooperative agreement funding.  Since 2002, CDC has provided $7 billion in 
PHEP funding to 62 grantees to help them prepare for public health 
emergencies.22, 23  In 2010, CDC awarded grantees nearly $700 million.24   
Emergency preparedness efforts conducted through the PHEP cooperative 
agreement are intended to support national preparedness as outlined in the 
NRF.25  Specifically, grantees use PHEP funding to support public health 
 
18 DHS, National Preparedness Guidelines, loc. cit. 
19 Ibid.  
20 Ibid. 
21 PHSA  319C-1(a) (42 U.S.C.  247d-3a(a)). 
22 PHEP grantees include all 50 States, 8 territories (Commonwealth of Puerto Rico, the Virgin Islands, 
American Samoa, Commonwealth of Northern Mariana Islands, Guam, Republic of the Marshall Islands, 
Republic of Palau, and Federated States of Micronesia), and 4 metropolitan areas (Washington, D.C., Chicago, 
Los Angeles County, and New York City). 
23 CDC, Press Release.  Accessed at http://www.cdc.gov/media/pressrel/2010/r100819c.htm on                
October 17, 2011. 
24 CDC, Instructions for Preparing and Submitting Budget Period 10 Extension Funding Applications.  
Accessed at 
http://www.bt.cdc.gov/cdcpreparedness/coopagreement/10/PHEP%20BP10%20Extension%20Guidance_Instru
ctions_Appendices_05-13-2010_FINAL.pdf on October 17, 2011. 
25 PHSA  319C-1(b)(2)(A) (42 U.S.C.  247d-3a (b)(2)(A)); CDC, Instructions for Preparing and Submitting 
Budget Period 10 Extension Funding Applications, loc. cit. 
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departments efforts to build all-hazards capabilities and capacity to 
effectively respond to the public health consequences of various types of 
incidents.  These incidents can include terrorist threats; infectious disease 
outbreaks; natural disasters; and biological, chemical, nuclear, and 
radiological emergencies.26   
In March 2011, CDC released new public health preparedness guidance, 
Public Health Preparedness Capabilities:  National Standards for State and 
Local Planning.  This guidance outlines how grantees should conduct their 
public health planning, beginning with a new 5-year PHEP cooperative 
agreement that became effective in August 2011.27  This new guidance 
breaks down planning elements by 15 capabilities and identifies planning 
priorities for each.   
Although the 2011 PHEP guidance references resources and training related 
to specific threats in several of the 15 capabilities, these references are 
interspersed throughout the document and often refer to other sources for 
more comprehensive planning information.  For example, for each 
capability, there is a suggested resources section that lists various guidance 
sources grantees can access, such as CDCs Radiation Emergencies Web site.  
CDC also provides technical guidance resources that can be used to aid 
specific incident planning that are not contained within this new PHEP 
capabilities guidance.  For example, CDC provides online technical 
resources that States and localities can access to guide their RN-specific 
public health planning. 
CDCs 2011 PHEP guidance encourages grantees to conduct and use risk 
assessments to help prioritize their all-hazards public health planning.  The 
guidance discusses risk assessments in terms of identifying public health 
threats to their jurisdictions, as well as vulnerabilities in their public health 
planning.  For example, the guidance notes that grantees should identify the 
potential hazards, vulnerabilities, and risks in the community that relate to 
the jurisdictions public health, medical, and mental/behavioral health 
systems ...28 The guidance further notes that grantees should consider the 
impact the identified risks pose to humans through interruption of public 
 
26 CDC, Funding, Guidance, and Technical Assistance to States, Localities and Territories.  Accessed at 
http://www.bt.cdc.gov/cdcpreparedness/coopagreement/index.asp#phep on October 17, 2011. 
27 CDC, Public Health Preparedness Capabilities:  National Standards for State and Local Planning       
(March 2011).  Accessed at http://www.cdc.gov/phpr/capabilities/index.htm on October 17, 2011; Homeland 
Security Grants:  Public Health Emergency Preparedness (PHEP).   Accessed at 
http://www.homelandsecurityfunding.info/GrantDetails.aspx?Grant=22347 on October 17, 2011. 
28 CDC, Public Health Preparedness Capabilities:  National Standards for State and Local Planning, p. 16. 
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health services and the impact of the risks to public health, medical, and 
behavioral health infrastructure.29   
However, these all-hazards public health risk assessments do not identify the 
specific incidents of greatest threat to the jurisdictions (e.g., RN incidents, 
hurricanes).  Identifying the highest priority threats can determine what 
incident-specific planning the locality should engage in beyond all-hazards 
planning.  However, States and localities are not required to use risk 
assessments to determine how to plan for their jurisdictions.   
Grantee distribution of PHEP funds.  Grantees have discretion to distribute 
PHEP funds in their jurisdictions as they deem appropriate and within PHEP 
guidance parameters.  Differences among States governmental structures 
can affect the distribution of these funds and determine whether the 
responsibility to create public health emergency preparedness plans lies 
primarily with the State or local public health departments.  For example, a 
centralized State may use PHEP funds at the State level and lead public 
health emergency preparedness planning efforts, whereas a decentralized 
State may distribute PHEP funds and public health emergency planning 
responsibilities to localities.  In some cases, the State and locality may share 
responsibility for public health emergency planning. 
Grantee PHEP planning activities.  To receive PHEP funding, grantees are 
required to prepare all-hazards emergency response plans.30  Grantees can, 
but are not required to, develop incident-specific emergency response plans 
(e.g., hurricane, biological incident, RN).31 
The NRF discusses several planning activities that States and localities can 
engage in to prepare for emergencies.32  These activities include creating 
written plans, holding training, conducting exercises, and purchasing 
equipment.  Written plans can outline the specific roles and responsibilities 
of the entities in a localitys jurisdiction, outline the aspects of a response 
that should be prepared, and establish how to conduct response actions.  
Training can address response actions that may be unfamiliar to emergency 
personnel (such as radiation decontamination) or serve as practice for the 
functions emergency personnel need to perform during an incident response.  
Exercises can be opportunities to test and improve response plans or to 
practice the response functions of various personnel.  Finally, purchasing 
 
29 Ibid. 
30 PHSA  319C-1 (b)(2)(A) (42 U.S.C. 247d-3a(b)(2)(A)). 
31 In some years, a public health threat may cause CDC to distribute additional funding to grantees to plan for a 
specific preparedness area.  For example, in 2008, CDC distributed additional funding to grantees for planning 
in light of the impending influenza pandemic.  
32 DHS, National Preparedness Guidelines, loc. cit. 
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equipment can help localities ensure that personnel are properly equipped to 
perform their roles in the event of an incident.  
Public Health Responsibilities During an RN Incident 
The Nuclear/Radiological Incident Annex of the NRF and other HHS 
documents identify five RN-specific public health areas of responsibility:  
population monitoring, decontamination, laboratory analysis, fatality 
management, and communications.33  Although States and localities are not 
required to engage in RN planning, if they choose to do so, their activities 
should include these five areas.34  For each, the Office of Inspector General 
used the NRF, CDC planning guidance, and input from ASPR and CDC 
subject matter experts to determine key components within each area.  See 
Appendix C for a detailed list of the key components for each area of 
responsibility. 
Population monitoring.  Population monitoring refers to identifying, 
screening, measuring, and monitoring people for exposure to or 
contamination from radioactive materials.35  Population monitoring can 
include establishing community reception centers (CRC) and population 
registries.36  CRCs are population monitoring sites (e.g., sports arenas, 
convention centers, and schools) where individuals are assessed for radiation 
exposure, contamination, and medical followup.37  At CRCs, localities can 
establish population registries that local public health officials can use to 
monitor and track affected individuals to study long-term radiological and 
psychological effects of an RN incident.   
Another important aspect of population monitoring is managing the 
behavioral health effects of an RN incident.  CDC recommends that a 
behavioral health professional be stationed at each CRC and be prepared to 
treat the psychological effects of an RN incident, such as posttraumatic 
stress, anxiety, depression, and concerns about exposure.38   
Population-monitoring activities are often the beginning stages of other RN-
specific public health areas of responsibility (e.g., decontamination, 
laboratory analysis, and communications).  For example, at CRCs, public 
health officials can decontaminate individuals, collect biological samples for 
 
33 DHS, Nuclear/Radiological Incident Annex, loc. cit.; CDC, Population Monitoring in Radiation Emergencies:  
A Guide for State and Local Public Health Planners (Population Monitoring, August 2007).  Accessed at 
http://www.bt.cdc.gov/radiation/pdf/population-monitoring-guide.pdf on October 17, 2011. 
34 The response to an RN incident will require other aspects of response outside public health, such as 
environmental assessments and security concerns. 
35 CDC, Roundtable on Population Monitoring Following a Nuclear/Radiological Incident (January 2005), p. 4.  
Accessed at http://www.bt.cdc.gov/radiation/pdf/population-monitoring-roundtable.pdf on October 17, 2011. 
36 CDC, Population Monitoring, p. 18. 
37 Ibid., p. 18. 
38 Ibid., p. 27. 
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laboratory analyses, and disseminate information to the public regarding the 
RN incident.      
Decontamination.  Decontamination consists of two steps:  screening and 
treatment.  Emergency response personnel first use screening criteria to 
determine whether an individual has been contaminated and, if so, the type 
of contamination (i.e., internal or external). 39  This can be done by using 
portable scanning devices for external contamination and by collecting 
clinical samples for laboratory analysis to detect internal contamination.  
Medical personnel can then determine the most appropriate treatment based 
on the type of contamination.   
Medical treatment for internal contamination varies based on the type of 
radioactive material involved.  Contamination by certain radioactive 
materials can be treated using pharmaceutical countermeasures, such as 
those stored in the Strategic National Stockpile.40  To treat external 
contamination, washing facilities can be set up near the site of the RN 
incident or at a CRC.41  Washing facilities should include a place for 
washing in warm water with soap, plastic bags for holding contaminated 
clothing, and new clothing for individuals to wear after decontamination.42  
In some cases, individuals may decontaminate themselves at home if they 
have minimal external contamination.43  Public health officials can prepare 
instructions on the proper procedures for self-decontamination.   
Laboratory analysis.  Laboratory analysis consists of collecting and 
processing clinical samples from individuals suspected of being internally 
contaminated.44  Localities should have a plan to collect clinical samples 
and to conduct laboratory analyses of them to determine the type and 
amount of radiation contamination.  For example, analysis of urine can show 
the type and quantity of radioactive materials in an individuals body.45  
Samples may be collected at CRCs or medical facilities and sent to 
laboratories for analysis.  Because many laboratories are equipped to 
analyze environmental samples, not clinical samples, public health planners 
should identify in advance the laboratories within their jurisdictions that can 
 
39 National Security Staff Interagency Policy Coordination Subcommittee for Preparedness and Response to 
Radiological and Nuclear Threats (NSSIPCS), Planning Guidance for Response to a Nuclear Detonation, p. 
105.  Accessed at http://hps.org/hsc/documents/Planning_Guidance_for_Response_to_a_Nuclear_Detonation-
2nd_Edition_FINAL.pdf. on October 17, 2011. 
40 The Strategic National Stockpile is managed by CDCs Office of Public Health Preparedness and Response.  
It stores and provides medicine and medical supplies to States in the event of a public health emergency.  
Accessed at http://www.bt.cdc.gov/stockpile/ on October 17, 2011. 
41 CDC, Population Monitoring, p. 16. 
42 Ibid., p. 16. 
43 NSSIPCS, op. cit., p. 83. 
44 CDC, Population Monitoring, p. 26.   
45 Ibid., p. 17. 
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perform these analyses.  If assistance from State or Federal resources will be 
needed, localities can involve them in planning, such as establishing when 
and how assistance will be requested.46   
Fatality management.  Fatality management consists of properly handling 
human remains that may be contaminated.47  An RN incident may result in 
fatalities from an initial blast or as a result of long-term exposure to 
radioactive materials.  Medical examiners, coroners, and morticians should 
properly handle human remains, which may be externally or internally 
contaminated, to prevent the spread of radioactive contamination to 
themselves, to other individuals, or to the environment.48  Localities can 
ensure that fatality management personnel have appropriate equipment and 
procedures to limit their radiation exposure.   
Communications.  An RN incident will require strategic, rapid 
communication to health care providers and the public.49  Public health 
officials can develop a communications strategy for quick information 
dissemination, such as establishing procedures for contacting other Federal, 
State, and local officials; identifying, establishing, and training a network of 
credible communications staff; and developing public messages about 
radiation exposure.50   
Messages to the public on how people should respond (e.g., evacuate or 
shelter in place) and messages to public health officials on incident details 
and response efforts can have a significant effect on the health and safety of 
a large number of people.51  Preincident messaging (e.g., public service 
announcements or other informational material) is critical to ensure that 
people know how to minimize their exposure in the event of an RN 
incident.52   
Coordinating the Response to a Radiological and Nuclear 
Incident 
According to the National Preparedness Guidelines and the NRF, State and 
local public health departments should plan to coordinate with entities at all 
levels (Federal, State, and local) that are able to assist in an RN response.53  
 
46 Ibid., pp. 2526. 
47 CDC, Information for Medical Examiners, Coroners, and Funeral Home Personnel.  Accessed at 
http://www.bt.cdc.gov/radiation/medicalexaminers.asp on October 17, 2011. 
48 CDC, Guidelines for Handling Contaminated Decedents, pp. 6-7.  Accessed at 
http://www.bt.cdc.gov/radiation/pdf/radiation-decedent-guidelines.pdf on October 17, 2011.      
49 CDC, Population Monitoring, p. 31. 
50 Ibid. 
51 Ibid. 
52 NSSIPCS, op. cit., p. 120. 
53 DHS, National Preparedness Guidelines, loc. cit.; DHS, NRF, loc. cit. 
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However, there are no requirements that States and localities coordinate with 
any entity for emergency planning.  
If Federal assistance is required by the locality, a large part of the response 
to an RN incident can be handled by HHS, DHS, and the Department of 
Energy (DOE).  Within HHS, ASPR will lead the public health and medical 
support response to any incident, including RN incidents.  CDC can provide 
additional support and technical expertise to States and localities in response 
to RN incidents.  For example, CDC may assist States and localities with 
setting up CRCs and conducting laboratory analysis.   
Other Federal departments can provide support for RN incident planning 
and response.  For example, DOE can provide expert radiation assistance 
through its National Nuclear Security Administration (NNSA).54  NNSA 
sources of assistance include the Radiation Emergency Assistance 
Center/Training Site program (REAC/TS), the Federal Radiological 
Monitoring and Assessment Center (FRMAC), and the Nuclear Emergency 
Support Team (NEST).55  DHS offers online training through FEMA, 
covering topics such as the regulations regarding radiation and how to 
handle hazardous (e.g., radioactive) material.56  States and localities are not 
required to take this training; however, it is available to assist with          
RN-incident planning.     
Localities can also coordinate with their States Radiation Control Programs 
(RCP) as a source of expertise on radiation. 57  The RCP in each State is 
designed to ensure the safe and effective handling of radiation, radioactive 
materials, and environmental radioactive materials (e.g., mammography 
machines, nuclear powerplants).58  RCPs may be housed in various 
departments within each State depending on how a State is structured (e.g., 
some may be within a public health department and others may be in 
emergency management).  RCPs include trained staff who can respond to 
RN incidents.  RCP staff can also help local health departments conduct 
training and preparedness exercises, in addition to providing input on RN 
public health response plans.  In the event of an RN incident, RCP staff can 
provide just-in-time training, identify the type of radioactive material 
 
54 DHS, Nuclear/Radiological Incident Annex, p. 18. 
55 Seven radiological emergency programs can provide immediate expert assistance in the event of an RN 
incident:  Aerial Measuring System, Accident Response Group, National Atmospheric Release Advisory 
Center, Radiological Assistance Program, REAC/TS, FRMAC, and NEST.  Accessed at 
http://nnsa.energy.gov/aboutus/ourprograms/emergencyoperationscounterterrorism/respondingtoemergencies on 
October 17, 2011. 
56 DHS, Regulations and Guides for Radiation Protection and Response.  Accessed at 
http://training.fema.gov/emiweb/downloads/301unt01.pdf on October 17, 2011. 
57 CDC, Population Monitoring, p. 4.  
58 RCPs exist in each State but often go by various titles.  RCP is used in this report to refer to any State entity 
responsible for the safety and use of radiological materials. 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  10   
   
present, and provide guidance on appropriate treatment methods.59, 60  
Locally, the medical community (e.g., hospitals, emergency medical 
services, clinicians) should be prepared to respond to an RN incident.   If a 
radiological agent is released through the water or food supply, clinicians 
will likely be the first to identify symptoms of radiation exposure when they 
treat contaminated individuals.  If an active release occurs, such as use of a 
dirty bomb, the medical community will be tasked with triaging, treating, 
and transporting affected individuals to treatment facilities.61   
To coordinate the public health response to RN incidents, localities can 
create Memorandums of Understanding (MOU) between various 
government sectors (e.g., police departments and public health departments) 
or between governmental and nongovernmental entities (e.g., public health 
departments and hospitals).  Such MOUs typically outline the agreed-upon 
roles and responsibilities in the event of an RN incident. 
HHS Radiological and Nuclear Incident Planning Guidance  
Within HHS, CDC and ASPR provide technical guidance to States and 
localities in developing RN-specific public health plans that are consistent 
with the NRF.  CDC and ASPR have online resources covering a variety of 
public health RN preparedness topics to educate State and local officials on 
types of RN incidents and ways to develop response plans that address local 
public health responsibilities.  In addition, the online resources can be 
downloaded in advance so that they are readily available when an incident 
occurs.  
CDC provides technical guidance and assistance to States and localities 
through its Web site and through toolkits and other guidance documents to 
facilitate the creation of emergency preparedness plans.  These include 
CDCs Radiation Emergency Preparedness Web site, Population Monitoring 
Toolkit, Medical Management Toolkit, and Laboratory Analytical Methods.62  
Through these resources, CDC sets broad goals and priorities, giving 
grantees flexibility in how to create their emergency response plans.  For RN 
 
59 ASPR, Radiation Emergency Medical Management (REMM), Developing a Radiation Response Plan.  
Accessed at http://www.remm.nlm.gov/responseplan.htm#team on October 17, 2011. 
60 Just-in-time training is delivered quickly when it is needed in response to an incident that requires certain 
skills and is given where it is needed and to the appropriate individuals (e.g., decontamination training in a 
hospital, after an RN incident, to emergency department personnel). 
61 C. M. Hrdina, N.C. Coleman, et al., The RTR Medical Response System for Nuclear and Radiological 
Mass-Casualty Incidents:  A Functional Triage-Treatment-Transport Medical Response Model, Prehospital 
and Disaster Medicine, vol. 24, no. 3, June 22, 2009. 
62 CDC, Radiation Emergencies Web site.  Links can be found at the following Web sites to order the toolkits:  
Population Monitoring Toolkit, accessed at http://emergency.cdc.gov/radiation/publichealthtoolkit.asp on     
June 29, 2011;  Medical Management Toolkit, accessed at http://emergency.cdc.gov/radiation/clinicians.asp on   
June 29, 2011;  and Laboratory Analytical Methods, accessed at  http://emergency.cdc.gov/radiation/labinfo.asp 
on June 29, 2011. 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  11   
   
incidents, this CDC technical guidance addresses public health 
responsibilities outlined in the NRF.  For example, CDC has provided 
toolkits and Web-based training for population monitoring and videos on 
how to use handheld radiation monitoring devices. 63 
ASPR published the Radiological Dispersal Device Playbook in April 2010, 
which provides guidance for Federal decisionmakers in coordinating with 
other Federal and local emergency support agencies in the event of an 
actual radiological terrorist attack in a U.S. city.64  While not intended as a 
guide for State and local planning, this playbook provides information about 
RN incidents and the scenarios surrounding various RN incidents that can 
assist planning.  For example, this playbook covers different radiological 
incident scenarios (e.g., radiological dispersal device or dirty bomb, 
radioactive source placed in a public area, contamination of the food and/or 
water supply) and includes information about radiological events, initial 
steps in response efforts, and Federal ESF #8 responsibilities.   
Additionally, ASPR maintains the REMM Web site, which has 
information on various types of RN scenarios, as well as information for 
first responders, hospitals, mental health professionals, and others.65   It 
includes information regarding the various aspects of planning for and 
response to an RN incident, such as developing a radiological response 
plan, population monitoring, decontamination, and fatality management. 
METHODOLOGY 
We reviewed selected localities preparedness for the public health aspects 
of planning and response for nonpowerplant RN incidents as of February 
2011.  We determined whether selected localities used a locally developed 
risk assessment to prioritize their public health planning for the response 
to an RN incident.   
We also determined the extent to which selected localities that engaged in 
RN incident planning included five RN-specific public health areas of 
responsibility (i.e., population monitoring, decontamination, laboratory 
analysis, fatality management, and communications) in their plans.  We 
determined whether these RN-specific planning activities included 
coordination with Federal, State, and local partners.  Finally, we 
determined what Federal guidance sources localities were aware of and 
have used to plan for an RN incident.   
 
63 CDC, Radiological Terrorism:  A Toolkit for Public Health Officials.  Accessed at 
www.bt.cdc.gov/radiation/publichealthtoolkit.asp on October 17, 2011. 
64 ASPR, Radiological Dispersal Device Playbook (April 2010).  Accessed at 
http://www.phe.gov/preparedness/planning/playbooks/rdd/pages/default.aspx on October 17, 2011. 
65 ASPR, REMM.  Accessed at http://www.remm.nlm.gov/index.html on October 17, 2011. 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  12   
   
Sample Selection 
Using U.S. Census Bureau data, we identified 40 of the most populous 
Metropolitan Statistical Areas (MSA).  From each of the 40 MSAs, we 
selected the most populous city (referred to as the selected locality) as 
the source of information about RN public health planning for that 
locality.  See Appendix A for the 40 most populous MSAs, populations, 
percentage of U.S. population, and selected localities.  See Figure 1 for a 
map showing the 40 selected localities. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Data Collection 
We coordinated with CDC to identify the appropriate State officials for 
each selected locality.  We contacted these officials to find out whether the 
State or the locality was responsible for the localitys RN public health 
emergency planning.  If State officials indicated that the State was 
responsible, we collected data from the State only.  If State officials 
indicated that the locality was responsible, we collected data from only the 
local official they identified.  Finally, if State officials indicated that the 
State and locality were jointly responsible, we collected data from both.     
After we identified the individuals responsible for RN public health 
planning in the selected localities, we sent them an information request.  
Respondents were asked to coordinate their responses among those 
entities within their jurisdictions that participated in this type of planning.  
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  13   
   
Respondents were from various departments, such as public health 
departments, emergency management, radiation control programs, and 
environmental health.   
One hundred percent of our sample responded to our request.  The request 
included open- and closed-ended questions concerning RN risk 
assessments, the planning activities for five RN-specific public health 
areas of responsibility, coordination with other entities, and awareness and 
use of available Federal guidance sources.  We incorporated CDC and 
ASPR input into the request, as appropriate.  We obtained documentation 
(e.g., planning documents, MOUs, after-action reports of exercises) that 
States and localities had completed as of February 2011 to determine the 
extent to which localities have engaged in public health planning for RN 
incidents.   
Data Analysis 
We analyzed the documentation for each of the 40 selected localities.  If 
the State had sole responsibility for preparedness in a selected locality, we 
counted the States responses as the localitys responses (i.e., four 
localities in four States).  Seventeen localities were responsible for their 
own preparedness.  For the 19 localities that held joint responsibility for 
preparedness with the State, we combined the responses when appropriate.  
For example, we first determined whether the locality had conducted 
planning for each of the five areas of responsibility; if not, we determined 
whether the State had conducted planning for that area that could 
supplement the localitys overall planning.  If the State had done such 
planning, we counted the locality as having planned for that area.  
Responses from States and localities are hereinafter referred to as 
localities responses. 
Risk assessments.  We determined whether localities had identified and 
prioritized threats for their jurisdictions.  If they had, we determined 
whether they identified RN incidents as one of their potential threats.66  
We then assessed localities ranking or scoring of RN incidents as 
potential threats.  We classified the various rankings and scores as  low-, 
moderate-, or high-priority threats.  We then determined whether the 
localities with and without planning had identified RN incidents as low-, 
moderate-, or high-priority threats. 
RN public health planning.  We determined what, if any, RN-specific 
public health planning activities localities engaged in by analyzing 
information request responses and preparedness documents.  We examined 
 
66 Localities used various methods to conduct their risk assessments and had different ways of prioritizing 
threats (e.g., scoring methods, rankings, tiers).   
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  14   
   
the documented types of RN-specific preparedness activities by the five 
public health areas of responsibility.  For laboratory analysis, we focused 
on laboratory analysis of clinical samples, not environmental samples.67  
We did not assess the technical aspects of a laboratory response.  We 
focused on more general planning for coordinating the laboratory analysis 
needs that would likely arise from an RN incident.   
To determine whether a locality had conducted planning in each of the five 
public health areas, we collected documentation showing whether the 
localities had created written plans, held training, conducted exercises, and 
purchased equipment.  Localities were counted as having planned for the 
five RN-specific public health areas of responsibility if they had 
documentation of any one of these four activities.  For example, if a 
locality had a written plan that addressed population monitoring and 
provided documentation of training, that locality was counted as having 
planned for population monitoring and as engaging in two of the four 
planning activities.  If a locality indicated it had no RN-specific planning, 
it was not included in the subsequent analyses of planning activities for the 
five public health areas.  We report the frequency of planning activities in 
each of these five areas. 
We determined whether planning addressed 30 key components for the 5 
RN-specific public health areas of responsibility.  We compiled these key 
components from the NRF, the Nuclear/Radiological Incident Annex, 
CDC guidance documents, and components identified by subject matter 
experts from ASPR and CDC.  Specifically, we identified 12 components 
for population monitoring, 4 for decontamination, 4 for laboratory 
analysis, 6 for fatality management, and 4 for communications.   
We also determined whether localities were in proximity to (i.e., 50 miles 
or less from) a nuclear powerplant and whether this proximity 
corresponded to their public health planning for nonpowerplant RN 
incidents.  Finally, for those localities that had not conducted RN-specific 
public health planning, we determined whether they planned to use their 
all-hazards plans if an RN incident were to occur.  
Coordination with other entities.  To determine whether and how localities 
have partnered with Federal, State, and local entities, we analyzed 
documentation of coordination.  We considered localities to have 
coordinated with an entity if they had engaged in one or more of the 
following activities:  jointly conducted training or held exercises, 
developed MOUs, helped develop written RN public health plans, outlined 
 
67 In the event of an RN incident, public health departments have the responsibility for clinical sampling and 
analysis, while other departments handle environmental sampling and analysis.   
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  15   
   
the entitys role in their RN public health plans, or served as a source of 
expertise for RN public health planning.  We provided localities with a list 
of possible entities that they may have coordinated with at the Federal, 
State, and local levels.  We also asked them to provide any additional 
entities with which they may have coordinated that were not on our list.  
We report the frequency of this coordination among the localities with 
RN-specific public health planning.   
Use of Federal guidance sources.  To determine whether State and local 
respondents were aware of or had used Federal guidance sources, we 
analyzed their responses to our information request.  We did not combine 
responses from local health departments that shared responsibility for 
planning with their States because we were interested in whether all 
entities involved in planning for the 40 selected localities were aware of or 
had used the available Federal guidance sources.  Specifically, if both the 
State and local health department were responsible for planning, each 
entitys response was counted separately.  Therefore, these analyses 
included 51 respondents (19 State respondents and 32 local respondents).   
We determined whether State and local respondents were aware of eight 
available Federal guidance sources:  CDCs Radiation Emergency 
Preparedness Web site, CDCs Population Monitoring Toolkit, CDCs 
Medical Management Toolkit, CDCs Laboratory Analytical Methods, 
ASPRs Radiological Dispersal Device Playbook, the REMM Web site, 
the NNSA Web site, and the REAC/TS Web site.   
We then determined which of these sources State and local respondents 
had used.  We asked respondents to rate each sources usefulness on a 
scale from 1 to 5, with 1 indicating not at all useful and 5 indicating 
very useful.  We calculated the average rating for each source.   
Finally, we asked whether and what additional guidance sources or 
materials would be helpful for localities RN planning.  We received 80 
open-ended responses from the 51 State and local officials and identified 5 
themes.  We report the frequency of guidance sources used, ratings of the 
usefulness of the sources, and additional guidance materials that localities 
reported would be useful.   
Limitations 
This evaluation was based on a purposive sample of the 40 most populous 
MSAs in the United States.  These findings cannot be projected to other 
localities.  
We assessed localities public health planning for RN incidents based on 
self-reported data.  If localities indicated they had not done any planning, 
we did not ask for documentation or support for this response.  However, 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  16   
   
we checked for documentation to support all responses from localities that 
indicated that they had done planning. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  17   
   
FINDINGS 
Thirty-six of the forty selected localities had 
conducted risk assessments, but RN-specific public 
health planning did not always correspond to 
localities prioritized threats  
The National Preparedness Guidelines and the NRF encourage, but do not 
require, the use of a locally developed risk assessment to prioritize a 
jurisdictions incident-specific emergency planning.  Additionally, CDC 
released new PHEP guidance in March 2011 that recommends grantees 
conduct all-hazards public health risk assessments.  However, such 
assessments do not identify the specific incidents of greatest risk to the 
localities.  Prioritizing incident-specific risks allows localities to use their 
limited resources to plan for the incidents that present the highest level of 
risk to them.     
As of February 2011, 36 of the 40 selected localities indicated that risk 
assessments had been conducted to prioritize threats in their jurisdictions.  
Four localities indicated that they had not conducted risk assessments.  Of 
the 36 localities that conducted risk assessments, 30 stated that RN 
incidents were identified among their threats.  Of those 30 localities, 24 
indicated that they had prioritized RN incidents among the other threats to 
their jurisdictions.68  See Table 1 for the number of localities that provided 
information regarding their risk assessments. 
 
Table 1:  Localities Risk Assessment Information 
  Identified RN 
Conducted Risk  Incidents as a  Determined RN 
Assessment  Threat  Threat Level 
Yes  36  30  24 
No  4  6  6 
Total  40  36  30 
Source:  OIG analysis of data from selected localities, 2011. 
 
68 Five of the twenty-four localities did not provide additional information regarding where RN incidents ranked 
among potential threats.  Four localities did not have this information available to them, and one did not provide 
a response about the specific ranking.   
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  18   
   
Nineteen localities had prioritized threats, but rankings did not 
always correspond to RN-specific public health planning 
Of the 24 localities that determined their RN threat level, 19 provided 
information regarding where RN incidents ranked relative to other 
potential threats to their jurisdictions.  Four localities ranked RN as a high-
priority threat, eight as a moderate-priority threat, and seven as a low-
priority threat.   
Whether RN incidents were identified as high-, moderate-, or low-priority 
threats did not correspond to whether they had prepared RN-specific 
plans.  Three of the four localities that identified an RN incident as a high-
priority threat did not have RN-specific plans.  Conversely, five of the 
seven localities that ranked an RN incident as a low-priority threat had 
RN-specific plans.   
Twenty-one of the forty selected localities conducted 
RN-specific public health planning  
The 2010 National Security Strategy identified a terrorist attack with a 
nuclear weapon as one of our Nations greatest and most urgent dangers.  
However, there are no requirements for localities to conduct RN-specific 
public health planning.  As of February 2011, 21 of the 40 localities had 
conducted public health planning activities in at least 1 of 5 public health 
areas of responsibility for RN incidents (e.g., population monitoring, 
decontamination, laboratory analysis, fatality management, and 
communications).  Planning in these five areas consisted of one or more of 
the four activities we reviewed:  creating written plans, holding training, 
conducting exercises, and purchasing equipment.  
The remaining 19 localities had not conducted planning in any of these     
5 areas.  Of these, four had not conducted risk assessments to identify 
incident-specific threats.  Three had conducted risk assessments but did 
not identify RN incidents as a threat to their jurisdictions, and two 
indicated an RN incident was a low-priority threat.69   
The NRC requires that nuclear powerplants have emergency plans for 
their facilities and the surrounding area in case of a powerplant RN 
incident.  However, neither NRC nor any other Federal entity requires 
localities to have public health emergency plans for nonpowerplant RN 
incidents.  Localities nonpowerplant RN-specific public health planning 
did not correspond to their proximity to a nuclear powerplant.  That is, of 
the 21 localities that conducted RN-specific planning, 9 were in proximity 
 
69 The remaining 10 of these localities had identified an RN incident as either high- (3) or moderate-priority (4) 
threat or identified an RN incident as a potential threat but did not rank or score any of their jurisdictional 
threats (3).  
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  19   
   
(i.e., 50 miles or less) to a nuclear powerplant.  Of the 19 localities without 
RN-specific plans, 8 were in proximity to a nuclear powerplant.  Appendix 
B notes whether each of the 21 localities with RN plans is in proximity to 
a nuclear powerplant. 
Of the 21 localities that had conducted RN-specific public health planning, 
population monitoring and decontamination were the 2 areas in which 
localities had most often planned, with 19 and 18 localities planning in 
these areas, respectively.  Fewer than half of the 21 localities had 
conducted RN-specific planning for laboratory analysis (7 localities) or 
fatality management (8 localities), while 12 localities had conducted 
planning for communications.   
Two localities had conducted planning for all five of the public health 
areas.  Seven had conducted planning for four of the areas, and four had 
conducted planning for three areas.  See Appendix B for a list of the areas 
of planning that the 21 localities addressed. 
Of the 19 localities that had not conducted RN-specific planning in any 
area, 11 indicated they would use their all-hazards plans to respond to an 
RN incident.  Of the remaining eight localities, five indicated they would 
rely on other plans, such as general emergency management plans, 
hazardous materials plans, or State support.  The remaining three localities 
did not indicate what planning they would use to guide an RN incident 
response. 
Nineteen of the twenty-one localities with RN-specific public 
health plans addressed population monitoring  
To address population monitoring in an RN incident, 19 localities had 
engaged in 1 or more of the 4 planning activities.  Specifically:  
  Thirteen localities created written plans.   
  Ten localities held training (e.g., how to set up CRCs, how to 
determine contamination levels). 
  Seven localities conducted exercises. 
  Thirteen localities indicated they purchased equipment or supplies 
(e.g., cots, medicines, population registry materials).   
However, these activities did not consistently address each of the 12 key 
components of population-monitoring planning we reviewed.  See      
Table C-1 in Appendix C for the number of localities with plans for the 12 
key components of population monitoring for RN incidents.   
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  20   
   
Eighteen of the twenty-one localities with RN-specific public 
health plans addressed decontamination  
To address decontamination in an RN incident, 18 localities had engaged 
in 1 or more of the 4 planning activities.  Specifically: 
  Twelve localities created written plans. 
  Seven localities held training (e.g., how to help individuals wash 
off and seal belongings, how to use scanning meters).  
  Five localities conducted exercises. 
  Ten localities purchased equipment (e.g., meters for measuring 
contamination levels in individuals).  
However, these activities did not consistently address each of the four key 
components of decontamination planning we reviewed.  See Table C-2 in 
Appendix C for the number of localities with plans for the four key 
components of decontamination for RN incidents.   
Seven of twenty-one localities with RN-specific public health 
plans addressed laboratory analysis  
To address laboratory analysis in an RN incident, seven localities had 
engaged in one or more of the four planning activities.  Specifically: 
  Five localities created written plans.   
  One locality held training (e.g., how to properly collect and handle 
clinical samples). 
  Two localities conducted exercises.  
  Two localities purchased equipment.  
However, these activities did not consistently address each of the four key 
components of laboratory analysis planning we reviewed.  See Table C-3 
in Appendix C for the number of localities with plans for the four key 
components of laboratory analysis for RN incidents.   
Eight of twenty-one selected localities with RN-specific public 
health plans addressed fatality management  
To address fatality management in an RN incident, eight localities had 
engaged in one or more of the four planning activities.  Specifically: 
  Seven localities created written plans.  
  No locality held training (e.g., how to set up control points). 
  One locality conducted exercises. 
  Two localities purchased equipment (e.g., field morgue 
equipment). 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  21   
   
However, these activities did not consistently address each of the six key 
components of fatality management planning we reviewed.  See Table C-4 
in Appendix C for the number of localities with plans for the six key 
components of fatality management for RN incidents.   
Twelve of twenty-one localities with RN-specific public health 
plans addressed communications  
To address communications in an RN incident, 12 localities had engaged 
in 1 or more of the 4 planning activities.  Specifically: 
  Eleven localities created written plans.   
  One locality held training (e.g., the chain of command and/or 
entity to contact for information).  
  Three localities conducted exercises. 
  Two localities purchased equipment (e.g., cell phones or radios). 
However, these activities did not consistently address each of the four key 
components of communications planning we reviewed.  See Table C-5 in 
Appendix C for the number of localities with plans for the four key 
components of communications for RN incidents. 
Localities varied in the extent to which they 
coordinated with Federal, State, and local partners for 
RN-specific public health planning 
The National Preparedness Guidelines and the NRF encourage 
coordination among all levels of government and nongovernmental 
entities in developing and executing emergency planning.  However, there 
are no requirements for such coordination.  The 21 localities with RN-
specific public health plans varied in the extent to which they coordinated 
their RN planning with Federal, State, and local partners.  Nineteen 
localities coordinated with several Federal departments and agencies, their 
State RCPs, and local medical community members, but these 19 localities 
varied in the level of documented coordination.   
Six localities coordinated with all three groups of partners (Federal, State, 
and local).  Nine localities coordinated with two groups, and four 
coordinated with one.  Examples of coordination include working with 
partners to develop plans; holding exercises involving Federal, State, or 
local entities; or creating written plans to coordinate with or rely on these 
entities during a response to an RN incident. 
Two localities did not coordinate with any of the groups.  Five localities 
did not coordinate with Federal partners, 11 did not coordinate with State 
partners, and 7 did not coordinate with local partners.  Table 2 lists the 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  22   
   
number of localities that coordinated, and did not coordinate, with entities 
in each of the three groups. 
 
Table 2:  Selected Localities Documented Coordination in Planning for RN Public Health 
Incidents 
Number of Localities 
Coordination Group  Coordinating With Partner 
Federal Partners 
CDC  12 
DOE  12 
FRMAC  11 
DHS  10 
NRC  10 
RAP  9 
REAC/TS  9 
NEST  2 
Environmental Protection Agency (EPA)*  2 
Food and Drug Administration (FDA)*  1 
United States Department of Agriculture (USDA)*  1 
Total number of localities coordinating with Federal partners  16** 
No Federal coordination  5 
State Partners 
State RCP      
Total number of localities coordinating with State partners                                  10 
No RCP coordination  11 
Local Partners 
Hospitals  13 
Emergency medical services  12 
County health department  8 
Clinicians  2 
Total number of localities coordinating with local partners  14** 
No local coordination  7 
* These Federal agencies were provided by two localities and were not included in our original list. 
** Totals exceed sum of preceding rows because localities coordinated with more than one partner. 
Source:  OIG analysis of data from selected localities, 2011. 
 
Sixteen of the twenty-one localities with RN-specific plans had 
coordinated with Federal partners 
The 16 localities that coordinated with Federal partners coordinated most 
often with CDC and DOE, with 12 localities coordinating with each.  Ten 
localities coordinated with DHS and NRC.  Nearly half of the 21 localities 
had coordinated with three DOE programs:  FRMAC, RAP, and 
REAC/TS.  Only two localities had coordinated with NEST.  Five of the 
twenty-one localities had not coordinated with the Federal partners we 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  23   
   
examined.  Two localities provided additional Federal partners with which 
they had coordinated.  One locality listed FDA, USDA, and EPA; the other 
locality listed only EPA. 
Ten of the twenty-one localities with RN-specific plans had 
coordinated with their State partners 
All 10 localities that coordinated with the State RCPs indicated that they 
had defined their State RCPs role within their written plans.  Eight 
localities indicated they had worked with the State RCPs to write public 
health RN-specific emergency plans.  Seven localities reported that the 
State RCPs served as sources of expertise in their planning efforts.  Fewer 
localities reported they had held training (three) and conducted exercises 
(two) involving their State RCPs.  Eleven localities had not coordinated 
with the State RCPs.   
Fourteen of the twenty-one localities with RN-specific plans 
had coordinated with local partners 
Of the 14 localities that coordinated with local medical community 
members, 9 defined medical community members roles in their written 
plans.  All nine defined the roles of hospitals.  Seven defined Emergency 
Management Services roles in their written plans.  County health 
departments roles were defined in five localities written plans, and two 
localities had defined the role of clinicians.   
In addition to defining the roles of medical community members, these 14 
localities had engaged with them in other ways.  Eight held exercises, four 
developed MOUs, and three conducted training.  One locality worked with 
medical community members to help write its local public health RN 
plans.  Seven localities had not coordinated with local medical community 
members. 
Most State and local officials are aware of Federal 
guidance sources available to aid RN-specific public 
health planning but requested more comprehensive 
and specific planning tools  
Most of the 51 State and local officials involved in planning for the 40 
selected localities were aware of the majority of the 8 guidance sources 
included in our information request.70  These sources included guidance 
from CDC, ASPR, and DOE.  Fewer respondents had used these sources 
 
70 We did not combine responses from local public health departments that shared planning responsibility with 
their States because we were interested in whether all entities involved in planning for the 40 selected localities 
were aware of or had used the available Federal guidance sources.  These analyses included 19 State and 32 
local respondents. 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  24   
   
in their planning.  Respondents generally rated the sources as useful but 
stated that more comprehensive and specific planning tools were needed.   
Between 12 and 38 State and local respondents reported using 
each of the Federal guidance sources  
The most frequently used source was CDCs Radiation Emergency 
Preparedness Web site; 38 respondents indicated they had used it.  The 
source used the least was ASPRs Radiological Dispersal Device Playbook 
(12 respondents).  However, the playbook had been released only 
approximately 6 months prior to our data collection.  Additionally, it is 
intended for Federal decisionmakers, not as a guide for State and local 
planning.  However, this playbook provides useful information about RN 
incidents that can assist local planning.  The remaining sources were used 
by 16 to 27 respondents.  See Table 3 for the number of respondents aware 
of each source, the average ratings of usefulness for each source, and the 
number of respondents that were unaware of each source. 
      
Table 3:  State and Local Awareness and Use of Federal Guidance Sources 
Number of   
Respondents  Number of 
  Aware of  Number of  Respondents  
  Guidance  Respondents  Not Aware of 
  Source   Using Guidance  Average  Guidance 
Federal Guidance Sources  (out of 51)  Source   Rating*  Source 
CDCs Radiation Emergency Preparedness 
48   38  4.1  3 
Web site 
CDCs Medical Management Toolkit  39   26  4.2  12 
CDCs Population Monitoring Toolkit  37   27  4.3  14 
DOEs REAC/TS Web site  35   23  4.4  16 
ASPRs REMM Web site  33   22  4.2  18 
DOEs NNSA Web site  32   18  3.7  19 
CDCs Laboratory Analytical Methods  27   16  3.5  24 
ASPRs Radiological Dispersal Device 
21   12  3.9  30 
Playbook 
* 1 = not at all useful, 2 = somewhat useful, 3 = neutral, 4 = useful, 5 = very useful. 
 
Source:  OIG analysis of data from selected localities, 2011.
 
State and local respondents requested additional guidance 
materials 
State and local officials provided comments regarding available guidance 
and the need for more.  These comments fell into five categories: 
  Fifty-three percent of comments discussed the need for more 
specific guidance materials, templates for planning, best practices, 
and standards for planning and coordination.   
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  25   
   
  Fourteen percent discussed the need to train State and local public 
health officials on the unique aspects of RN incident public health 
response.   
  Nine percent identified a need for a consolidated list or Web site 
list of resources.   
  Eight percent identified a need for more promotion of the current 
resources.   
  Eighteen percent were classified as other and did not fall into 
any of the above categories.  Examples of these comments include: 
  requesting more funding at the local level; 
o
  naming other resources found helpful;  
o
  stating that if HHS required it, States and localities would 
o
plan for RN incidents; 
  suggesting that RN tools to estimate mass casualty and 
o
mass illness be made similar to pandemic influenza-
medical surge materials; 
  suggesting that planners need assistance in understanding 
o
the need for coordination; and  
  requesting guidance that is easier to understand. 
o
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  26   
   
RECOMMENDATIONS  
The 2010 National Security Strategy identifies a terrorist attack with a 
nuclear weapon as one of the greatest and most urgent dangers facing the 
American people.  In Japan, the release of radiation from a nuclear 
powerplant after an earthquake and tsunami on March 11, 2011, further 
underscores the importance of preparedness for all radiological incidents.  
Although NRC regulates nuclear powerplants and requires them to have 
emergency planning, no requirements exist for localities to have public 
health emergency plans for nonpowerplant RN incidents, such as terrorist 
attacks.  However, localities may not need an RN-specific public health 
plan if an RN incident is not identified as a high-risk threat for their areas.        
The National Preparedness Guidelines recommend incident-specific 
planning based on a jurisdictions risk assessment.  CDC provides           
62 grantees with PHEP funding to develop all-hazards plans, which can 
also be used for incident-specific planning.   In March 2011, after data 
collection for this report was completed, CDC released new guidelines for 
the next 5-year cycle of the PHEP cooperative agreement.  However, there 
are no requirements that PHEP grantees conduct RN-specific planning or 
use their jurisdictions risk assessments to prioritize their public health 
emergency planning.  Using risk assessments to prioritize incident-specific 
planning is one way localities can be strategic in the use of their limited 
resources. 
Our report focused only on State and local preparedness for the public 
health aspects of planning and response for nonpowerplant incidents.  We 
found that 36 of the 40 selected localities conducted risk assessments to 
identify threats to their jurisdictions.  However, localities that rated an RN 
incident as a high-priority threat did not always conduct RN-specific 
planning.  Conversely, over half of those that rated RN incidents as low 
priority had RN-specific planning. 
We also found that 21 of the 40 selected localities had conducted RN-
specific public health planning.  These 21 localities varied in which of the 
5 public health areas their planning addressed, as well as the types of 
planning activities they had engaged in within each area.  A localitys 
proximity to a nuclear powerplant did not correspond to its public health 
planning for nonpowerplant RN incidents.   
Further, we found that coordination between localities and Federal, State, 
and local partners varied.  Finally, most of the State and local respondents 
were aware of the Federal guidance sources in our review but expressed a 
need for more comprehensive and specific planning tools.   
Therefore, we recommend that CDC: 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  27   
   
Work with grantees to more closely align incident-specific 
public health planning with their jurisdictions prioritized 
threats 
The 2011 PHEP guidance encourages grantees to conduct all-hazards 
public health risk assessments.  However, CDC should provide additional 
guidance on the use of incident-specific risk assessments.  Specifically, 
CDC should work with grantees to ensure that incident-specific risk 
assessments are considered in their jurisdictions public health emergency 
priorities and subsequent planning.  CDC should work with grantees to tie 
PHEP-funded planning activities to specific local threats.   
Provide more specific guidance that outlines the public health 
areas of responsibility and the key components of each area to 
include in RN-specific public health planning  
Although 21 localities had conducted RN-specific public health planning, 
the public health areas of responsibility addressed in this planning varied 
and only 2 localities addressed all 5 areas.  Therefore, CDC, in 
coordination with grantees, could improve RN incident planning by taking 
the following actions: 
  Prioritize the planning areas in which grantees should focus their 
efforts and resources to improve public health preparedness to 
respond to an RN incident. 
  Provide a comprehensive list of the components of an RN-specific 
public health plan that may not be included in a general all-hazards 
plan. 
  Encourage sharing of RN incident public health planning strategies 
among States, localities, and other health care providers (e.g., 
hospitals, EMS) so that promising practices and creative ideas can 
be identified. 
  Provide grantees with information on guidance materials available 
from HHS and other Federal departments.  
Provide more guidance on coordination with other entities for 
RN-specific public health planning  
CDC should continue to provide information to grantees regarding the 
entities that they should coordinate with for RN-specific public health 
planning.  Grantees should know about available resources in their 
jurisdictions as well as at the Federal level so they can consider 
incorporating these partners into their RN-specific public health planning.   
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  28   
   
Provide more training to grantees about the unique aspects of 
an RN incident  
CDC should continue to work with grantees to develop training that 
addresses the unique public health scenarios that result from RN incidents.  
Grantees may not be aware that these unique scenarios could require 
planning beyond an all-hazards plan.  This training could be conducted by 
CDC, or CDC could develop training materials that grantees could use to 
conduct their own training. 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CDC concurred with all four of our recommendations and provided 
additional information about its current efforts in the 2011 PHEP 
guidance.  Specifically, CDC noted that it is working with States and 
localities to tie their PHEP-funded planning activities to the threats 
identified as priorities in their jurisdictions.  CDC also notes that the 2011 
PHEP guidance encourages grantees to assess their preparedness status 
and to determine their priorities.  CDC plans to provide more explicit 
guidance regarding the jurisdictional risk assessment process and how to 
use the outcomes to identify and prioritize specific threats and to develop 
strategies and planning activities to mitgate those risks.  Finally, CDC will 
require, rather than strongly encourage, grantees to conduct risk 
assessments to identify hazards, vulnerabilities, and risks for their 
jurisdictions public health systems. 
In response to our second recommendation, CDC noted that in the 2011 
PHEP guidance, RN incidents are well represented in 9 of the 15 
capabilities.  CDC emphasized that public health planning is only one 
component of RN incident planning and that State and local public health 
agencies must coordinate planning with State and local Emergency 
Management as well as RCPs.  CDC plans to incoporate more specific 
planning guidance for RN incidents when developing individual technical 
assistance plans for jurisdictions that have identified RN incidents as a 
high-priority threat. 
In response to our third recommendation, CDC plans to continue to 
provide guidance and technical assistance to grantees that have identified 
RN incidents as a high-priority threat.  CDC noted that it should work with 
other Federal agencies to share information on available RN incident 
guidance and resources with State and local partners. 
Finally, in response to our fourth recommendation, CDC will continue to  
work with grantees to identify training resources and technical assistance 
for grantees using its existing training resources. 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  29   
   
We support CDCs efforts to address these issues and encourage it to 
continue making progress in these areas.  For the full text of CDCs 
comments, see Appendix D. 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  30   
   
APPENDIX A 
Forty Most Populous Metropolitan Statistical Areas and the Selected Localities 
Percentage 
of U.S. 
Metropolitan Statistical Area   Population  Selected Locality 
Population 
(Cumulative) 
New YorkNorthern New JerseyLong Island  19,069,796  6.2  New York City, NY 
Los AngelesLong BeachSanta Ana  12,874,797  10.4  Los Angeles, CA 
ChicagoNapervilleJoliet  9,580,567  13.5  Chicago, IL 
DallasFort WorthArlington  6,447,615  15.6  Dallas, TX 
PhiladelphiaCamdenWilmington  5,968,252  17.6  Philadelphia, PA 
HoustonSugar LandBaytown  5,867,489  19.5  Houston, TX 
MiamiFort LauderdalePompano Beach  5,547,051  21.3  Miami, FL 
WashingtonArlingtonAlexandria  5,476,241  23.1  Washington, DC 
AtlantaSandy SpringsMarietta  5,475,213  24.9  Atlanta, GA 
BostonCambridgeQuincy  4,588,680  26.3  Boston, MA 
DetroitWarrenLivonia  4,403,437  27.8  Detroit, MI 
PhoenixMesaScottsdale  4,364,094  29.2  Phoenix, AZ 
San FranciscoOaklandFremont  4,317,853  30.6  San Francisco, CA 
RiversideSan BernardinoOntario  4,143,113  32.0  Riverside, CA 
SeattleTacomaBellevue  3,407,848  33.1  Seattle, WA 
MinneapolisSt. PaulBloomington  3,269,814  34.1  Minneapolis, MN 
San DiegoCarlsbadSan Marcos  3,053,793  35.1  San Diego, CA 
St. Louis  2,828,990  36.1  St. Louis, MO 
TampaSt. PetersburgClearwater  2,747,272  36.9  Tampa, FL 
BaltimoreTowson  2,690,886  37.8  Baltimore, MD 
DenverAuroraBroomfield   2,552,195  38.7  Denver, CO 
Pittsburgh  2,354,957  39.4  Pittsburg, PA 
PortlandVancouverBeaverton  2,241,841  40.2  Portland, OR 
CincinnatiMiddletown  2,171,896  40.9  Cincinnati, OH 
SacramentoArden-ArcadeRoseville  2,127,355  41.6  Sacramento, CA 
ClevelandElyriaMentor  2,091,286  42.2  Cleveland, OH 
OrlandoKissimmee  2,082,421  42.9  Orlando, FL 
San Antonio  2,072,128  43.6  San Antonio, TX 
Kansas City  2,067,585  44.3  Kansas City, MO 
Las VegasParadise  1,902,834  44.9  Las Vegas, NV 
San JoseSunnyvaleSanta Clara  1,839,700  45.5  San Jose, CA 
Columbus  1,801,848  46.1  Columbus, OH 
CharlotteGastoniaConcord  1,745,524  46.6  Charlotte, NC 
IndianapolisCarmel  1,743,658  47.2  Indianapolis, IN 
AustinRound Rock  1,705,075  47.8  Austin, TX 
Virginia BeachNorfolkNewport News  1,674,498  48.3  Virginia Beach, VA 
ProvidenceNew BedfordFall River  1,600,642  48.8  Providence, RI 
NashvilleDavidsonMurfreesboroFranklin  1,582,264  49.3  Nashville, TN 
MilwaukeeWaukeshaWest Allis  1,559,667  49.8  Milwaukee, WI 
Jacksonville  1,328,144  50.3  Jacksonville, FL 
 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  31   
   
APPENDIX B 
Planning for 5 Radiological/Nuclear-Specific Public Health Areas Among 
the 21 Localities With Radiological/Nuclear-Specific Planning and Proximity 
to Nuclear Powerplants 
Is 
Locality 
Within 50 
Total  Miles of a 
Number of  Nuclear 
Locality  Population  Laboratory  Fatality  Areas  Power-
Code  Monitoring  Decontamination  Analysis*  Management  Communications  Addressed  plant? 
1  X  X  X  X  X  5  Yes 
2  X  X  X  X  X  5  No 
3  X  X  X    X  4  No 
4  X  X  X    X  4  No 
5  X  X    X  X  4  Yes 
6  X  X  X    X  4  Yes 
7  X  X    X  X  4  No 
8  X  X  X  X    4  Yes 
9  X  X  X    X  4  No 
10  X  X      X  3  No 
11  X  X      X  3  No 
12  X  X    X    3  Yes 
13  X  X      X  3  Yes 
14    X    X    2  Yes 
15  X      X    2  No 
16  X  X        2  No 
17  X  X        2  No 
18  X  X        2  No 
19  X  X        2  Yes 
20  X          1  Yes 
21          X  1  No 
 
       Total 
Number 
19  18  7  8  12   
of 
Localities  
Source:  Office of Inspector General analysis of data from selected localities, 2011. 
* Laboratory Analysis refers to whether localities had a plan for laboratory analysis; it does not indicate that the locality has the 
capability to perform the analyses required in a radiological or nuclear incident. 
 
 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  32   
   
APPENDIX C 
Localities Planning for the Key Components for Each of the Five 
Radiological/Nuclear-Specific Public Health Areas of Responsibility 
 
Table C-1:  Population Monitoring  
Number of Localities 
  With Plans 
Establishing contamination screening criteria (e.g., level of 
contamination that requires treatment)  13 
Developing radiation survey methods (e.g., procedures to properly 
screen population using various methods)  13 
Identifying radiation dose or risk estimation (e.g., guidelines to 
determine level of risk from contamination or exposure)  12 
Developing plans to establish community reception centers (CRC; e.g., 
locations to house a large number of individuals)  10 
Developing a system for population registry (e.g., tracking system to 
monitor contaminated individuals)  8 
Developing a system for epidemiological investigations (e.g., 
monitoring the effects of radiation on public health)  6 
Developing plans for handling special populations (e.g., disabled, 
elderly, children)  6 
Establishing protocols and procedures for clothing services (e.g., 
providing fresh clothes for individuals who have external 
contamination)  5 
Transporting the public away from the incident site and/or to the CRCs  7 
Establishing washing facilities (e.g., facilities for external 
decontamination washing)  5 
Establishing procedures for handling psychosocial issues (e.g., effects 
of stress resulting from the incident)  4 
Developing procedures for collecting human clinical biomarkers/lab 
samples (e.g., procedures for how and when to collect)  2 
Note:  Total does not add to 19 because localities planned for more than 1 of the 12 components. 
Source:  Office of Inspector General (OIG) analysis of data from selected localities, 2011. 
 
Table C-2:  Decontamination 
Number of Localities 
  With Plans  
Identifying individuals in need of decontamination and/or treatment 
12 
(e.g., measuring levels of contamination)  
Developing plans to communicate decontamination guidelines (e.g., 
11 
instructions to the public on how to wash) 
Establishing decontamination centers (e.g., facilities where the public 
6 
can wash off external decontamination) 
Identifying radioactive isotopes in individuals (e.g., properly using and 
4 
reading equipment) 
Note:  Total does not add to 18 because localities planned for more than 1 of the 4 components. 
Source:  OIG analysis of data from selected localities, 2011. 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  33   
   
Table C-3:  Laboratory Analysis  
Number of Localities 
  With Plans 
Developing a sample prioritization plan   2 
Determining throughput (e.g., number of samples analyzed per hour, 
4 
per day) 
Determining analytic capability (e.g., types of analyses that can be 
2 
performed on specific radionuclides) 
Determining analytic capacity (e.g., maximum number of samples that 
2 
can be analyzed) 
Note:  Total does not add to seven because localities planned for more than one of the four components. 
Source:  OIG analysis of data from selected localities, 2011. 
 
Table C-4:  Fatality Management  
Number of Localities 
  With Plans 
Establishing procedures for morgues (e.g., procedures to house 
4 
contaminated human remains) 
Establishing procedures for burial of contaminated remains (e.g., 
3 
special caskets, sealing of gravesites) 
Establishing procedures for autopsies (e.g., minimizing exposure from 
2 
autopsy on contaminated human remains) 
Establishing procedures for funeral homes (e.g., guidelines for 
2 
handling  contaminated remains) 
Establishing procedures for setting up control points (e.g., monitoring 
responders entering a mass casualty site containing contaminated  2 
human remains) 
Establishing procedures for transport of contaminated remains (e.g., 
implementing Department of Transportation regulations on  2 
transporting radioactive materials) 
Note:  Total does not add to eight because localities planned for more than one of the six components. 
Source:  OIG analysis of data from selected localities, 2011. 
 
Table C-5:  Communications  
Number of Localities 
  With Plans 
Drafting messages that can be immediately communicated to the 
10 
public if a radiological or nuclear (RN) incident occurs 
Establishing a communications strategy  (e.g., identifying points of 
7 
contact) 
Identifying credible sources to deliver messages to the public  4 
Conducting preincident messaging (e.g., making public service 
3 
announcements about how to respond to an RN incident) 
Note:  Total does not add to 12 because localities planned for more than 1 of the 4 components. 
Source:  OIG analysis of data from selected localities, 2011. 
 
 
 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  34   
   
APPENDIX D 
List of Abbreviations and Acronyms 
ASPR...................... Assistant Secretary for Preparedness and Response 
CDC ................................... Centers for Disease Control and Prevention 
CRC............................................................. community reception center 
DHS.................................................. Department of Homeland Security 
DOE ..................................................................... Department of Energy 
EPA ................................................... Environmental Protection Agency 
ESF ........................................................... Emergency Support Function 
FDA........................................................ Food and Drug Administration 
FEMA ................................... Federal Emergency Management Agency 
FRMAC.............. Federal Radiation Monitoring and Assessment Center 
HHS..................................... Department of Health and Human Services 
IND ............................................................... improvised nuclear device 
MOU .................................................. Memorandums of Understanding 
MSA .......................................................... Metropolitan Statistical Area 
NEST................................................ Nuclear Emergency Support Team 
NNSA .................................... National Nuclear Security Administration 
NRC .................................................... Nuclear Regulatory Commission 
NRF ........................................................ National Response Framework 
PHEP ........................................ Public Health Emergency Preparedness 
PHSA ............................................................. Public Health Service Act 
RCP .............................................................. Radiation Control Program 
REAC/TS .... Radiation Emergency Assistance Center and Training Site 
REMM .............................. Radiation Emergency Medical Management 
RN ................................................................ radiological and/or nuclear 
USDA .................................................... U.S. Department of Agriculture 
 
 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  35  APPENDIX E 
Agency Comments 
,<I 
("~ 	
DEPARTMENT OF HEALTH & HUMAN SERVICES  Public Health Service 
Agency for Toxic Substances 
and Disease Registry 
Atlanta GA 30333 
TO; 	 Daniel R. Levinson, Inspector General 

Department of Health and Human Services (HHS) 

FROM: 	 Thomas R. Frieden, M.D., M.P.H., Director 

Centers for Disease Control and Prevention 

SUBJECT: 	 OIG Draft Report: Local Public Health Preparedness for Radiological and Nuclear 
Incidents, OEI-04-10-00250 
The Centers for Disease Control and Prevention (CDC), Division ofState and Local Readiness 
(DSLR), appreciates the opportunity to review and comment on the Office ofInspector General's 
draft report, "Local Public Health Preparedness for Radiological and Nuclear Incidents."  Thank 
you for your review of this important issue. 
As stated in the draft report, the objective ofthis review was to determine the extent to which 
selected localities were prepared for a public health response to a radiological andlor nuclear 
(RN) incident by I) using their risk assessments to prioritize planning; 2) engaging in planning 
activities for five public health areas of responsibility; 3) coordinating with federal, state, and 
local partners; and 4) using federal guidance sources. The draft report identified four findings 
regarding local public health preparedness for radiological and nuclear incidents, and also 
provided recommendations to CDC to address these findings.  Please see tire attached for the 
OIG recommendations and CDC's related responses. 
Thank you for your review of local public health preparedness for radiological and nuclear 
accidents.  Please ask your staff to direct any questions or comments to Mr. ShaUll Ratliff, 
CDC's OIG Liaison, by telephone at (404) 639-2809, or bye-mail at iggao@cdc.gov. 
Thomas R. Frieden, M.D., M.P.H. 
Attachment 
1 
OEI-04-10-00250  Local Public Health Preparedness for RN Incidents  36  OIG Recommendations and CDC Responses 
Office ofInspector General (OIG) Recommendation: CDC should work wi th grantees to 
more closely align incident-specific public health planning to their jurisdictions' prioritized 
threats. 
DSLR Response: DSLR concurs in principle with this recommendation. CDC is working with 
states and localities to tie PHEP-funded planning activities to the threats or risks jurisdictions 
have identified as priorities. In April 2011, CDC released a new funding opportunity 
announcement (FOA) for the Public Health Emergency Preparedness (PHEP) cooperative 
agreement that included guidance to assist its 62 state, local, and territorial awardees in 
demonstrating measurable and sustainable progress toward achieving 15 specifically developed 
public health preparedness capabilities. These capabilities, described in CDC's Public Health 
Preparedness Capabilities: National Standards for State and Local Planning, 
(http://www.cdc.gov/phpr/capabilities/index.htm) are designed to assist state and local public 
health departments in identifying gaps in preparedness, determining specific jurisdictional 
priorities, and developing plans for building and sustaining capabilities. These national 
standards support an integrated, all-of-nation, capabilities-based approach to planning as 
advocated in Presidential Policy Directive-8: National Preparedness.  The need to prcpare for RN 
incidents is well-represented within the national standards, as nine of the 15 capabilities 
explicitly reference radiological preparedness and include specific information for RN planning 
at the state and local levels. Although threat prioritizations differ among jurisdictions, public 
health agencies are expected to factor RN threats into their individual prioritization methods. 
CDC's 2011 PHEP cooperative agreement guidance included a planning process that public 
health departments could use to help determine their preparedness priorities, plan appropriate 
preparedness activities and develop associated budgets, and demonstrate and evaluate 
achievement ofcapabilities. In releasing the PHEP guidance, CDC strongly recommended that 
awardees assess their current preparedness state, determine jurisdictional priorities, and develop 
short-and long-term plans based on their jurisdictional risk assessments and other jurisdictional 
inputs such as hazards and vulnerability analyses, emergency management plans,after-action 
reports/improvement plans, and previous performance measurement results. Awardees were 
then expected to develop appropriate budgets for the incident-specific, PHEP-funded activities 
they planned to conduct to address specific jurisdictional risks. 
CDC supports having state and local public health jurisdictions perform risk assessments.  Such 
risk assessments currently are recommended in the Public Health Preparedness Capabilities: 
National Standards for State and Local Planning document.  In developing the next PHEP 
funding opportunity announcement in 2012 and subsequent continuation guidance documents, 
CDC plans to provide more explicit guidance describing the jurisdictional risk assessment 
process and how to use the outcomes of that process to identify and prioritize specific incidents 
of greatest threat to jurisdictions and to develop strategies and PHEP-funded activities designed 
to reduce/mitigate the threats and risks.  In the future, CDC also will require, rather than strongly 
encourage, that awardees conduct risk assessments that identify the potential hazards, 
2 
OEI-04-10-00250  Local Public Health Preparedness for RN Incidents  37  vulnerabilities, and risks in the community that relate to the jurisdiction's public health, medical, 
and mentallbehavioral health systems. 
CDC will use the results of its current risk-based funding pilot to help inform the improved 
guidance it provides to awardees. CDC awarded $10 million in FY 2011 funding to 10 major 
urban areas (includes 14 states and the four directly funded localities) for an all-hazards public 
health risk reduction funding initiative. This funding is intended to promote and accelerate the 
development of strategies that mitigate the public health risks associated with higher population 
areas.  It is expected that through risk-based funding, awardees will accelerate their work on 
conducting and utilizing risk assessments, resulting in useful practices from the field that will 
help to better align incident-specific public health planning with jurisdictions' identified and 
prioritized threats. 
Office ofInspector General (OIG) Recommendation: CDC should provide more specific 
guidance that outlines the public health areas of responsibility and the key components ofeach 
area to include in RN-specific public health planning and improve RN incident planning, 
DSLR Response: DSLR concurs in principle with this recommendation. The need to prepare 
for RN incidents is well-represented within CDC's Public Health Preparedness Capabilities: 
National Standards for State and Local Planning, as nine of the 15 capabilities explicitly 
reference radiological preparedness. Public health areas of responsibility and the key 
components ofeach area regarding RN-specific public health planning that can improve RN 
incident planning are covered in the following capabilities: community preparedness, public 
health laboratory testing, community recovery, emergency operations coordination, fatality 
management, mass care, medical countermeasure dispensing, non-pharmaceutical interventions, 
and responder safety and health. Each ofthese capabilities includes RN preparedness guidance 
with various level ofdetail and identifies the role ofpublic health during RN incidents. 
Public health is a single component of a comprehensive RN plan.  State and local public health 
agencies must coordinate their plans and conduct planning with their state and local emergency 
management agencies and radiation control programs. Although public health has a significant 
role in this planning, such plaruling is a shared responsibility with other sectors. It should also be 
noted that given the variations in how statesllocalities operate, their public health structure, and 
responsibilities (EMS, fire department, how they work with other state and local governments, 
etc.), states and localities must have the flexibility to determine how they plan to coordinate such 
activities. 
To further support this recommendation, DSLR plans to incorporate more specific guidance 
regarding RN-specific public health planning when developing individual technical assistance 
strategies and plans for those jurisdictions that identify RN incidents as a high-priority threat for 
their jurisdictions. This guidance could include: 
 	 Information on the components of an RN-specific public health plan (population 

monitoring, decontamination, laboratory analysis, fatality management, and 

communications) that may not be included in a general all-hazards plan. 

 	 Information on guidance materials, toolkits, and other resources available from ffilS and 
other federal departments. 
3 
OEI-04-10-00250  Local Public Health Preparedness for RN Incidents  38   	 Sharing ofpublic health planning strategies for RN incidents among states, localities, 
and other healthcare providers (e.g., hospitals, EMS) so that promising practices and 
creative ideas can be identified. 
Office of Inspector General (OIG) Recommendation: CDC should provide more guidance on 
coordination with other entities for RN-specific public health planning. 
DSLR Response: DSLR concurs in principle with this recommendation. CDC, along with other 
federal departments and agencies, should share information on available RN guidance and other 
resources with state and local partners. 
CDC emphasizes to its awardees that RN preparedness remains a key component within nine 
public health preparedness capabilities. Additionally, CDC and other federal agencies and 
organizations are active members of and participating in ASTHO's National Alliance for 
Radiation Readiness (NARR), a new and growing organization whose mission is to enhance 
radiological preparedness capability and capacity in public health and health. care systems 
through a coalition of organizations committed to improving the nation's ability to prepare, 
respond, and recover from radiological emergencies at the local, state, and national levels. 
CDC will continue to provide guidanee and technical assistance to awardees that highlight the 
importance ofRN-specific public health planning for those jurisdictions that identify RN 
incidents as a high-priority threat for their jurisdictions using the many helpful resources 
provided in CDC's Public Health Preparedness Capabilities: National Standards/or State and 
Local Planning document. 
Office of Inspector General (OIG) Recommendation: CDC should provide more training to 
grantees about the unique aspects of an RN incident. CDC should continue to work with 
grantees to develop training that addresses the unique public health scenarios that result from RN 
incidents. 
DSLR Response: DSLR concurs in principle with this recommendation.  CDC will continue to 
identify training resources for awardees and provide and coordinate technical assistance using 
existing training resources. 
4 
OEI-04-10-00250  Local Public Health Preparedness for RN Incidents  39   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Dwayne Grant, Regional 
Inspector General for Evaluation and Inspections in the Atlanta regional 
office, and Jaime Durley, Deputy Regional Inspector General.   
Hannah Burk served as the lead analyst for this study.  Other principal 
Office of Evaluation and Inspections staff from the Atlanta regional office 
who contributed to the report include Sarah McLaulin; central office staff 
who contributed include Kevin Farber and Talisha Searcy. 
 
 
OEI-04-10-00250      Local Public Health Preparedness for RN Incidents  40   
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is 
to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the 
health and welfare of beneficiaries served by those programs.  This statutory mission is carried out through 
a nationwide network of audits, investigations, and inspections conducted by the following operating 
components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with 
its own audit resources or by overseeing audit work done by others.  Audits examine the performance of 
HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  These assessments help 
reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, 
and the public with timely, useful, and reliable information on significant issues.  These evaluations focus 
on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of 
departmental programs.  To promote impact, OEI reports also present practical recommendations for 
improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and 
misconduct related to HHS programs, operations, and beneficiaries.  With investigators working in all 
50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the 
Department of Justice and other Federal, State, and local law enforcement authorities.  The investigative 
efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support for OIGs internal 
operations.  OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty cases.  In 
connection with these cases, OCIG also negotiates and monitors corporate integrity agreements.  OCIG 
renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement 
authorities.