Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

 

LOCAL PUBLIC HEALTH 

PREPAREDNESS FOR 

RADIOLOGICAL AND 

NUCLEAR INCIDENTS

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 Nation’s 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 RNspecific 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 RNincident 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/NuclearSpecific 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 
 

OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 1

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/DHSINDResponse.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 2

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

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.

 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.

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. 1–199.

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.
 

OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 3

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 department’s 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 HHS’s 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

All-Hazards and Risk-Based Planning

 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. 

Both the National Preparedness Guidelines and the NRF support the 

development of all-hazards emergency response planning.17

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. 

 All-hazards 

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. 
 

OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 4

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 incidentspecific planning supplement all-hazards planning according to each 

jurisdictions’ risk assessment. This allows emergency planning to be 

tailored to a jurisdiction’s specific needs and identified risks.20 Using risk 

assessments to determine planning priorities also allows States and localities 

Public Health Emergency Preparedness Cooperative 

Agreements 

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 NRF’s incident-specific annexes to develop plans for 

these risks. 

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

18 DHS, National Preparedness Guidelines, loc. cit.

 Specifically, grantees use PHEP funding to support public health 

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.
 

OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 5

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

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 CDC’s 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. 

 This new guidance 

breaks down planning elements by 15 capabilities and identifies planning 

priorities for each. 

CDC’s 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 jurisdiction’s 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.
 

OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 6

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 locality’s 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.
 

OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 7

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

Population monitoring. Population monitoring refers to identifying, 

screening, measuring, and monitoring people for exposure to or 

contamination from radioactive materials.

 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. 

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

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.

 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. 

38

Population-monitoring activities are often the beginning stages of other RNspecific 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.
 

OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 8

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 individual’s 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_Detonation2nd_Edition_FINAL.pdf. on October 17, 2011.

40 The Strategic National Stockpile is managed by CDC’s 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.
 

OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 9

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. 25–26.

 

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.
 

OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 10

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

Localities can also coordinate with their States’ Radiation Control Programs 

(RCP) as a source of expertise on radiation.

 States and localities are not 

required to take this training; however, it is available to assist with 

RN-incident planning. 

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

54 DHS, Nuclear/Radiological Incident Annex, p. 18.

 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 

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 11

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 

CDC’s 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 12

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

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.

 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. 

65

METHODOLOGY

 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. 

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 13

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 locality’s 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 14

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 State’s responses as the locality’s 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 locality’s 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 15

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

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 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. 

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 16

the entity’s 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 

entity’s 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: CDC’s Radiation Emergency 

Preparedness Web site, CDC’s Population Monitoring Toolkit, CDC’s 

Medical Management Toolkit, CDC’s Laboratory Analytical Methods,

ASPR’s 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 source’s 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 17

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 18

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 

jurisdiction’s 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

Conducted Risk 

Assessment

Identified RN 

Incidents as a 

Threat

Determined RN 

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 19

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 highpriority threat, eight as a moderate-priority threat, and seven as a lowpriority 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 highpriority 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 Nation’s 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 20

(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 21

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 22

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 RNspecific 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 23

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

Coordination Group

Number of Localities 

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 24

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 25

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 CDC’s Radiation Emergency 

Preparedness Web site; 38 respondents indicated they had used it. The 

source used the least was ASPR’s 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

Federal Guidance Sources

Number of 

Respondents 

Aware of 

Guidance 

Source 

(out of 51)

Number of 

Respondents 

Using Guidance 

Source 

Average 

Rating*

Number of 

Respondents 

Not Aware of 

Guidance 

Source

CDC’s Radiation Emergency Preparedness 

Web site 48 38 4.1 3 

CDC’s Medical Management Toolkit 39 26 4.2 12

CDC’s Population Monitoring Toolkit 37 27 4.3 14

DOE’s REAC/TS Web site 35 23 4.4 16

ASPR’s REMM Web site 33 22 4.2 18

DOE’s NNSA Web site 32 18 3.7 19

CDC’s Laboratory Analytical Methods 27 16 3.5 24

ASPR’s Radiological Dispersal Device 

Playbook 21 12 3.9 30

* 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 26

• 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:

o requesting more funding at the local level;

o naming other resources found helpful; 

o stating that if HHS required it, States and localities would 

plan for RN incidents; 

o suggesting that RN tools to estimate mass casualty and 

mass illness be made similar to pandemic influenzamedical surge materials;

o suggesting that planners need assistance in understanding 

the need for coordination; and 

o requesting guidance that is easier to understand. 
 

OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 27

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 jurisdiction’s 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 RNspecific 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 locality’s 

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 28

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 29

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 30

We support CDC’s efforts to address these issues and encourage it to 

continue making progress in these areas. For the full text of CDC’s 

comments, see Appendix D. 
 

OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 31

APPENDIX A

Forty Most Populous Metropolitan Statistical Areas and the Selected Localities

Metropolitan Statistical Area Population

Percentage 

of U.S. 

Population 

(Cumulative)

Selected Locality

New York–Northern New Jersey–Long Island 19,069,796 6.2 New York City, NY

Los Angeles–Long Beach–Santa Ana 12,874,797 10.4 Los Angeles, CA

Chicago–Naperville–Joliet 9,580,567 13.5 Chicago, IL

Dallas–Fort Worth–Arlington 6,447,615 15.6 Dallas, TX

Philadelphia–Camden–Wilmington 5,968,252 17.6 Philadelphia, PA

Houston–Sugar Land–Baytown 5,867,489 19.5 Houston, TX

Miami–Fort Lauderdale–Pompano Beach 5,547,051 21.3 Miami, FL

Washington–Arlington–Alexandria 5,476,241 23.1 Washington, DC

Atlanta–Sandy Springs–Marietta 5,475,213 24.9 Atlanta, GA

Boston–Cambridge–Quincy 4,588,680 26.3 Boston, MA

Detroit–Warren–Livonia 4,403,437 27.8 Detroit, MI

Phoenix–Mesa–Scottsdale 4,364,094 29.2 Phoenix, AZ

San Francisco–Oakland–Fremont 4,317,853 30.6 San Francisco, CA

Riverside–San Bernardino–Ontario 4,143,113 32.0 Riverside, CA

Seattle–Tacoma–Bellevue 3,407,848 33.1 Seattle, WA

Minneapolis–St. Paul–Bloomington 3,269,814 34.1 Minneapolis, MN

San Diego–Carlsbad–San Marcos 3,053,793 35.1 San Diego, CA

St. Louis 2,828,990 36.1 St. Louis, MO

Tampa–St. Petersburg–Clearwater 2,747,272 36.9 Tampa, FL

Baltimore–Towson 2,690,886 37.8 Baltimore, MD

Denver–Aurora–Broomfield 2,552,195 38.7 Denver, CO

Pittsburgh 2,354,957 39.4 Pittsburg, PA

Portland–Vancouver–Beaverton 2,241,841 40.2 Portland, OR

Cincinnati–Middletown 2,171,896 40.9 Cincinnati, OH

Sacramento–Arden-Arcade–Roseville 2,127,355 41.6 Sacramento, CA

Cleveland–Elyria–Mentor 2,091,286 42.2 Cleveland, OH

Orlando–Kissimmee 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 Vegas–Paradise 1,902,834 44.9 Las Vegas, NV

San Jose–Sunnyvale–Santa Clara 1,839,700 45.5 San Jose, CA

Columbus 1,801,848 46.1 Columbus, OH

Charlotte–Gastonia–Concord 1,745,524 46.6 Charlotte, NC

Indianapolis–Carmel 1,743,658 47.2 Indianapolis, IN

Austin–Round Rock 1,705,075 47.8 Austin, TX

Virginia Beach–Norfolk–Newport News 1,674,498 48.3 Virginia Beach, VA

Providence–New Bedford–Fall River 1,600,642 48.8 Providence, RI

Nashville–Davidson–Murfreesboro–Franklin 1,582,264 49.3 Nashville, TN

Milwaukee–Waukesha–West 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 32

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

Locality 

Code

Population 

Monitoring Decontamination

Laboratory 

Analysis*

Fatality 

Management Communications

Total 

Number of 

Areas 

Addressed

Is 

Locality 

Within 50 

Miles of a 

Nuclear 

Powerplant?

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 

of 

Localities 

19 18 7 8 12

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 33

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

(e.g., measuring levels of contamination) 12

Developing plans to communicate decontamination guidelines (e.g., 

instructions to the public on how to wash) 11

Establishing decontamination centers (e.g., facilities where the public 

can wash off external decontamination) 6

Identifying radioactive isotopes in individuals (e.g., properly using and 

reading equipment) 4

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 34

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, 

per day) 4

Determining analytic capability (e.g., types of analyses that can be 

performed on specific radionuclides) 2

Determining analytic capacity (e.g., maximum number of samples that 

can be analyzed) 2

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 

contaminated human remains) 4

Establishing procedures for burial of contaminated remains (e.g., 

special caskets, sealing of gravesites) 3

Establishing procedures for autopsies (e.g., minimizing exposure from 

autopsy on contaminated human remains) 2

Establishing procedures for funeral homes (e.g., guidelines for 

handling contaminated remains) 2

Establishing procedures for setting up control points (e.g., monitoring 

responders entering a mass casualty site containing contaminated 

human remains)

2

Establishing procedures for transport of contaminated remains (e.g., 

implementing Department of Transportation regulations on 

transporting radioactive materials)

2

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 

public if a radiological or nuclear (RN) incident occurs 10

Establishing a communications strategy (e.g., identifying points of 

contact) 7 

Identifying credible sources to deliver messages to the public 4 

Conducting preincident messaging (e.g., making public service 

announcements about how to respond to an RN incident) 3 

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 35

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
APPENDIX E 

Agency Comments 

("~ DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service ,<I 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 
OEI-04-10-00250 Local Public Health Preparedness for RN Incidents 40

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.
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 OIG’s 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.