The concept of bringing out a special issue of Journal of Pharmacy and Bioallied Sciences on Chemical, Biological, Radiological, and Nuclear (CBRN) Disaster Management is apt and timely.  I am sure this initiative of yours and efforts poured therein will result in raising the level of awareness amongst the biomedical scientists in general and pharmacists in particular.  Through the medium of this letter, I will briefly dwell on of the major Medical Preparedness and Mass Casualty Management issues of CBRN mitigation and training undertaken under the aegis of the National Disaster Management Authority (NDMA). 

CBRN, an acronym referring to Chemical, Biological, Radiological, and Nuclear, is in common use worldwide, with the term 'CBRN Defence' used in reference to CBRN passive protection, contamination avoidance, and CBRN mitigation.  Effects of CBRN agents are varied and dependant on the agent involved, impingement area, incident conditions (weather, terrain, time), and exposures to life, systems, and environment.  The CBRN terrorism activities differ from a normal terrorist attack, because CBRN agents additionally cause contamination and specific health hazards.  The agent used may affect health of victims like chemical/radiation burns, heat burns, injuries, infection, poisoning, disabilities, etc.  The net result is psychological vulnerability and neuropsychological sequel, fleeing of affected community due to fear of unknown, resulting in exponential spread of disaster victims, and overwhelming of hospitals by people believing themselves to be affected.  The worst case scenario is much more threatening. 

The National vision for CBRN Disaster management is as follows:

To prevent the incidence by taking all 'reasonably practical' technical safety and security measures. In the event of occurrence of CBRN event - take timely, managed, controlled, coordinated, and effective response measures to mitigate their consequences (so as to minimize risks to health, life, and environment). 

CBRN incidents can be mass casualty situation, and are responded to under the assumption that they are deliberate malicious acts with the sole intention to kill, sicken, and/or disrupt society.  Suddenness, lack of warning, difficulty in detection and incubation period in case of biological emergencies are some of the additional challenges in management of CBRN casualties.  Moreover, even if warning is there, people\'s response will be a challenge.  Medical First Responders are likely to be health care providers, including emergency departments, primary care physicians, and hospitals.  Prioritization of care to maximize the use of available resources enhances the survival of the disaster victims.  During a mass casualty event involving CBRN agents, the Utilitarian Rule -- *Do the Greatest Good for the Greatest Number of Disaster Victim in the light of limited resources* -- must be followed. 

CBRN incidents call for the decontamination, which entails immediate removal of the unabsorbed contaminant from the body of victim, followed by treatment of a significant numbers of casualties while ensuring the safety of the responder.  The training through mock exercise needs to be conducted to hone skills and develop reflexes of the responders, so that they can promptly remove victim from the 'agent' source and also remove 'agent from' contaminated personnel.  The key of success is swiftness and correctness.  Other important commandments are as follows:

Triage -- prioritizating patients based on clinical condition. Resuscitate and treat patients as per triage. Decontaminate the victims so as to prevent spread of contamination. Transport victims on priority as per triage classification. Re-triage constantly (a dynamic process) throughout all the phases of management. Only move the dead when it is affecting the response. Training, both theoretical and practical, with periodic refresher training. 

Training and research are two integral critical components to combat the evolving threat of CBRN incidents.  Mitigation of CBRN emergencies is easy, provided we are prepared, equipped, and trained for the same without slightest relaxation. 

The system challenge requires innovative and multidisciplinary medical management approach for preparedness for response, training, hospital safety and security.  The recent Mayapuri Cobalt-60 radiation exposure incidence has exposed the faults and weak links of the whole system.  In this incident, it became apparent that the community and the governance both are not fully equipped and prepared for meeting such situations.  Lessons learnt should be used to plug the voids The Common Wealth Games 2010 shall be a litmus test to test our preparedness and response capabilities to manage covert CBRN scenarios.  Therefore, there is a strong need to prepare comprehensive emergency plans to tackle CBRN incidents keeping in mind the system challenges, and build capacities matching with threat perception, raise the level of preparedness and hone response mechanisms.  This calls for a vibrant institutional system to be put in place.  The NDMA is actively working towards institutionalizing an approach towards CBRN Disaster Management and has formulated valuable guidelines depicted in [Table 1](#T1){ref-type="table"}. 

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CBRN disaster management guidelines

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Management of mass casualty incidents due to covert attacks involving CBRN agents or human-made accidents involving them, requires overall preparedness and risk reduction at all levels including development of an efficient response mechanism.  This needs contingency planning, capacity development in terms of provision of basic infrastructure, trained human resources, equipment, and evolvement of coordination and implementation mechanisms.  The nodal ministries, technical support organizations, and other stakeholders & emergency functionaries have a big role to play at all levels.  Disaster Management Authorities at various levels (National, State, and District) should come up with implementable Action Plans and Standard Operating Procedures and assign dedicated resources for achieving the same. 

I congratulate the Editor-in-Chief and Members-Editorial Board of the Journal of Pharmacy and Bio-allied Sciences for this special issue.