Introduction
Radiation response readiness is crucial because radiological incidents—whether from nuclear power plant accidents, medical emergencies involving radioactive materials, or acts of terrorism—pose significant public health risks. While the probability of these incidents is low, the consequences can be very high. Effective preparedness ensures that emergency responders can quickly assess and mitigate these risks, minimizing exposure to radiation and protecting both individuals and communities. A well-coordinated response can significantly reduce the likelihood of long-term health effects, such as cancer,Reference Richardson, Leuraud and Laurier1 and helps maintain public trust in health and safety systems during crises.
A radiological incident could result in hundreds of thousands of lives impacted or lost. Without proper coordination, planning, and resources to coordinate the response to a radiological incident, many more lives may be affected. For this reason, effective coordination across all levels of government and other non-governmental organizations before a radiological incident occurs may enhance preparedness and response. During the preparedness phase of the disaster cycle, partners can define roles and responsibilities and collaborate on strategic thinking. While these preparedness actions are common in other incidents such as natural disasters, radiological incidents have unique hazards and considerations that require input from experts from multiple sectors. Previous after-action reports from emergency responses show that coordination and communication across sectors and levels of government have experienced difficulties and need improvement.Reference Copper, Mayigane and Pei2–Reference Savoia, Agboola and Biddinger5
An interdisciplinary approach involving public health, health care, radiation control, and emergency management is essential for effective radiological incident response. Public health agencies provide critical information on radiation exposure risks and health effects, while health care providers are vital for treating and testing those affected and managing long-term health monitoring. Specifically, radiation control programs provide important information on public health impacts of radiation, radiation safety, and other specialized radiation expertise. Emergency management agencies ensure that available resources are allocated efficiently, communication systems are in place, and assistance processes are established. Collaboration among these sectors facilitates comprehensive planning, training, and resource sharing, ultimately leading to a more resilient system that can respond swiftly and effectively to any radiological incident. Establishing agency expectations and identifying known gaps is paramount for preparedness.
Key Challenges in Radiation Readiness
There are several key challenges that currently present barriers to effective radiation readiness and response. Some of these challenges include interagency communication and collaboration, cross-sector coordination, public communication, training and workforce capacity, and funding and resource gaps. These challenges can be especially difficult for response at the state and local level as these jurisdictions bear much responsibility in responding to a radiological incident.
Interagency Communication and Collaboration
Effective response requires seamless communication and collaboration between public health, radiation control, emergency management, and health care sectors, but differing priorities, protocols, and planning and response standards can create silos.4 This can result in confusion during a crisis. Considering the breadth of agencies that would be involved, barriers to inter-agency communication are highly impactful in response to a radiological incident. Swift and efficient communication and coordination among local emergency services and public health agencies to deploy state resources are vital to an effective response.
Training and Workforce Capacity
There are gaps in training and capacity within the radiation readiness workforce in several key areas. First, many emergency responders, including first responders and health care personnel, may lack specialized training in radiological incidents.Reference Leek, Keren, Blumenthal, Irwin and Musolino6 While they receive general emergency response training, specific instruction on radiation detection, decontamination protocols, and medical management of radiation exposure can be insufficient. Limited exercises and drills that specifically address radiological incidents can hinder preparedness as responders may not have the opportunity to practice their skills in realistic settings, especially with scenarios of increasing complexity. This gap can lead to delays in effective response and increased risk for both responders and the public.Reference Leek, Keren, Blumenthal, Irwin and Musolino6 Secondly, health agencies are struggling with recruitment and retention. Even within agencies that provide regularly scheduled training, personnel turnover and conflicting priorities can impact readiness.Reference Leider, Yeager, Kirkland, Krasna, Hare Bork and Resnick7 Finally, the integration of radiological incident planning within broader emergency management frameworks can be lacking, leading to disjointed efforts and unclear roles during an actual incident. With many varied priorities, response scenarios, and federal requirements, it is difficult to maintain a sustained interest in high-consequence, low-probability events such as radiological incidents.
Funding and Resources
Jurisdictions currently face several funding gaps and resource challenges in radiation readiness that can hinder effective emergency response. A primary issue is the constrained resources, particularly in rural and underserved areas. Many health agencies may encounter challenges in updating training, equipment, medical countermeasures, and technology necessary for a rapid and effective response to radiological incidents. These agencies often rely on federal resources to fill these gaps. This financial strain can lead to gaps in preparedness as jurisdictions may prioritize other emergency needs over training and resources specific to radiological incidents.
In rural and suburban areas, funding and resource challenges may be exacerbated. The lower population density can mean that resources and emergency and radiation control personnel are more spread out, making rapid response more complicated. Additionally, rural areas may have limited access to advanced medical facilities, medical countermeasures, or specialized radiation detection equipment (i.e., Portal monitors and handheld Geiger counters).
State and local focus areas
Current areas of focus for radiation readiness in state and local jurisdictions emphasize preparedness, coordination, and community resilience. One significant initiative is the establishment of community reception centers, which serve as designated locations for the public to receive information, medical evaluations, and potential decontamination following a radiological incident. These centers are crucial for managing public concerns and ensuring that resources are effectively allocated to those affected.8 Additionally, the distribution of potassium iodide is a key preventative measure, as it helps protect the thyroid from absorbing radioactive iodine during nuclear power plant incidents.9 State and local health departments are actively working on plans for efficient distribution and public education regarding potassium iodide’s benefits and usage.
Jurisdictions are also working to address communication and public perception of radiological incidents. Public perception and understanding of radiation risks are complicated.Reference Slovic10 Community members may lack awareness of the necessary protective measures or may not trust the information provided by authorities. On the other hand, rural and suburban communities often exhibit strong social networks and a close-knit population, which can be advantageous during a crisis. These characteristics can facilitate community resilience and grassroots mobilization in the event of a nuclear incident.Reference Straub, Gray, Ritchie and Gill11 Engaging local leaders and organizations in emergency planning helps to build trust and ensures that information flows effectively during a response.Reference Ramsbottom, O’Brien, Ciotti and Takacs12 Radiation readiness professionals are encouraged to support these efforts by providing resources for training and education, promoting public awareness about radiation safety, and encouraging local jurisdictions to develop tailored emergency response plans. This collaborative approach can strengthen overall preparedness and enhance the ability to protect public health and safety in the face of potential radiological incidents.
Another critical focus area involves the decontamination of emergency workers, who are often first responders in radiological incidents. Ensuring that these personnel have access to effective decontamination protocols and resources is essential for their safety and operational readiness.13 Jurisdictions are also investing in deployable resources, such as specialized equipment and personnel, to quickly respond to radiological incidents. All-hazard strike teams are being developed to address a wide range of potential emergencies, including radiological incidents, which enhances flexibility and efficiency in response efforts. Furthermore, comprehensive exercise planning and implementation are crucial for testing and refining these response strategies.
Addressing Gaps and Challenges
Addressing these challenges requires ongoing professional and community education, community engagement, and comprehensive planning to ensure that jurisdictions can respond effectively to potential radiological incidents. Regular drills, tabletop, functional, and full-scale exercises help identify gaps in preparedness and foster collaboration among various agencies. Communication and coordination can and should be enhanced through multidisciplinary training and exercises to develop experience and inter-agency relationships. Responders, transportation (air and ground), hospitals, radiation control programs, and support agencies can train and exercise together to learn from and understand each other’s roles and responsibilities. These efforts will require focused prioritization of training programs, resource allocation, and collaborative exercises tailored to radiological incidents. With these factors in mind, there is an opportunity for a radiation readiness network to benefit the field through promotion of coordination, collaboration, workforce capacity, and evidence-based practice.
Discussion
In June 2008, the U.S. Centers for Disease Control and Prevention (CDC) and the Conference of Radiation Control Program Directors (CRCPD) sponsored the “Roundtable on Communication and Teamwork: Keys to Successful Radiological Response.”14 During this roundtable, participants recommended the development of a network of organizations involved in radiation readiness to help advance the nation’s capacity to respond to radiological incidents. As a result of this recommendation, a workshop was planned and scheduled for April 1-2, 2009, in Atlanta, Georgia. This workshop was titled, “Alliance to Expand Radiological Emergency Preparedness in Public Health.”15 This workshop was also sponsored by CDC and CRCPD. The primary objective of this workshop was to produce an action plan to carry out the recommendations put forward at the 2008 roundtable, including the recommendation to create this network.
At the 2009 workshop, the following 4 focus areas were identified: develop consistent radiological response capabilities, nationwide; build alliances among public health organizations concerned with improving radiation readiness in public health; encourage and facilitate multiagency participation in radiological training and exercises; and leverage existing funding to expand radiation readiness, and further explore potential funding mechanisms to better use and sustain radiation readiness capabilities in the future.15
The workshop organizers convened more than 30 experts in the fields of health physics, radiation control, public health preparedness, hospital preparedness, epidemiology, and emergency response to address the four major focus areas. Representatives from organizations identified as key links to further developing partnerships for effective radiation readiness in public health were invited to attend. These organizations included the Association of State and Territorial Health Officials (ASTHO), CRCPD, the Council of State and Territorial Epidemiologists (CSTE), and the National Association of County and City Health Officials (NACCHO).15
As a result of the workshop, participants believed that development and implementation of a formal alliance was a worthwhile goal. Participants further recommended that this alliance should have a formal structure with a vision, mission, and charter as a starting framework, with founding members acting in an advisory capacity. The role of the alliance would include serving as a repository of knowledge, facilitating opportunities for cross-training within the public health community, promoting or facilitating provision of funding for radiological incidents in public health preparedness cooperative agreements, and serving as a communication portal to provide a strong unified voice for the radiation protection community. Additional objectives for the alliance would be to develop consistent, comprehensive radiation readiness capabilities nationwide, increase communication among interested parties, and share information, resources, and tools.15
From this roundtable and workshop, the National Alliance for Radiation Readiness (NARR) was formed.15 CDC developed a cooperative agreement funding opportunity for which ASTHO was the successful grant recipient.14 The NARR collaboratively developed a charter, created by-laws, and identified a membership structure—including an executive committee, member organizations, and federal partners.14
The NARR is structured to promote collaboration across these different fields (Figure 1). The NARR is led by a sponsoring organization that provides administrative support, a federal partner who provides funding, and an executive committee that provides expert input.16 Historically, CDC has been the sole provider of funding for the NARR and ASTHO has been the sole organization that has served as the sponsoring organization. The leadership group makes collaborative decisions about the strategic direction of the NARR.16 There are 2 other types of organizations involved in the NARR: member organizations and federal partners. Member organizations typically represent associations of professionals from public health, health care, and emergency management.17 Federal partners are federal agencies that would have a role in response to a radiological incident.Reference partners18
Figure 1. NARR Organization Chart. This figure shows the organization chart for the NARR. The NARR is collaboratively overseen by the sponsoring organization, the funding agency, and the executive committee. Member organizations and partner federal agencies make up the participants. Member organizations have a staff representative from the administrative side of the organization and a member representative from their association membership. Federal agencies have an agency liaison who serves as the main point of contact to the NARR.
As a result of the groundwork of the early roundtable and workshop, the NARR is now an interdisciplinary partnership of organizations representing public health, health care, and emergency management. The following are the member organizations of the NARR: American Academy of Pediatrics, American Association of Poison Control Centers, American Hospital Association, American Medical Association, American Public Health Association, Associations of Schools and Programs of Public Health, Association of Public Health Laboratories, ASTHO, CRCPD, CSTE, Health Physics Society, International Association of Emergency Managers, National Alliance of State Animal and Agricultural Emergency Programs, NACCHO, National Association of State EMS Officials, National Disaster Life Support Foundation, National Emergency Management Association, National Public Health Information Coalition, Radiation Injury Treatment Network, and the Society for Disaster Medicine and Public Health.17 The following agencies are the federal partners of the NARR: Administration for Strategic Preparedness and Response, CDC, Federal Bureau of Investigation, Federal Emergency Management Agency (FEMA), U.S. Department of Agriculture, U.S. Department of Energy, U.S. Department of Homeland Security, U.S. Environmental Protection Agency (EPA), U.S. Food and Drug Administration, and U.S. Nuclear Regulatory Commission.Reference partners18
The purpose of the NARR is to be the collective “Voice of Health” in radiation readiness through the participation in national dialogs, provision of thoughtful feedback on policies and guidance, convening of partners to raise awareness and resolve emerging issues, developing mechanisms for sharing resources and tools, and building and sustaining long-term competencies.15 The NARR leads its own efforts and assists other organizations to build radiological emergency preparedness and response and recovery capacities and capabilities.15 The mission of the NARR 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.”19 The vision of the NARR is to “to become a more protected, resilient nation through a comprehensive and integrated approach to radiological emergencies.”19
The NARR serves to advance radiation readiness in several different capacities: (1) sharing knowledge and best practices, (2) providing expert input on policies and programs, (3) promoting communication and collaboration, and (4) serving member and federal partners’ needs during a response to a radiological incident. The NARR hosts regular meetings with members and federal partners, including an annual business meeting where members and federal partners share updates about their activities and an in-person annual meeting to discuss broader strategies and challenges in the field. The NARR also does activities such as webinars, trainings, presentations, creation of resources, and others to help build capacity to respond to a radiological incident.
The NARR has a Standard Operating Procedure (SOP) that allows the alliance to activate during a radiological incident. The NARR Executive Committee, in collaboration with the sponsoring organization and funding agency, hold decision-making authority to activate the NARR SOP. Under activation of the SOP, the NARR can provide support to members, federal partners, and others through communications and expert input. As of the publication of this article, the NARR SOP has been exercised, but never activated.
Over the last decade, the NARR has worked to increase collaboration, evidence, and training opportunities in radiation readiness. Through the years, the NARR has grown from a group of five organizations to a larger network of 20 member organizations and 10 federal partners.15, 17, Reference partners18 The increase in membership opened opportunities for increased collaboration and communication among contributors to the field of radiation readiness. These groups share research, resources, and opportunities with each other through the NARR. This increased collaboration and communication means that partnerships are primed for response to a radiological incident and expertise can be more easily shared across disparate groups. Should there be a major radiological incident, the NARR could boost crucial information through its member organizations that each reach up to tens of thousands of professionals. The NARR has also created a website (radiationready.org) that hosts a repository of radiation readiness resources.20 NARR members, federal partners, and others share research materials, trainings, plans and exercises, and guidance through this repository. This repository has created an easily accessible, centralized location to gather relevant best practices and evidence. This encourages practitioners to use evidence-based practices in their radiation readiness programming. During a radiological incident, the resource repository would be a convenient place to quickly find reference materials to aid in decision-making. The NARR has also provided expert input into the response to the Fukushima Daiichi nuclear disaster, helped share radiological risk and security information throughout Russia’s invasion of Ukraine, and provided perspectives on the addition of radiation considerations into CDC’s Public Health Emergency Preparedness capabilities.21–Reference Whitcomb, Ansari and Buzzell23 The NARR has also increased radiation readiness training and resources. NARR members and federal partners collaborate to develop webinars, workshops, resources, and other trainings on relevant topics. NARR has also coordinated groups of cross-sector experts to develop public health radiation training modules, a laboratory sample prioritization framework, and resources and guidance for traveler screening at ports of entry and cytokine use following a nuclear detonation.24–26
NARR collaboration increases awareness and builds preparedness and response capacity for professionals already working in radiation readiness and other relevant professionals looking to get more involved. This has been particularly important over the last few years as there has been a decline in the radiation workforce.Reference Kramer27 The radiation workforce has been aging into retirement and there is less interest from young professionals in joining the field. These factors, combined with the burnout and turnover of many preparedness professionals during and after the pandemic, have created a loss of institutional knowledge and experience across the emergency preparedness workforce.Reference Stone, Kintziger, Jagger and Horney28 In light of these challenges, the work of the NARR is critical to ensure that radiation readiness professionals stand ready to respond to a radiological incident.
Over the last several years, the NARR has focused on future visioning and continued capacity building. This has included activities such as strategic planning, webinars, and exercises.
The NARR hosted several webinars to keep radiation readiness professionals informed on best practices and guidance. This included webinars on topics such as new guidance from FEMA on the first 72 hours of a response to a nuclear detonation and understanding mental models to improve first responders’ actions during a radiological incident.Reference Leek, Keren, Blumenthal, Irwin and Musolino6, 29, Reference Leek, Keren, Lawson and Webster30 These webinars were well received and together reached almost 800 interested professionals. Comments in a non-research evaluation survey for these webinars reflect a continued need for education and training:
“I am a new ROSS [Radiolofical Operations Support Specialist], and will incorporate this information into rad/nuke information passed on to my team [mostly emergency planners focused on all hazards Prep&Response]”
“We are involved in emergency response. This will assist us to determine where our counterparts may be lacking in understanding.”
“Thank you for continued learning. It is so important to mentor those entering the field right now. Or those changing disciplines due to retirements, new nuclear direction, or company right-sizing.”
“Powerful concepts to use for training and education on this topic. Risk perception…. to radiological threats is prohibitively high since most response partners aren’t knowledgeable in this area. Lack of willingness of partners to work towards rad/nuc preparedness has been a major barrier as a result. Also since the probability is low and funding is scarce.”
“Great presentation, kept me fully engaged. Loved the work you are doing and the use of simulation with first responders/hazmat. I think that is really beneficial for the little amount of time they to train on hazmat.”
At the 2024 NARR Annual Meeting, the NARR also completed a discussion-based exercise to test the NARR SOP. During the discussion, participants discussed the flow of information into and out of the NARR during a radiological incident. Participants highlighted ways the NARR can provide support without superseding governmental response or decisions internal to member organizations. Participants recommended that the NARR could be most supportive to responding agencies by organizing meetings, quickly sharing resources, and developing just-in-time training. In spring 2024, the NARR also participated in the 6th International Nuclear Exercise (INEX-6), which was organized and led by the EPA for the United States.31 ASTHO staff facilitated the INEX-6 module on health impacts and NARR members and federal partners attended the exercise as players. This exercise highlighted several important gaps in long-term recovery from a nuclear detonation such as training and capacity of health care providers, long-term monitoring and follow-up, response to mental health needs, and more. The NARR is primed to provide support to close those gaps.
Over the last year, the NARR has collaboratively developed a five-year strategic planning goal. NARR members and federal partners participated in a series of strategic planning conversations led by ASTHO staff. These conversations answered questions like “In one sentence, describe your vision for what the NARR will achieve in five years?” and “What can we do to increase the impact of the NARR?” among others. Based on these discussions, ASTHO staff collated the input into a five-year strategic planning goal. By establishing this goal, the NARR seeks to demonstrate tangible progress towards its mission and vision through measurable objectives. The goal is shown in Figure 2.
Figure 2. NARR Five-Year Strategic Planning Goal. This figure describes the five-year strategic planning goal collaboratively developed by the NARR.
In the future, this goal will help to advance the field of radiation readiness by generating evidence about gaps within the cross-sector workforce, then providing resources to fill those gaps. Based on this goal, the NARR will create an assessment to identify gaps in radiation readiness and a baseline level of radiation readiness knowledge among NARR members and federal partners. The NARR will use the results of the assessment to provide targeted resources, training, and technical assistance. These activities will advance capacity to respond to a radiological incident within the NARR and beyond.
Limitations
Although NARR is a network of partners and experts who work in radiation readiness, the NARR does not provide direct support services outside of communication and collaboration during a radiological incident. The NARR does not have physical assets that can be deployed in an emergency. During a radiological incident, the NARR may share information, communicate with partners, organize meetings and events, or provide technical support to governmental entities participating in the response. The NARR would not have a specific, designated role in a governmental response unless invited to participate by a governmental entity. Because of NARR’s role outside of governmental response, the NARR has clear delineations for what it can and cannot provide during a radiological incident. Despite these clear delineations, the NARR can assist in convening disparate experts and expediting the communication process throughout the disaster cycle.
Conclusions
Responding to a radiological incident remains a complex process, involving coordination and input from experts representing several fields. Coordination among public health, emergency management, radiation control, and health care organizations can be integral to an effective, life-saving response. Jurisdictions may also need support to quickly access expert input, provide just-in-time training, and share best practices. The NARR is poised to be a facilitator both ahead of and during a radiological incident. In service of its mission, the NARR will continue to support capacity building in the workforce and serve as a conduit for information, training, and subject matter expertise. Through this collaboration, the NARR can help to strengthen the nation’s readiness to respond to radiological incidents.
Acknowledgments
The authors are grateful to the NARR members and federal partners for their participation in the alliance, without which this work would not be possible. The authors acknowledge a special thanks to the NARR Executive Committee for their leadership of the NARR and input on this manuscript. Thank you to the ASTHO and CDC staff who provide administrative support to the NARR.
Author contribution
AE led planning, drafting, organization, and submission for this paper; PP, RG, CW, LF, and PR contributed to conceptualization and drafting of this paper. All authors reviewed and edited the draft.
Funding statement
This project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award with 100 percent funded by CDC/HHS through Grant Number 6 NU38PW000018-01-03. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of CDC or HHS.
Competing interests
The authors have no competing interests to disclose.
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