A radiological or nuclear event has a low probability of occurrence but will have a devastating impact on human life. Given the fact that it will cause huge impacts on a health system’s ability to provide medical care, this topic still warrants attention and should not be ignored. Due to their catastrophic outcomes, radiological emergencies and nuclear events are types of events that elicit apprehension and fear amongst the public, first responders, first receivers, and the medical community as whole. Historically, knowledge of nuclear threats and incidents has been predominantly theoretical and based on limited actual events. However, the past century following WWII has seen the progressive development of nuclear technology from utilization in defense systems and energy generation, to applications in medicine and oncology care.Reference McKenna 1 While society reaps positive benefits from these technological advancements, the threat of unintentional nuclear accidents and improper handling of radiological materials, along with intentional nuclear attacks and use of radiological devices, remains. This has created a novel need for safety measures and methods to mitigate unnecessary exposures.Reference McKenna 1
Whether accidental or intentional, the human impact caused by these events is severe and long-lasting. Reference Pomper and Tarini 2 This necessitates further discussion about the health sector’s disaster preparedness capacity for nuclear and radiological events. A 2017 article exploring the readiness and knowledge of medical personnel to treat irradiated and radiologically contaminated patients revealed that education, preparedness, and training of prehospital and health system personnel and systems are lacking.Reference Dallas, Klein and Lehman 3 This paper presents a review of the literature on health system and public health preparedness for nuclear and radiological incidents.
Methods
A search was conducted for English language or professionally translated articles via: Cochrane, PubMed, open-source military sources, and Google Scholar. Search terms included “radiological emergency preparedness,” “radiologic emergency preparedness,” “radiological disaster,” “radiological event,” “radiological emergency,” “nuclear disaster medicine,” “nuclear disaster,” “nuclear event,” “nuclear terrorism,” “radiologic decontamination,” “radiological decontamination,” “CBRNE (chemical, biological, radiological, nuclear, explosive),” “patient contamination,” and “PPE for radiological response.” The dates of the searches were from the 1940s to 2024. Search results included case reports, government publications, literature reviews, published experiments, and expert opinions. All articles were sorted thematically based on the initial aims, search terms, and research findings. Subdivisions and new categories emerged through the research process. An UpToDate search using the search terms “radiological,” “radiation,” and “nuclear” was also conducted to cross-reference the articles found in the review and identify any missed resources. The team found that all relevant articles cited in UpToDate had already been included through the initial review process.
The reviewers included experts in the nuclear/radiation/disaster medicine field, including physicians, emergency managers, public health officials, and radiation health safety officers. Articles were reviewed and selected based on their appropriateness to address the study questions: What is the evidence supporting health sector preparedness for mass casualties from nuclear and radiological incidents? What are the most effective methods to improve preparedness and response? The reviewers were randomly assigned articles to evaluate based on a predetermined scoring criteria developed by the research team. Each article was reviewed by 2 reviewers and if there was disagreement, a consensus was reached through discussion. Reviewers assigned “yes” or “no” answers for each category. Results were then organized into a spreadsheet for inclusion. The final categories that emerged through the process were prevention and policy, prehospital mechanisms, hospital readiness, training and education, infrastructure, psychosocial, and communication. This study was determined to meet exempt criteria under 45 CFR 46.104(d) by the UT Southwestern IRB, protocol number STU-2020-1265.
Results
Initial search results produced 293 papers, of which 100 articles adequately addressed the study questions. Of these 100 articles, 24 analyzed actual radiological events while the remaining were based on theoretical incidents. Of the articles discussing radiological medical preparedness broadly, 34 focused on prehospital mechanisms, 64 on hospital readiness, and 56 on training and education. Of the 64 articles covering hospital readiness, 43 focused on the effects of radiological events on medical staff and 32 mentioned special equipment needs. Prevention and policy measures were addressed by 30 articles, focusing on the historical and structural preventive measures in place along with policy initiatives. Forty articles addressed the effects of these events on community infrastructure. Psychosocial effects following radiological events were discussed in 39 papers while 41 articles addressed the importance of communication as an integral component of nuclear disaster response (Figure 1).
Figure 1. Categorical Distribution of Articles.
Discussion
These reviewed articles suggest a greater need for radiological event preparedness and education which may dispel misconceptions about the safety and effectiveness of nuclear disaster response. This review found 7 commonly recurring themes that are essential to prevent, prepare, and respond to a radiological event (Table 1).
Table 1. Thematic Distribution
Prevention and Policy
While radiological disaster readiness and response is multifaceted and focuses on preparedness for such events, a discussion on past and current methods for prevention is warranted. The latter half of the 20th century was fueled by an inconsistently regulated international nuclear arms race. In response, international summits targeting disarmament brought world leaders together to address global nuclear security. These efforts have supported the reduction of nuclear weapons and creation of a global nuclear energy framework. While assessment of the impacts of these summits proves to be largely successful, momentum has slowed, and some goals have only been partially completed.Reference Pomper and Tarini 2 –Reference Hogan and Kellison 5
Preventive measures through global nonproliferation have stagnated due to ongoing tensions between the global powers, with increased concerns about security of nuclear materials.Reference Hick, Weinstock and Coleman 6 –Reference Dallas, Bell and Stewart 8 The involvement of non-state actors in addition to ongoing international tensions necessitates efforts to ensure the safety of these assets by increasing physical and cyber security while developing engineering mechanisms to withstand accidental and intentional emergencies.Reference Pomper and Tarini 2 , Reference Potter, Ferguson and Spector 9 , Reference Socol, Gofman and Yanovskiy 10
A multifaceted approach is necessary to ensure nuclear security goals. International collaboration on all aspects of this agenda must be encouraged. Efforts must be dedicated to strengthening security and defense campaigns, improving threat detection technology and processes, supporting intelligence efforts, and utilizing diplomacy for nuclear deterrence.Reference Bunn 4 , Reference Pradeep Kumar, Shanmugha Sundaram and Sharma 11 , Reference Patel, Neylan and Bavaro 12 Furthermore, the current literature supports the need for intersectoral policy development focusing a formalized response framework.Reference Coleman, Cliffer and DiCarlo 13 –Reference Farhat, Alinier and Chaabna 15
Prehospital Response Mechanisms
Prehospital nuclear response teams include hazardous materials, fire and rescue, police, government agency representatives, and emergency medical system (EMS) personnel. The primary objectives of these teams when responding to radiological disasters include prevention of further infrastructure damage, protection of the public, decontamination, and disposal or neutralization of radiation material.Reference Dainiak, Waselenko and Armitage 16
During the initial response phase for a radiologic disaster, prehospital personnel (PHP) deploy and utilize field radiation detection equipment to estimate radiation levels and establish control zones, which delineate areas with hazardous radiation levels.Reference Farhat, Alinier and Chaabna 15 It is recommended that response teams be trained and equipped with a radiation monitor for data gathering and establishment of control zones.Reference Socol, Gofman and Yanovskiy 10 Computer software programs such as the IMAAC modeling program by the National Atmospheric Release Advisory Center in the U.S. can utilize data from PHP radiation monitors to determine locations of fallout radiation zones that pose a significant risk to PHP.Reference Knebel, Coleman and Cliffer 17 Authorities may be able to establish evacuation zones and direct placement of safe triage sites based on these models.Reference Desai, Bell and Harris 18 –Reference Redlener 21 Zones of damage are not easily demarcated, but using modeling after a blast can help focus efforts on areas where predicted casualty survival is greatest with early medical attention.Reference Desai, Bell and Harris 18 , Reference Redlener 21 Lines of communication must remain intact to inform PHP of shifting zones of radiation exposures.Reference Chertoff 22
Prehospital responders are most vulnerable to exposure due to a lack of radiation health knowledge and contact with potentially contaminated patients.Reference Sandifer and Walker 23 Emergency responders must be educated about exposure levels before engagement in these regions.Reference Davis 24 According to the Federal Emergency Management Agency, any potential exposure over 5 rem exceeds the OSHA yearly limit and first responder involvement past a 5 rem exposure area is strictly voluntary after they are informed of the risks and trained in protective measures.Reference Chertoff 22 To protect themselves, first responders must limit radiation exposure, utilize shielding, and increase distance from radiation sources.Reference Chertoff 22 RESRAD-RDD is a tool provided by the Argonne National Laboratory to help first responders calculate “stay time” within radiation zones to limit exposure and to guide intervals for the rotation of personnel.Reference Chertoff 22 Proper personal protective equipment (PPE) (eye and face protection, particle filter mask, gown, and foot covers) assists in minimizing exposure to alpha and beta ionizing particles when external contamination is present.Reference Chertoff 22 , Reference Rump, Becker and Eder 25 , Reference Noel, Bruce and Ryan 26 Protection against gamma and neutron radiation is only possible with robustly engineered structures containing metal, concrete, or layers of materials.Reference Gale and Armitage 7
All responders will require external decontamination by trained PPE-protected personnel at scheduled intervals.Reference Flynn and Goans 27 , Reference Rojavin, Seamon and Tripathi 28 Decontamination involves the removal of clothing and showering with copious amounts of water from the head down to the feet. Clothing should be double bagged and saved for testing to help estimate total body radiation dosage.Reference Barnett, Parker and Blodgett 29 PHP should have early medical assessments and dose estimations performed to determine the need for further medical care.Reference McKenna 1 To help avoid contamination within emergency vehicles and the spread of radiation particles, it is necessary to remove clothing from stable patients by cutting/rolling the clothes off instead of pulling clothing off and wrapping the patient in a sheet. This will remove about 70-80% of deposited contamination.Reference Rump, Becker and Eder 25 , Reference Bushberg, Kroger and Hartman 30 All emergency vehicles used within radiation zones must be decontaminated before reuse.Reference Yan and Yu 31
The primary goals of the initial disaster response are first aid and life/limb salvage, prevention of the acute effects of radiation through adequate decontamination, early recognition of acute radiation syndrome (ARS), and utilization of medical countermeasures.Reference Hogan and Kellison 5 , Reference Chertoff 22 , Reference Flynn and Goans 27 , Reference Rojavin, Seamon and Tripathi 28 Areas outside the greatest destruction called “grey zones” will produce the largest numbers of casualties with survivable injuries, and EMS should be directed to these areas to maximize response efforts.Reference Redlener 21
Hospital Capabilities and Response
Robust hospital capabilities are an essential component of an emergency response to a radiologic event.Reference Covello 32 However, current evidence shows that hospitals and clinicians are unprepared to handle these incidents; therefore, it is ideal to preemptively enhance the capabilities of local health systems.Reference Dallas, Klein and Lehman 3 , Reference Desai, Bell and Harris 18 , Reference Redlener 21 , Reference Williams, O’Malley and Nocera 33 Hospital disaster response preparation can be grouped into policies and procedures, technology (PPE, communications, decontamination supplies, treatment), and staff readiness (knowledge and competence).Reference Razak, Hignett and Barnes 34
Previous radiological disasters have highlighted the need for health system support from both local and federal governments.Reference Coleman, Sullivan and Bader 35 , Reference Loh and Amir 36 All hazards disaster planning at the federal level must include a registry of hospitals capable of treating radiation casualties and develop hospital surge support models.Reference Coleman, Sullivan and Bader 35 , Reference DiCarlo, Maher and Hick 37 Government disaster plans should include resupply mechanisms, evacuation/sheltering procedures, security protocols, and risk assessments for local hospital systems.Reference Ahmadi Marzaleh, Rezaee and Rezaianzadeh 38 Local and federal governments can assist with hospital preparedness by coordinating periodic radiologic disaster drills, constructing medical training programs, and standardizing protocols.Reference Gale and Armitage 7 , Reference Linney, Kernohan and Higginson 39
Early hospital response occurs within the first 72 hours of an event. Patient influx may overwhelm larger regional medical and trauma centers in the initial phases and shift to more distant facilities in the following days.Reference DiCarlo, Maher and Hick 37 The primary goals of the initial response are providing medical stabilization, preventing acute effects of radiation, recognizing ARS, and utilizing medical countermeasures.Reference Hogan and Kellison 5 , Reference Chertoff 22 , Reference Flynn and Goans 27 , Reference Rojavin, Seamon and Tripathi 28 Life threatening injuries should be prioritized over stable patients presenting with radiation exposure, and lifesaving care should be delivered before decontamination. Measures should also be taken to keep critically injured contaminated patients in a separate area from non-contaminated patients.Reference Albanese, Sudlarska, Smith and Nriagu 40
A review by Razak et al. notes there is ambiguity and an overall lack of knowledge and capability around the decontamination process.Reference Razak, Hignett and Barnes 34 If done properly, disrobing and decontamination with soap and water can remove up to 90% of external radiation sources from patients.Reference Rojavin, Seamon and Tripathi 28 , Reference Kazzi, Buzzell and Bertelli 41 –Reference Chilcott, Larner and Matar 43 Detection equipment must be on hand and maintained by hospitals to facilitate proper patient assessment and decontamination and safety. Hospitals should be prepared to construct decontamination shower areas that drain into separate designated tanks, with access entrances separate from hospital and emergency department access points. Hospital disaster plans must also include internal and external decontamination protocols to prevent cross-contamination within the facilities.Reference Moore, Geller and Clark 44 , Reference Li, Dos Reis and Ansari 45
Multiple types of patients are anticipated during the early hospital response phase of a nuclear disaster: EMS-transported injured, contaminated, potentially contaminated, evacuated, sheltered persons, and people seeking reassurance.Reference Crick, McKenna and Buglova 46 Trauma and burn victims are likely to overwhelm hospital bed capacities as it is estimated that 70% of patients will suffer from trauma and burns from structural fires and radiation sources.Reference Hick, Weinstock and Coleman 6 , Reference Gale and Armitage 7 , Reference Dainiak, Waselenko and Armitage 16 , Reference Bell and Dallas 47 Combined radiation burns and traumatic injuries generate competing causes of death. Early evaluation, supportive care, prompt treatment, and surgical care if needed for those affected by combined injuries are critical for survivability.Reference Moore, Geller and Clark 44 , Reference Bell and Dallas 47
Special attention must be given to preparing for special populations including pediatrics. The hematopoietic system in children is much more radiosensitive than that in adults. The modeling parameters of acute radiation injury identified indicate that young children are nearly twice as sensitive to the acute effects of radiation as adults. Modeling also strongly suggests that the pediatric patient population is more sensitive to the effects of radiation and places a significantly higher demand on health facilities compared to the adult.Reference Adams, Sumner and Casagrande 48 Building emergency department clinical pathways for response is one strategy that can help facilitate the nuanced considerations for pediatric patients.Reference Ranse, Mackie and Crilly 49
During the acute response phase, accurate early dose estimates are imperative as they guide treatment. Radiological triage should focus on recognizing those who may have received greater than 2 Grays of radiation. Patients without nausea or vomiting within 4 hours from a radiological event most likely have not received a dose over 2 Grays and may survive without medical intervention.Reference Gale and Armitage 7 In the case of delayed direct bioassays, a more reliable mechanism for dose estimation is the absolute lymphocyte count reduction rate at 48 hours after irradiation.Reference Dainiak, Gent and Carr 50 Alternately, estimated radiation doses can be determined by biological dosimetry analysis of blood, urine, nasal swabs, and clothing samples.Reference Gale and Armitage 7 In the case of delayed dosimetry, medical treatment may be best guided using a medical management algorithm such as the METREPOL system.Reference Dorr and Meineke 51 Moreover, staff radiation doses must be periodically assessed after initial medical responses have commenced.Reference Yan and Yu 31 It is important to note that data from case studies and modeling suggests there is a minimal medical hazard associated with the treatment of patients exposed to radiation who have been externally decontaminated.Reference Hogan and Kellison 5 , Reference Davis 24 , Reference Mapstone and Brett 52 , Reference Dara and Farmer 53 Regarding treatments, hospitals may stock necessary medical treatment agents.Reference Potter, Ferguson and Spector 9 , Reference Bushberg, Kroger and Hartman 30 Agents such as Prussian blue and potassium iodide can be utilized to reduce internal contamination if available.Reference Potter, Ferguson and Spector 9 , 54 , Reference Adams and Casagrande 55 However, effectively treating internal contamination with Prussian blue demands that a substantially larger stockpile of the antidote be established and timely distribution methods assured.Reference Adams, Yeddanapudi and Clay 56 , Reference Rios, Cassatt and Hollingsworth 57
Health care staff are the most critical aspect of the radiological disaster response.Reference Ahmadi Marzaleh, Rezaee and Rezaianzadeh 38 , Reference Ahmadi Marzaleh, Rezaee and Rezaianzadeh 58 Radiation response teams should include nuclear medicine specialists to assist in the construction of radiation triage, treatment and response plans, education, oversight of patient screening and decontamination, the direction of radiologic assays, and dose estimates.Reference Hogan and Kellison 5 , Reference Rump, Becker and Eder 25 , Reference Barnett, Parker and Blodgett 29 , Reference Bushberg, Kroger and Hartman 30 , Reference DiCarlo, Maher and Hick 37 , Reference Moore, Geller and Clark 44 , Reference Ahmadi Marzaleh, Rezaee and Rezaianzadeh 58 –Reference Borron 62 Response personnel should include hospital administration, radiation safety officers, and clinicians like hematologists, radiation oncologists, wound care specialists, and nuclear medicine specialists who are equipped to treat patients with radiation exposure.Reference Hick, Weinstock and Coleman 6 , Reference Gale and Armitage 7 , Reference Dainiak, Waselenko and Armitage 16 , Reference Barnett, Parker and Blodgett 29 , Reference Wolbarst, Wiley and Nemhauser 42 , Reference Adams, Yeddanapudi and Clay 56 , Reference Salner 63 The value of this was recognized in the medical literature in which such a multi-disciplinary approach led to the development of a planning manual that was broadly utilized throughout the State of Connecticut.Reference Dainiak, Carpini and Bohan 64
For a hospital to be properly equipped to handle a radiological mass casualty event, having it functional and readily available is essential. PPE, radiation detectors, decontamination supplies, medications, and antidotes must be accessible.Reference Ochi, Tsubokura and Kato 19 , Reference Mortelmans, Gaakeer and Dieltiens 65 Additionally personal dosimeters can assure medical staff does not exceed specific levels of radiation exposure. Equipment should be kept in working order and efforts should be made to limit the effects of a potential electromagnetic pulse on essential medical devices.Reference Klebers 66 –Reference Vandre, Klebers and Tesche 68
PPE is required for decontamination, hospital triage, and initial medical treatment. Level C PPE is recommended for the initial providers.Reference Hogan and Kellison 5 , Reference Moore, Geller and Clark 44 , Reference Borron 60 , Reference Holland and Cawthon 69 , Reference Nazari, Sharififar and Marzaleh 70 Staff must receive appropriate PPE training aligning with their tasks. It is important to note that while understanding the appropriate equipment and its designated use is just as important as having it available, no level of PPE can protect against high-energy radiation.Reference Moore, Geller and Clark 44 Currently, there is a lack of standardization in the requirements across response groups.Reference Noel, Bruce and Ryan 26 , Reference Ahmadi Marzaleh, Rezaee and Rezaianzadeh 38 , Reference Nazari, Sharififar and Marzaleh 70
Training and Education
Medical preparedness and education must also be expanded. Normalizing preparedness for these radiological incidents within existing training, education, and exercise frameworks, and other’s experiences will increase responders’ knowledge and efficacy when responding to nuclear disasters.Reference Huyar and Esin 71 –Reference Kawasaki, Kitamiya and Yoshida 73 Community stakeholders must be included in training activities to promote a smooth communitywide response, specifically incorporating local first response, law enforcement, and psychological services.Reference Wolbarst, Wiley and Nemhauser 42 , Reference Al-Sulaimani, Al-Balushi and AL-Balushi 72 In health care facilities, an effective and well-designed training methodology must facilitate coordination amongst hospital departments.Reference Ahmadi Marzaleh, Rezaee and Rezaianzadeh 38 , Reference Moore, Geller and Clark 44
Preparedness and education also serve as a method of improving health care workers’ willingness to care for patients from nuclear or radiological events. There is often an unfounded fear associated with treating patients exposed to radiation, which can be minimized through proper training, education, and exercises.Reference Williams, O’Malley and Nocera 33 , Reference Ji, Wang and Zou 74 Proper training equips responders with an understanding of the utility of personal protective equipment, distance-dependent dose reduction, and the effectiveness of the decontamination processes in reducing the risk of secondary contamination for health care workers.Reference Williams, O’Malley and Nocera 33 , Reference Awosan, Ibrahim and Saidu 75 Development of biodosimetry hands-on training programs for laboratory personnel in nuclear disaster scenarios have shown to decrease the fear of personal radiation exposure.Reference Albanese, Martens and Arnold 76 Ultimately, increasing the confidence and capabilities of those responding to a nuclear or radiation incident through training will improve resilience.Reference Sandifer and Walker 23
Lastly, public and community education is essential to building community resilience to a nuclear disaster. Educating the public on protective measures against radiation exposure and life-saving actions for emergencies may empower them to initiate crucial steps before first responders arrive, minimizing morbidity, and increasing trust in the community response mechanisms, ultimately strengthening community resilience.Reference Socol, Gofman and Yanovskiy 10 , Reference Redlener 21 , Reference Fauzi Rahman Jayaraman, Shariff and Zaini 77
Infrastructure
Infrastructure components necessary for medical response to a radiological emergency include health care facilities, transportation systems/roadways, communication systems, decontamination sites, municipality services, shelters, and food sources.Reference Hick, Weinstock and Coleman 6 , Reference Redlener 21 , Reference Chertoff 22 Given that these components feed into the continuity and functionality of the health sector, they must be strategically addressed.
When a hospital system fails, community disaster response mechanisms are disabled.Reference Sandifer and Walker 23 After action analysis from the Fukushima nuclear accident emphasized generating an effective radiation emergency medical system with multiple levels of hospitals designated as radiation treatment centers and offsite facilities staged near nuclear power plants.Reference Loh and Amir 36 , Reference Ojino 78Additionally, nuclear palliative care centers were recommended in fixed and mobile forms to assist with pain management and psychological support.Reference Desai, Bell and Harris 18
Transportation and communication pathways are needed to maintain a flow of people and resources. Roadways and waterways must be cleared and maintained to allow for evacuation mechanisms, EMS movement, and supply routes.Reference Chertoff 22 , Reference Sandifer and Walker 23 , Reference Hasegawa, Ohira and Maeda 79 Communication systems must maintain functionality to ensure the passage of information for an effective response and evacuation.Reference McKenna 1 , Reference Desai, Bell and Harris 18 For those patients that are contaminated, preparedness measures must account for the multiple factors that determine how quickly they can get to definitive care for treatment.Reference Yeddanapudi, Clay and Durham 80 A scarcity of specialized subject matter expertise in austere settings must also be accounted for. Furthermore, this can be exacerbated by lack of robust training, prior planning, and inability to contain the area to minimize exposure.Reference Smith and Weir 81
During nuclear and radiological events, hospitals can get overwhelmed with uninjured patients. Community decontamination sites are therefore another important infrastructural component that should be considered to help redirect possibly contaminated but uninjured patients away from hospitals.Reference Flynn and Goans 27 Due to limited decontamination capabilities in most communities, pre-hospital decontamination will likely be employed only in very specific cases, such as prolonged evacuation or heavy contamination.Reference Gale and Armitage 7 , Reference Levitin, Siegelson and Dickinson 82
Facilities dedicated to bioassays and personal dosimetry are in short supply but serve a major role in all radiological event response phases.Reference McKenna 1 A nuclear response plan should identify the nearest laboratories capable of analysis of bioassays to assist with dose estimates.Reference Bushberg, Kroger and Hartman 30 Most communities do not have local facilities with the required capacities, and even tertiary laboratory facilities will be easily overwhelmed by a large-scale incident requiring rapid processing of thousands of specimens. To prepare for such an event, biodosimetry networks are proposed, aiming to recruit multiple private and public local and international laboratories.Reference Dainiak, Albanese and Kaushik 83 , Reference Blakely, Port and Abend 84 These networks could offer significant surge capacity support.
Power grids are susceptible to electromagnetic pulse (EMP) damage, which can disrupt functioning of critical infrastructure components within a specific region. Planned protection of transformers would reduce recovery time. The creation of a national executive agency is needed to oversee EMP events and to ensure preventative measures are taken to support critical infrastructure and to help mitigate regional system damage. 85
Veterinary and agricultural protection should be incorporated into infrastructural readiness and recovery planning with measures to reduce the passage of contaminated food into the food supply chain. Recommended measures include repurposing farmland to avoid crop contamination and ensuring procurement of uncontaminated animal feed.Reference Beresford, Fesenko and Konoplev 86
Communication
Proper risk communication during a radiological event is essential as it influences the response from multiple sectors. First responders must receive accurate information about the threat and scene to deliver treatment and implement appropriate incident command effectively and safely.Reference Williams, O’Malley and Nocera 33 , 54 , Reference Wieder 87
Post-event communication should present a clear and consistent message about the extent of the risk or reassure individuals about the lack of risk.Reference Wieder 88 Complete and accurate information increases public trust and prevents panic.Reference Barnett, Parker and Blodgett 29 , Reference Dainiak, Albanese and Kaushik 83 , Reference Blakely, Port and Abend 84 A breakdown in this process can create perceived inconsistencies, rumors, and delayed resource mobilization, which can result in unnecessary delays in care.Reference Sato 89 –Reference Kunkler, Adams and Manger 91
Effective communication during a radiological emergency should clearly convey the message to its intended audience. The International Atomic Energy Agency denotes that a specific radiological professional should be the point of contact. 92 , 93 It is recommended that materials for the public should be read at a sixth-grade or lower level.Reference Ferguson, Barnett and Kennedy 94 Confusion caused by unclear messages can be further exacerbated by the expansion of the communication channels during an event.Reference Rojavin, Seamon and Tripathi 28 , Reference Wieder 88 , Reference Sato 89 , Reference Ferguson, Barnett and Kennedy 94 Response planning should include a way for the response organizations to communicate with the public, pathways for inter and intra-organizational communication, and plans for communication feedback loops, all while applying evidence-based communication measures to effectively reach the community.Reference Ferguson, Barnett and Kennedy 95 –Reference Parikh 97 Many use social media during emergencies for guidance, and studies suggest that the social media platform X has the widest reach.Reference Ferguson, Barnett and Kennedy 94 During radiological emergencies, these preferred communication channels may be unavailable. Emergency response plans must therefore incorporate redundancies. Sirens, emergency alert systems, wireless emergency alerts, and other more traditional channels like radio and television can all be effective options.Reference Ferguson, Barnett and Kennedy 94 One common, consistent message should be communicated to the public, providing clear instructions, and emphasizing whether sheltering in place or staying indoors is recommended.Reference Redlener 21 , Reference Rojavin, Seamon and Tripathi 28 , Reference Wieder 88 , Reference Ferguson, Barnett and Kennedy 94
Psychosocial
The perceived health consequences of radiological exposures are often greater than the actual threat, leading to heightened community reactions.Reference Socol, Gofman and Yanovskiy 10 , Reference Turcanu, Sala and Perko 96 Radioactive dispersal devices, or “dirty bombs,” aim to generate fear rather than cause mass destruction.Reference Gale and Armitage 7 The relative rarity of a nuclear event contributes to social stress resulting in an estimated 75% of “affected” people having a psychosocial response.Reference Rojavin, Seamon and Tripathi 28 , Reference Bell and Dallas 47 , Reference McCormick, Tajeu and Klapow 98 This makes psychiatric disorders among the top health concerns post-exposure. Even in events where the radiological impact was negligible, major psychological impacts were noted.Reference McKenna 1 , Reference Dallas, Klein and Lehman 3 , Reference Ahmadi Marzaleh, Rezaee and Rezaianzadeh 38 , Reference Hasegawa, Murakami and Nomura 99
Hospital disaster plans must also take into consideration the heightened hesitancy of staff reporting to work after a radiological event.Reference Dallas, Klein and Lehman 3 Following the nuclear accident at Fukushima in 2011, health care staffing at medical facilities nearest to the event declined significantly.Reference Ochi, Tsubokura and Kato 19 , Reference Redlener 21 , Reference Mapstone and Brett 52 Employee absenteeism can be alleviated by ensuring security, providing timely information, addressing sources of fear, and offering programs to ensure family safety for hospital staff.Reference Ochi, Tsubokura and Kato 19 , Reference Loh and Amir 36 Adequate staff training and clear communication will help alleviate fears of radiation exposure and empower their willingness to respond.Reference Dallas, Klein and Lehman 3 , Reference Williams, O’Malley and Nocera 33
Limitations
The potential catastrophic effects that nuclear disasters can have on a community or region demands proper planning for an effective response. While military preparedness and response measures exist, non-military mechanisms require attention and improvement. Another limitation was regarding the methodology of this review. While PRISMA guidelines were followed in the final revision of the article, they were not included in the initial process. The integrity of this review met many of the PRISMA criteria for a scoping review; however, it may not have had all the components.
Conclusion
The threat of nuclear warfare and the possibility of future nuclear accidents has only grown over the past century with the proliferation of nuclear power sources and the growing threats from state and non-state actors. Efforts have been made to increase global security measures related to nuclear materials; however, they fall short when considering the rapid growth of nuclear fuel power sources worldwide.Reference Bunn, Malin and Roth 100 To mitigate this risk, health care and government entities must implement measures to protect the public from radiological disasters. Most importantly, education and training of health care personnel and the community are lacking regarding nuclear disaster readiness. This knowledge and training gap causes confusion, disorganization, and increased casualties.Reference Dara and Farmer 53 Preplanning and recurrent training at the local, regional, and federal levels are imperative to prepare communities and prehospital entities for disaster response. Key components of regional safety and security are communication mechanisms and infrastructure support.
The authors of this review hope that articles like this will continue to expose the need for further research in this field, reinforce the importance of preparedness for these types of disastrous events, and lead to a reduction in preventable loss of life and the profound suffering that these events are capable of inflicting on communities.
Author contribution
Jay Pandya—methodology resources, writing, reviewing, editing, and data analysis.
Andrew Stricklin—methodology resources, writing, reviewing, editing, and data analysis.
Chaverle K. Noel—methodology, resources, writing, reviewing, editing, and data analysis.
Sarah Hockaday—methodology, resources, writing, reviewing, editing, and data analysis.
Benjamin Russell—resources, data analysis, and reviewing.
Benjamin J. Ryan—conceptualization, methodology, resources, writing, reviewing, editing, and data analysis.
John White—conceptualization, resources, reviewing, editing, and data analysis.
Dagan Schwartz—conceptualization, methodology, resources, writing, reviewing, editing, data analysis.
Curt A. Harris—conceptualization, resources, reviewing, editing, and data analysis.
Kelly Klein—conceptualization, resources, writing, reviewing, editing, and data analysis.
Raymond Fowler—conceptualization, reviewing, editing, and data analysis.
Cham Dallas—resources, writing, reviewing, editing, and data analysis.
Raymond Swienton—conceptualization, methodology, resources, writing, reviewing, editing, and data analysis.
Competing interests
The authors have no conflicts of interest to report.
Open access
