1074: From Wastewater to Radiological Readiness: Detecting and Responding to Public Health Threats

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This is Public Health Review
MORNING Edition for Monday,

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February 23rd, 2026.
I'm John Sheehan with news from

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the Association of State and
Territorial Health Officials.

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Today, two conversations about
very different kinds of

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preparedness, wastewater
surveillance and radiological

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emergency response.
First, Allison Wheeler, manager

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of the Wastewater Surveillance
Unit at the Colorado Department

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of Public Health and
Environment, shares how her team

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detected measles in wastewater
before clinical cases appeared,

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helping local partners identify
an outbreak early and act

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quickly later.
Doctor Ziad Kazi, professor of

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emergency medicine at Emory
University and president of the

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American College of Medical
Toxicology.

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We'll explain what a
radiological emergency really

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looks like, from accidental
exposures to nuclear incidents,

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and what to think about and
prepare for with mass gatherings

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like, for example, the upcoming
FIFA World Cup.

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But first, here's Allison
Wheeler explaining Colorado's

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approach to wastewater
surveillance.

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So we started a pilot project
for measles wastewater testing

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back in May of 2025.
And we always do a pilot project

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when we bring on new pathogens
so that we can evaluate the

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assay for sensitivity and we can
figure out what the data means

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and so when to report data to
our local public health

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departments and our public
stakeholders.

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So it was in early August where
we detected measles genetic

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material in a wastewater sample
from Grand Junction.

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And 1st we detected a really low
level detection and then the

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sample directly after that.
Since wastewater utilities

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submit 2 samples per week, that
was a very high level detection.

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And so we were pretty sure that
this indicated a community

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transmission of measles in Grand
Junction.

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So we reached out to our Mesa
County public health partners

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and alerted them of these
wastewater detections.

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And their first response was, we
don't have any measles cases.

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And we said, yeah, but we think
there might be something going

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on.
And so we would recommend at a

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minimum reaching out to your
healthcare providers to remind

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them that measles is indeed
circulating in Colorado and to

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remind them of the symptoms and
to not hesitate to test patients

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that presented with those
symptoms.

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And so sure enough, two days
later they identified their

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first case, and then after that
they identified and a total of

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11 cases that were part of that
outbreak.

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That's wild.
You absolutely caught it before

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even cases were coming in.
We did, and I think that's the

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power of wastewater
surveillance, especially with

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these emerging or reemerging
pathogens.

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And what is it about measles
that makes it detectable in

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wastewater?
And what other sorts of

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pathogens do you usually come
across?

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Yeah.
So we have a set of defined

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targets that we test for.
So we started with COVID.

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We test for flu, A&BRSVEV,
D68-M, pox, and of course

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measles.
And part of what we do when we

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are figuring out which pathogens
we're going to test for, because

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we only have so many resources,
is we determine if that pathogen

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is shed in the gut or through
urine or another way to get into

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the wastewater system so we
might be able to detect it.

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And measles virus is in fact
shed in urine, feces and

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respiratory secretions of
infected individuals.

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And so we knew that we could,
well, we thought we could detect

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it in wastewater and we did.
And that allows us that that

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early warning signal to identify
us if there is a problem in a

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certain community.
And so we know that measles is

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shed in urine for four days
before rash onset and four days

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after.
And so that's part of the reason

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that we added this.
As you know, we wanted to pilot

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measles to see if it was
beneficial to test for it in

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wastewater, and we found that it
was.

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Yeah.
And then you, you find yourself

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knowing ahead of the other
health agencies that this is

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coming.
What, what do you do?

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How do you, how do you act on
that?

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And how do you how do you engage
your partners to take action?

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Yeah.
You know, I think we, we've

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learned some lessons for sure.
And so I think we, we work very

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closely with our other groups at
CDPHE, including our vaccine

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preventable disease team.
And they're also, they have to

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be supportive of what we're
doing and, and they are.

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And so we work with them.
We work with our EPI response

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unit who works very closely with
our local public health agency.

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We work with, we worked with
Mesa County Public Health.

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And then of course we loop in
our comms teams.

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And so we then we can figure out
together how best to message the

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wastewater results to folks in
the community, whether that's

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healthcare providers or whether
it's the public too.

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And so we've learned that that
consistent, clear language about

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wastewater surveillance is
really needed to help our

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partners understand the results.
And we also have learned that we

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need to continue our education
outreach to our local public

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health partners to make sure
that they understand the

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benefits of wastewater
surveillance data and how to use

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it, how to act.
And so specifically right now,

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one of our team members is
working on an education camp

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campaign specifically for public
information officers at local

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health departments so that they
can feel confident in relaying

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those results to their
communities.

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Yeah.
And in addition to sort of that

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speedy response and that early
detection, are there other

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benefits to wastewater
surveillance either enhancing or

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complementing traditional
disease surveillance?

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Absolutely.
I think a major advantage of

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wastewater surveillance is the
ability, its ability to monitor

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the health of an entire
community in a cost effective

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and non invasive way.
And so we know that with people

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that are infected with measles
can shed the virus in their

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urine up to four days before the
rash onset.

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And so this allows wastewater
surveillance to pick up the

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virus before the person even
knows they're sick.

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And so this overcomes some of
the challenges of traditional

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case reporting, including the
delay between infection and

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testing.
And with a disease as

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transmissible as measles, we, we
don't really need trends.

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Yes, it's good to have trends to
understand what's happening with

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levels of disease in the
community.

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But with a disease as
transmissible as measles, we act

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on those detections rather than
those increasing trends.

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And so we, we tend to message a
little bit differently with

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these emerging pathogens than we
do with say our our traditional

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targets like COVID or flu or
RSV.

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I see because they're so
transmissible, it's more of a

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red alert situation.
Correct.

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And so it sounds like
communication with colleagues

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across the health system, the
public health system, was, was

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pretty key.
What other lessons did you learn

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in engaging, you know, other
parts of the system?

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Yeah.
I think one of the things that

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that we learned is that we need
to involve our vaccine

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preventable disease team and our
health department leadership

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early on in the process of
bringing on a new target to make

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sure that they support
surveillance for, you know, in

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this case, vaccine preventable
diseases and wastewater.

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If they don't, you know, we
we're, we would be collecting

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this data with no one using it.
And, and we don't want to do

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that.
And so the other thing that

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we've really learned is that we
need to teach our internal teams

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how to use and interpret the
data.

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It it's not very intuitive if
you're not familiar with this

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viral concentration data in
wastewater.

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So we really encourage their
participation in calls with our

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team, our wastewater
surveillance team and also with

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local health departments so that
they can explain the clinical

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relevance of what we're finding
in wastewater.

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And then I would say, I
encourage all folks that are

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even interested, you know, we
have teams here at CDPHE that

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reach out to us that say, hey,
we're interested in seeing if we

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could do wastewater surveillance
for X pathogen.

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Can you do that?
And so we talk through it to see

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if it's even viable, if it fills
any surveillance gaps, of

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course, if if that pathogen is
even shed in wastewater, and

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what value it would bring to
their current surveillance

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system.
Yeah.

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So it sounds like the field
itself is still being developed.

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You're still learning what you
can find from wastewater.

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Absolutely.
We are learning every a single

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day and it's been we've been
involved in this for almost 5

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1/2 years now.
How much do other public health

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systems use wastewater
surveillance?

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I mean, is it?
Is it widely used?

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It is, I think now throughout
the United States, I think at

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least every state is involved in
wastewater surveillance at

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different levels.
Of course, we were one of the

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early adopters back in 2020
during the pandemic, but now at

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least most states are testing
for the viral respiratory

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targets.
So COVID, flu and RSV.

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Other states, especially the
the, the six centers of

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excellence that CDC has
designated, they're doing some

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more advanced work.
And so we're doing a pilot

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project for seeing if we can
detect antimicrobial resistant

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genes in wastewater, so we can
determine the prevalence of

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antimicrobial resistance in
communities.

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We're looking for fungal
targets.

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We're looking for arboviruses
like West Nile virus to

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determine if that can be a
supplemental surveillance

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system.
So it really depends state to

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state, but yes, most states are
involved in wastewater

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surveillance now.
It seemed like the expertise in

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parsing the data was a pretty
was a pretty fundamental need

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for this kind of work.
Do you have any other tips or

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advice for for systems that want
to expand their use of

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wastewater surveillance?
Yeah, definitely.

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You know one of the things that
we recognize here at CDPHE on

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our wastewater surveillance team
is that we are not an expert in

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all of the pathogens for which
we monitor.

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And so we very, we involve our
other subject matter experts,

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you know, that work in vaccine
preventable diseases or

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healthcare acquired infections
or our zoonotic team depending

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on what we're monitoring.
We, you know, one thing that I

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would recommend is, is starting
with those partners early on in

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when you're considering bringing
on a target.

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So you can determine if number
one, that target is, is shed in

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wastewater.
If we're going to be able to

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pick it up, what kind of
surveillance gaps that

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wastewater surveillance may fill
by doing surveillance for that

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target and how that subject
matter expert team would use

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that data.
We want to make sure that

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they're going to use it.
I also think it's really

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important to involve your
leadership so that they're under

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understanding and supportive of
wastewater surveillance for

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whatever target you may do, may
understand how to interpret and

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use the data because often times
they're asked by either media or

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national officials how and what
we're doing at the state, right?

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So it's really important for
them to be involved.

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I think 2, letting it, letting
people know that the wastewater

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surveillance team doesn't have
to be the expert in that

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specific target that you're
monitoring is important, right?

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That can leave a lot of stress
for the wastewater surveillance

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team, and so that's when that
subject matter expert team

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becomes really valuable.
Encourage them to join calls

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with the local health
departments so that they can

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explain the clinical relevance
of what you're finding in in

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wastewater surveillance data.
And then I think it's important

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to make sure that you're
teaching your local public

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health departments, even the
public, how to use this

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wastewater surveillance data so
that even public stakeholders

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can use it to assess their own
disease risk.

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And then I would always
encourage other state health

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departments or local health
departments to reach out to

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either your center of
wastewater, center of excellence

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in your region, or to reach out
to the Colorado team.

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We're always happy to talk to
other states involved in this

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work and share our experience.
Allison Wheeler is manager of

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the Wastewater Surveillance Unit
of the Colorado Department of

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Public Health and Environment.
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our show notes.
Now let's hear from Doctor Ziad

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Qazi, professor of emergency
medicine at Emory University and

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president of the American
College of Medical Toxicology.

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It's important to think about
different scenarios where one

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would encounter radiation.
For example, you know, we often

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think of radiation as an
invisible energy that is

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released for rejected material.
But remember, you can also

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disperse this material without
an explosive device.

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You can disperse this material
in the food supply or in in a

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water supply, drinking supply.
You can also release the

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material in the air, dispersing
it manually.

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That's often referred to as a
radiological dispersal device.

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But there are also scenarios
where you don't even disperse

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the material.
Actually, the material is

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sealed.
It's sealed and unshielded,

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which means any shield
surrounding the material is

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removed and the material is
sealed, meaning it's one block

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of material.
It's not indispensable

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mechanically.
And such material could be

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emitting radiation, exposing
people in the environment of

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this material and the
surrounding of this material to

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radiation.
We call that a radiological

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exposure device.
There are other scenarios, more

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significantly dangerous and
impactful scenarios like a

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nuclear detonation.
People often think of radiation

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in terms of nuclear detonation,
and that nuclear detonation, of

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course, brings a, brings a lot
of trauma and burns and, you

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know, and fires with it.
It can also generate the large

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amount of radioactive debris
that can become suspended in air

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and create a radioactive cloud
that contaminates the

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surrounding environment.
So those two scenarios, the

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nuclear detonation and the
improvised nuclear device, which

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are a bit similar, these are the
probably the most significant

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and dangerous scenarios.
And finally, another scenario

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that people think about is the
nuclear power plant emergency,

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such as what happened in
Fukushima as we are approaching

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March 11th, the day the the
anniversary of the Fukushima

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nuclear power plant emergency
that also leads to dispersal of

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a jet material in the
environment.

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However, these material come
from the nuclear power plant

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itself and they become
potentially released outside the

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nuclear power plant in the
environment, contaminating the

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area as well as food, water,
potentially exposing people to

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radiation.
Now of course, these are all

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very rare scenarios.
Some of them have never

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happened.
However, the most common

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scenario is going to be
accidental.

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We have occasional radiation
accidents in the United States

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and all around the world when a
radiation source is misplaced,

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is lost, occasionally stolen,
you know, the car accident, you

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know, truck carrying a Courier
truck carrying rejected material

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may have an accident spilling
the material on the road or

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inside the truck with the
accident rollover, you know,

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leading to some radiation
hazards as well.

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So that's a brief summary of
potential scenarios that we we

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should think about when we are
considering a radiation incident

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or emergency.
Yeah, and you've described sort

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of a wide range of scenarios
from from, you know, relatively

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small and contained to
unbelievably bad.

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In the case of considering a
radiological event in a context

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of a mass gathering, such as the
upcoming World Cup, what do

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organizers have to think about
when trying to protect?

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People going to see the event.
Professionals and organizing

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these large events, these mass
gatherings have a lot of

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resources and have a lot of
expertise in planning these and

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preparing for any potential
emergency.

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Radiation emergency is only one
aspect of this preparation and

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certainly they have a lot of
resources they can use.

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And one of the things that I
always say to people is

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radiation is one of the easier
hazards to detect.

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Personally, I would, you know, I
would really think that if you,

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if you had given me a choice
between a radiation or a

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chemical emergency, I would
definitely prefer to prepare for

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a radiation emergency because I
know I can detect it with

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radiation detectors.
There's also the rejective

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material speaks to us by
emitting limited types of

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radiation that we can detect in
most cases relatively easily.

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So that's one important thing to
consider.

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The other thing that I would
like to just mention is that we

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should keep it simple.
So our response agencies should

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keep it simple in terms of the
preparation and the response.

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Always try to keep the guidance
and their planning easy to

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understand and and apply.
Of course using best evidence

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available, supportive experts
that are available at the state

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and local level as well as the
federal level.

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And from an operational
standpoint, what are the first

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steps that organizers that
emergency response that public

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health overseeing everything,
what are what are the steps that

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need to happen of?
Course, initially it's supposed

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to recognize that a radiation
emergency has occurred because

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radiation exposures, you know,
often do not lead to a rapid

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onset.
Signs and symptoms that are

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easily detected or you know,
discerned by by by responders or

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by people themselves.
Initially it may just be signs

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and symptoms that are similar to
the food poisoning.

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Of course, if there is a
explosion or if there's any, you

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know, overt, overt incident
that's happening, it is part of

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our protocols to check for
rejected material.

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So that will potentially help us
in this situation identify that

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there's a radiation emergency as
well happening.

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But once we start having an idea
about what is the type of

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scenario that we are dealing
with out of the list of

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scenarios that I gave you at the
beginning.

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And also recognizing that
there's a radiation emergency

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happening or the radiation
exposure happening, which I told

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you is a little bit challenging
potentially in some cases

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because the symptoms are delayed
and onset and non specific.

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But once that's identified, you
know, you should not need to

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start thinking about several,
several considerations.

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First is the of course the
rescue of the victims, but while

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maintaining your responders and
1st receivers at the hospital

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safe.
So in that situation, you must

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really consider what is the
level of personal protective

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equipment that that you need to
use.

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For example, are you going to
use specifically the respirator

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or not an air purifying
respirator?

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That's the main consideration
here because otherwise the skin

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protection, it's going to be
somewhat similar.

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You know, whether it's a level D
or level level C.

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What's going to vary is the
respiratory protection, whether

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you use a surgical mask, A995
mask, or an air purifying

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00:22:26,520 --> 00:22:29,280
respirator.
Assuming you know the only

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hazard available on the scene is
from radiation, you need to also

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consider wearing those limiters
for responders to, to, to, to be

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able to track their doses, you
know, because they may be

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exposed to some secondary
radiation.

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So having a bozometer on their
body is, is important.

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You need to also look for the
radioactive material on the

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these victims, right?
So you need radiation detectors.

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So that's an operational
consideration.

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You know, you won't be able to
do that without these radiation

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detectors that are available.
They're handheld.

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Some of them are portal monitors
where you have people pass

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through the, the, the, the
portal and other, other methods

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of detection.
So these are a few

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considerations that must be made
in the radiation emergency by

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the responders, by the agencies
that are, you know, addressing

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this this event.
Yeah.

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And what does treatment look
like after that?

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Once it's been established that,
oh gosh, there is radiological

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material, it is, you know, the,
the victims have been exposed to

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it.
You know they're being safely

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removed from the site, Then
what?

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Then decontamination.
Then, you know, if people are

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stable and don't have any life
threatening emergencies, then

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you should look for the material
and wash it out.

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00:23:47,200 --> 00:23:50,320
Now, of course, removing the
clothing, especially when you're

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when someone's dressed with
clothes that cover most of their

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00:23:53,320 --> 00:23:56,560
body, you know, remember the
detective material is like dust

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or debris, you know, radioactive
debris.

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And I like to think of it as
dust or dirt or mud, right?

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And if you're really wearing a
shirt, long pants, you know,

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00:24:06,480 --> 00:24:10,720
that really covers about 85%
plus of your body surface area.

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00:24:11,400 --> 00:24:14,440
So simply by removing this
closing, get rid of 85% of this

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00:24:14,440 --> 00:24:18,440
radioactive debris, assuming
it's uniformly located on your

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00:24:18,440 --> 00:24:20,880
on your body, you're left with
your head, your face, your

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00:24:20,880 --> 00:24:22,640
hands, you know, potentially
your feet.

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00:24:22,720 --> 00:24:26,480
So in this situation, then you
did you look for the material

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with the detector and then you
wash it.

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00:24:28,680 --> 00:24:30,320
You can wash it with water, with
soap and water.

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00:24:30,960 --> 00:24:33,200
And then you repeat the
radiation survey and see if

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00:24:33,200 --> 00:24:35,360
you've done a good job that you
were you able to get rid of that

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dirt.
So it takes time to do this.

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You know, it takes somebody was
trained and using the detector

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00:24:40,600 --> 00:24:43,720
and trained in decontamination
while they're weighing the

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00:24:43,720 --> 00:24:47,640
appropriate PPE little bit we
mentioned, and then they're

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00:24:47,640 --> 00:24:50,360
decontaminated at that point,
you know, they're not

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00:24:50,360 --> 00:24:53,200
contagious, right?
So they're, you know, they're

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00:24:53,200 --> 00:24:58,320
going to be evaluated for the
potential for illness right from

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00:24:58,320 --> 00:25:00,560
this radiation exposure.
Now, remember, there's some

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00:25:00,560 --> 00:25:02,080
cases where there's no
contamination.

401
00:25:02,720 --> 00:25:04,880
Remember I told you about that
ideological exposure device

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00:25:04,880 --> 00:25:08,960
scenario where you you place an
unshielded sealed source and

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00:25:08,960 --> 00:25:12,120
that exposes people.
People in that environment are

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00:25:12,120 --> 00:25:14,160
not even contaminated because
they didn't touch it.

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00:25:14,160 --> 00:25:16,000
They didn't touch it and they
were just standing there.

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00:25:16,200 --> 00:25:19,640
But they've experienced this
exposure to radiation similar to

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00:25:19,640 --> 00:25:22,880
someone who's getting an X-ray
or ACT scan.

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00:25:23,280 --> 00:25:26,960
Remember, these people go to the
CT scan department or room, they

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00:25:26,960 --> 00:25:29,440
get scanned and they come back
to the emergency department

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00:25:29,440 --> 00:25:31,280
afterwards and they're not
considered contaminated.

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00:25:31,480 --> 00:25:33,360
Same in the scenario.
So in these cases, you don't

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00:25:33,360 --> 00:25:35,680
need to decontaminate these
these victims.

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00:25:36,040 --> 00:25:38,920
And of course, in that case, a
Level D personal protective

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00:25:38,920 --> 00:25:41,000
equipment with a simple surgical
mask is sufficient.

415
00:25:42,400 --> 00:25:45,440
Doctor Ziad Khazi, professor of
emergency medicine at Emory

416
00:25:45,440 --> 00:25:48,280
University and president of the
American College of Medical

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00:25:48,280 --> 00:25:51,920
Toxicology.
You can join ASTO and Dr. Kazi

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00:25:51,920 --> 00:25:55,160
for a webinar focused on public
health preparedness and response

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00:25:55,160 --> 00:25:57,080
related to the upcoming FIFA
World Cup.

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00:25:57,760 --> 00:26:00,200
This session will highlight
response operations to a

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00:26:00,200 --> 00:26:02,760
radiological incident during a
mass gathering.

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00:26:03,400 --> 00:26:06,240
Doctor Kazi will address key
response considerations from a

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00:26:06,240 --> 00:26:09,720
health department and public
health lens, including triage,

424
00:26:09,760 --> 00:26:12,520
contamination management,
radiation safety rules and

425
00:26:12,520 --> 00:26:15,640
detection assets, community
reception centers, medical

426
00:26:15,640 --> 00:26:18,720
countermeasures and more.
There will be time for AQ and a

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00:26:18,720 --> 00:26:20,920
session to address questions
from attendees.

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00:26:21,360 --> 00:26:23,760
You can find a registration link
in the show notes.

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00:26:25,920 --> 00:26:27,960
This has been public health
review morning edition.

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00:26:28,040 --> 00:26:30,600
I'm John Sheehan for the
Association of State and

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00:26:30,600 --> 00:26:32,000
Territorial Health Officials.