They were designed to measure respondents' objective and self-assessed preparedness for a variety of WMD terrorist incident scenarios. The specificity in each narrative assured--to the extent possible in a mail survey--that all respondents shared a common notion of the scale and nature of what was meant by "WMD terrorist incident.
Bioterrorism and Emergency Preparedness - inskookamtio.gq
During a three-day period in July, 20 individuals present to a local hospital's emergency room complaining of fever, night sweats, headaches, coughing, and joint pains. Initially, an untimely flu epidemic is suspected.
However, after the third day, concern grows more acute: Additional patients are admitted with more severe symptoms; and laboratory personnel who analyzed patient blood samples begin reporting similar symptoms. Several days later, ERs and physicians have seen enough cases to alert local and state public health authorities, who immediately undertake large-scale surveillance and dispatch an investigation team. The state health department also notifies the CDC [Centers for Disease Control and Prevention], at which point other federal agencies are alerted. It is quickly determined that all patients had visited a regional airport in the last 10 days.
The governor orders the airport closed and quarantined. Fire and HAZMAT [hazardous materials] teams report to the scene to investigate and determine if there is a continuing threat. The National Guard is called to assist police with airport closure and crowd control. Days later, seven of those affected die.
All victims' blood specimens test positive for brucellosis. A statewide and international alert is activated urging anyone who passed through the airport to contact their local health department. News agencies report that brucellosis can be fatal, creating panic. Local ERs are crowded with patients complaining of flu-like symptoms. An explosion in a building with people inside results in numerous injuries and some fatalities, but minimal structural damage.
As first responders arrive on the scene, they observe the following: Twenty-five individuals have been killed by the blast; there are more casualties than would be expected for an explosion alone; and unlikely symptoms among the survivors include sweating, disorientation, muscle tremors, convulsions, and eye pain exhibited by individuals.
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Soon, some of the responders also start to experience similar symptoms. A highly toxic and persistent chemical agent is suspected of having been released by the explosion. Both state and federal emergency management officials are notified. Cross- contamination becomes a major concern, as victims find their way to local hospitals and responders operate in an area potentially covered with an active chemical agent. As the media pick up the story, panic begins to spread among the large crowd that has formed outside the building and in the nearby vicinity. Just prior to the September 11 attacks, RAND completed a nationwide survey of state and local response organizations.
Respondents were asked a series of questions about their organization's preparedness for emergency response in general and specifically for WMD-type  incidents. In addition, they were also given a series of scenarios--more moderate than those used in Dark Winter --addressing hypothetical threats and were asked to assess their own organization's level of preparedness and ability to respond to such incidents. See the sidebar describing the WMD scenarios. Here, we focus specifically on the survey's findings on preparedness in relation to local planning activities.
One tool for ensuring an effective response is whether public health departments and general acute care hospitals--both public and private--at the local level have mutual aid agreements that address sharing of resources and personnel in the event of a WMD-related incident. As shown on the top left bar chart in Figure 1 above the line , two-thirds of local public health departments and 85 percent of hospitals have informal or formal mutual aid agreements with other city, county, state, or regional organizations for disasters and emergency response in general.
Figure 1. Percentage of Local Public Health Departments and Hospitals with Informal or Formal Mutual Aid Agreements However, as shown on the top right side of the figure, only one out of ten local health departments and hospitals have mutual aid agreements that specifically address incidents involving WMD. Whether these mutual aid agreements address WMD specifically may be of less import than the fact that, in general, most health organizations have such mechanisms in place to address the sharing of resources and personnel in the event of a disaster or an emergency.
As shown in the bottom right of the figure, public health departments and hospitals in large metropolitan counties  were more than twice as likely as other counties to have mutual aid agreements that address WMD-related incidents. A more specific measure of preparedness for dealing with terrorist threats inside our borders is whether a health department or hospital has plans or standard operating procedures SOPs in place that specifically address response to a biological or chemical incident.
As noted above and as shown in the WMD scenarios sidebar , we presented survey respondents with several different scenarios involving the use of a biological or of a chemical weapon.
Are Local Health Responders Ready for Biological and Chemical Terrorism?
For each scenario, we asked survey respondents to assess their organization's level of preparedness along several different dimensions. These included whether the organization had response plans that addressed a similar scenario, what aspects of the organization's response the plans addressed, and how recently those response plans had been exercised. The scenarios, reviewed by subject-matter experts, were scaled to moderate size: sufficient to test the preparedness of an organization to respond but not large enough to be expected to overwhelm the capabilities of most organizations.
Figure 2. Percentage of Local Public Health Departments and Hospitals with Response Plans or SOPs As shown on the top left of Figure 2, only about one-third of local public health departments and hospitals reported having plans or SOPs in place for response to a moderate-sized biological scenario. Furthermore, public health departments and hospitals in large metropolitan counties were only somewhat more likely than other counties to have such response plans.
In that survey, only 20 percent of local public health agencies LPHAs reported having a comprehensive response plan for biodefense. Figure 3. When Response Plans or SOPs Were Last Exercised For incidents involving chemical weapons, the survey findings shown on the right of the figure suggest that the preparedness of the public health system for chemical incidents is similar to that for biological incidents.
However, hospitals appear to be somewhat better prepared than the public health agencies, with more than 50 percent having response plans or SOPs for a moderate-sized chemical incident. Overall, large metropolitan counties appear to be better prepared than other counties: One-third of public health departments and two-thirds of hospitals have response plans for this type of incident.
A third component of preparedness is how recently response plans or SOPs have been exercised. In general, as shown in Figure 3, response plans for a chemical incident were more likely to have been exercised within the past year than response plans for a biological incident; one out of three public health departments and hospitals had exercised their chemical incident plans within the past year.
Figure 4. Presence of Interagency Disaster Preparedness Committee or Task Force As the Dark Winter exercise made clear, integration between the public health and medical communities and that of other local emergency responders is a key concern. Our survey results as shown in Figure 4 suggest that the degree of integration between public health and hospitals with the planning activities of other emergency responders is greater for disaster and emergency response in general than for incidents involving the use of biological or chemical weapons. For example, many counties reported they had interagency task forces or committees that address disaster and emergency preparedness in general.
As shown on the top left side of the figure, two-thirds of local public health departments and just over three-quarters of hospitals indicated such task forces existed in their region. Most organizations belonged to these interagency task forces if they had been established locally. However, only a little more than one-half of these interagency task forces specifically address planning for WMD-related incidents.
Large metropolitan counties were more likely to have inter-agency disaster preparedness task forces that addressed planning for these types of incidents. Figure 5. Another measure of integration is whether response plans address communication with other emergency responders or other health facilities in the event of an emergency involving biological or chemical weapons. Of the local public health departments and hospitals with response plans for incidents specifically involving biological or chemical weapons, the majority as shown in Figure 5 indicated that their plans or SOPs addressed communications with first responders and other health organizations within their area.
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However, when survey respondents were asked their opinions about whether hospitals and public health agencies overall are well-integrated with the bioterrorism planning and preparedness activities of other emergency response organizations within their communities, both hospitals and public health agencies felt that public health agencies in general were not well-integrated, as shown in Figure 6. Organizations in large metropolitan counties were more likely than other counties to consider public health agencies to be well-integrated.
However, respondents differed in their opinions about how well-integrated hospitals in their communities were with respect to local bioterrorism planning and preparedness activities. Hospitals 50 percent were more likely than public health departments 27 percent to assess local hospitals as being well-integrated with the planning and preparedness of other emergency responders. Figure 6. The mailings of anthrax-laced letters in have underscored the critical importance of timely and effective communication by public health authorities to the media, the public, and other health providers and emergency responders about dealing with such bioterrorist incidents.
The initial communication gaps and delays by federal health authorities in responding to requests for information left many local public agencies wondering how prepared their own departments might be to handle such information requests. More generally, since September 11, local public health agencies have reported receiving numerous requests from the community for information, including among other topics questions about vaccination and medication availability, level of local preparedness, and the existence of local emergency response plans for biodefense.
As shown in Figure 7, our survey found that of those local public health departments with a written emergency response plan or whose organization is included as part of the local OEM's emergency response plan , most 81 percent have plans that generally address communications with the media for disasters or emergencies. Figure 7. Plans for Disseminating Public Health Information Although not shown in the figure, of the one-third of public health departments with a response plan or SOP for a biological incident, two out of three of these plans addressed procedures for rapidly notifying and disseminating emergency information and diagnostic results to other health care providers, health and safety personnel, or emergency responders.
Half of the plans also addressed procedures for rapidly notifying and disseminating emergency health information in the event of a chemical incident. However, as shown on the right side of the figure, only one out of ten local public health departments said they had written materials or information that could be rapidly distributed to medical or public health professionals and to emergency responders to inform them about how to handle a biological incident.
Large metropolitan counties were only somewhat more likely 17 percent to have such written materials. This is a noteworthy finding in the aftermath of the recent anthrax incidents, where public health departments in New York City and Washington, D. To help address this problem, the Centers for Disease Control and Prevention CDC have recently made available web bioterrorism resources for public health professionals to reference when providing information to the public.
The after-action review of the Dark Winter exercise found the United States unprepared for bioterrorist attacks. The simulation underscored the importance of strengthening the public health response at the local, state, and federal levels. Compared to the Dark Winter simulation, the biological scenario presented in RAND's nationwide survey was more modest in magnitude. Yet only a third of local public health departments and hospitals in the United States reported having plans or SOPs in place to address response to even a moderate-sized biological scenario.
Overall, large metropolitan counties with a population of one million or more appear to be better prepared for biological or chemical terrorism than other counties, in that they were more likely to have. One might argue that since large metropolitan counties are more likely to be targets of terrorist attacks, they should be better prepared.
However, as the survey findings suggest, there is significant room and reason for improvement in planning for biological and chemical terrorist attacks even within our larger counties. For instance, because these findings are based on self-reported data, one might expect an upward bias in the reporting of organizational preparedness. Further, these findings are relevant not just to response preparedness for biological or chemical terrorist incidents, but to any acts of terrorism inside the United States involving the use of radiological or nuclear weapons or even conventional explosives.
Our analyses focused on two types of terrorist incidents--chemical and biological attacks--where public health agencies and hospitals clearly will play an important role in the response. Based on the survey findings, local planning for chemical incidents--whose effects will be manifested immediately--appears to be somewhat further along than planning for biological attacks. In terms of the investigation of, and response to, a biological terrorist attack, there is special cause for concern. Biological attacks evolve in fundamentally different ways than other emergencies. The release of a biological weapon may take days or even weeks to be detected.
Law enforcement and other local authorities may be unfamiliar with the evolving nature of a bioterrorist attack and uncertain of the role local public health agencies and medical care providers may play in the investigation and detection of such an attack. Public health has traditionally been peripheral to emergency planning in general; many hospitals and public health agencies are unfamiliar with the incident command system used by other emergency responders.
In various tabletop exercises and analyses of disaster response, confusion continues to exist between health and medical professionals and other emergency responders over who has what authority and who is in charge of the response. The anthrax attacks in fall were another example of how differences between law enforcement and public health and medical officials in their investigative approach and objectives resulted in delays, duplication of effort, and communication breakdowns.
To date, these two rapid pathways have not been invoked for vaccines. Emergency Use Authorization EUA is an option in pandemic and bioweapon response for both civilian and military populations. After a declaration of emergency by the Department of Health and Human Services secretary, this program allows for use of an unapproved medical product or a product that has been approved but not for the specific use applicable to the situation at hand that is the best available treatment or prevention for the threat in question.
One challenge to licensing vaccines for response to bioweapon threats is the absence of some of these disease agents in the natural world.