Lessons Learned from a Full-Scale Bioterrorism Exercise

Lessons Learned from a Full-Scale

Bioterrorism Exercise

Commentary

Emerging Infectious Diseases Vol. 6, No. 6, November–December 2000

Lessons Learned from a Full-Scale

Bioterrorism Exercise

During May 20-23, 2000, local, state, and

federal officials, and the staff of three hospitals

in metropolitan Denver, participated in a

bioterrorism exercise called Operation Topoff.

As a simulated bioterrorist attack unfolded,

participants learned that a Yersinia pestis

aerosol had been covertly released 3 days

earlier at the city’s center for the performing

arts, leading to >2,000 cases of pneumonic

plague, many deaths, and hundreds of secondary

cases. The exercise provided an opportunity

to practice working with an infectious agent

and to address issues related to antimicrobial

prophylaxis and infection control that would

also be applicable to smallpox or pandemic

influenza.

The sequence of events and the exact date

of the exercise were not specified. However, the

probable weekend and possible bioagents were

suggested, which enabled us to begin preparations

approximately 8 weeks ahead. Preparations

included temporary appointments to the

governor’s 19-person Expert Emergency Epidemic

Response Committee, which was created

by enactment of a bioterrorism and pandemic

influenza response law on March 15, 2000;

recruitment of 25 epidemiologic and emergency

management personnel from the 1,050 employees

of our department and assignment to

disaster response teams (e.g., surveillance, field

investigation, and emergency management

coordination); and establishment of a command

center by reserving conference rooms and

installing telephone, computer, and television

equipment. Colorado’s bioterrorism and pandemic

influenza response law was not enacted

to prepare for the exercise, but proved extremely

useful. We recommend that state

health agencies review their statutory authority

and evaluate whether these laws would be

adequate to deal with the threats of

bioterrorism and pandemic influenza. During

the exercise, we were provided information

either from other participating agencies or from

exercise controllers, and it was our task to

investigate and respond. The staff reviewed

mock medical records, analyzed laboratory

specimens, interviewed patients, conducted

meetings and group conference calls to assess

surveillance data and decide on the next steps,

drafted public health and executive orders,

made written requests to federal officials for

specific assistance, participated in news conferences,

and packaged mock antibiotics for

distribution at a prophylaxis clinic. By the end

of day one, 783 cases and 123 deaths from

plague had been reported from 16 hospitals

(three participating hospitals and 13 simulated

facilities). By the end of day two, 1,871 cases

and 389 deaths were attributed to pneumonic

plague, with 307 patients requiring ventilatory

support. Cases were reported from six states

outside Colorado. By the end of day three, 3,700

cases and 950 deaths were reported, including

at least 780 secondary cases.

The exercise required state health department

personnel to develop new working relationships.

Although hospitals and local and

state health agencies often collaborate with the

Centers for Disease Control and Prevention in

controlling an epidemic, we were unaccustomed

to working closely with the Federal Bureau of

Investigation, the U.S. Attorney for the District

of Colorado, the Federal Emergency Management

Agency, the Regional Office of the U.S.

Public Health Service, and the Colorado Office

of Emergency Management. Although lines of

authority were clear, much time was spent in

consultation and debate through scheduled

bridge calls. Many persons joined these calls,

and decision-making became inefficient, although

not impossible. In a true incident, a

central location for face-to-face meetings should

be large enough to accommodate representatives

from all agencies involved, but one difficulty

encountered with arranging such meetings

was that each agency seemed most comfortable

in its own command center.

Another lesson we learned concerned our

own organization. In addition to the surveillance,

field investigation, and emergency

management coordination teams, we needed

teams to address laboratory testing, mass

fatalities, legal problems, information technology,

infection control, public and professional

communications, and antibiotic and vaccine

administration. During a disaster, no routine

agency business can be conducted, as all employees

are involved in the public health response.

Finally, activities cannot depend on the

direction of one or two key persons, such as the

executive director and the state epidemiologist;

other skilled, informed persons must be able to

Commentary

Vol. 6, No. 6, November–December 2000 Emerging Infectious Diseases

assume leadership roles. An electronic database

documenting events, decisions, and requests for

resources should be maintained. These logs

enable staff to monitor the epidemic and the

public health response rapidly.

In Colorado, where plague is endemic, we

are familiar with the public health management

of single plague cases, but the magnitude of the

simulated epidemic and the fact that infection

was spreading from person to person after a

short (2- to 3-day) incubation period quickly

overwhelmed the available resources. The

challenge to our surveillance system was not in

detecting the outbreak but rather in maintaining

surveillance at each of the 22 acute-care

hospitals in metropolitan Denver. Our hospital

surveillance system usually relies on reporting

by infection control practitioners, but during

the exercise these practitioners had many

additional responsibilities. In a true bioterrorist

attack, emergency response teams of state or

local health department employees should be

set up and sent to each hospital to monitor

cases and provide information to a central

command center.

As more cases were identified, an anticipated

issue emerged: who should receive

antimicrobial prophylaxis? The governor’s

committee debated whether to limit prophylaxis

to close contacts of infectious cases or offer it

more widely (e.g., to all health-care workers,

first responders, and public safety workers and

their families) to gain the support and participation

of key workers. The committee decided

on the latter approach, but not unanimously.

The process of isolating plague patients

until they are no longer contagious and identifying

close contacts is typically straightforward.

Isolation, however, was not possible during this

exercise. The hospitals had too many patients

and worried-well persons and too few healthcare

workers and empty rooms to permit

isolation of pneumonic plague patients. Case

reporting was delayed, and there were too few

trained public health workers to conduct

interviews and locate contacts in a timely

manner. As a result, an executive order was

issued quarantining all persons in metropolitan

Denver in their homes. With infection control in

the general population supposedly managed by

the order, we could turn our attention to securing

additional supplies, staff, beds, and equipment

for the hospitals.

However, quarantining two million persons

is not simple. Essential workers must be

identified, be given prophylaxis and protective

barriers, and be permitted to do their jobs.

Other members of the community can stay in

their homes only a few days before they need

fresh supplies of food. Therefore, a one-time,

blanket quarantine order is unlikely to be

successful and cannot be enforced unless these

and many other issues are addressed. The

hospitals were quite demanding in their requests

for reinforcements, and we made great

efforts to assist them. However, by day three of

the exercise it became clear that unless controlling

the spread of the disease and triage and

treatment of ill persons in hospitals receive

equal effort, the demand for health-care services

will not diminish. This was the single

most important lesson we learned by participating

in the exercise.

Richard E. Hoffman and Jane E. Norton

Colorado Department of Public Health and

Environment, Denver, Colorado, USA