Preparing for the Unknown

by Christina M. Flowers

U.S. emergency responders face an ever-growing list of responsibilities related to the emergency preparedness capabilities within their own communities. Those responsibilities influence not only current response tactics but also the overall planning for and mitigation of threats.  Preparedness now encompasses the preparation and planning for all potential emergencies – including chemical, biological, radiological, nuclear, and explosive (CBRNE) threats, naturally occurring infectious-disease outbreaks, natural disasters such as hurricanes and earthquakes, and various mass-casualty accidents and incidents that could significantly affect the morbidity and mortality of American citizens.

To successfully address each of these risks, major emphasis is being placed on what is known as “all-hazards preparedness” – a term that refers to the idea that a locality must be flexible enough to respond to, mitigate, and recover from any of these types of events in an efficient and effective manner.

Exercise, Exercise, Exercise!

Training and exercises, in particular, are essential for developing well-rounded all-hazard capabilities. Training helps emergency-response personnel become familiar with responsibilities and to acquire the skills necessary to perform assigned tasks. Exercises provide a means not only to validate plans, checklists, and response procedures, but also to evaluate the skills of response personnel.

The Homeland Security Exercise Evaluation Program (HSEEP) is a capabilities-based “toolkit” that provides templates, standardized methodologies, and terminologies to be used during exercise design, development, conduct, evaluation, and improvement planning. HSEEP also is useful because it puts a strong emphasis on objective assessments of capabilities. Being objective allows an organization to recognize not only strengths but also areas for improvement. Once identified, these areas for improvement can be shared and corrected prior to a real incident.

There are seven principal types of exercises described by HSEEP. Four of them – Seminars, Workshops, Tabletop Exercises, and Games – are intended to familiarize participants with (or develop new) plans, policies, agreements, and procedures. The remaining three – Drills, Functional Exercises, and Full-Scale Exercises – are operations-based and are designed to: (a) validate plans, policies, agreements, and procedures; (b) clarify roles and responsibilities; and (c) identify resource gaps in an operational environment.

Best Practices: The Cities Readiness Initiative

One of the main advantages of exercises frequently overlooked is the benefit of networking. Because all emergencies are local, in one sense or another, there are many community partners who will play response roles during large-scale response and recovery efforts. The Cities Readiness Initiative (CRI) serves as a prime example. A pilot program created by the federal Centers for Disease Control and Prevention (CDC), CRI is designed to help increase a community’s ability (within 48 hours of the decision to do so) to deliver medicines, medical supplies, and other essential supplies and equipment to the general public during a large-scale public-health emergency – an attack involving biological-warfare agents, for example.

Prior to the 2001 anthrax attacks on Capitol Hill, it was commonly assumed that the quickest and most effective response by almost any U.S. community that was victim to a bioterrorist attack should and would be spearheaded only by public-health officials. However, CRI has alerted responders to the realization that the implementation of mass prophylactic procedures would require not only much more manpower than previously assumed, but also a broader spectrum of skill sets than are likely to be available from local or even state health departments. CRI exercises therefore have brought in, among other participants: police and other law-enforcement personnel to carry out site-security assessments; firefighters and hazmat specialists to serve as support personnel; public information specialists and even the media to plan and carry out various public-outreach campaigns; and local, city, and state officials to plan and implement the continuity-of-operations plans needed to ensure the continued availability of government authority and material resources.

Some school systems also participate – by providing buses, for example, to deliver medications door-to-door in certain local communities – and numerous private-sector businesses and companies also have become involved. Bringing this wide range of local stakeholders together during an exercise can have a significant impact on both the effectiveness and the timeliness of the response procedures – planned ahead of time, it should always be emphasized – and on the implementation of those procedures as soon as possible after an actual bioterrorism attack.

Ensuring an Efficient and Effective Response

In 1970, the World Health Organization (WHO) estimated that the theoretical release of 50 kg of anthrax in an urban area of approximately five million people could result in almost 100,000 casualties, making it similar in lethality to an atomic bomb. Following a large-scale anthrax attack, prophylactic medication must be administered within 48 hours of exposure to produce the greatest life-saving effects. For that reason, most local jurisdictions base their response procedures on the anticipation of the threat, rather than waiting for laboratory confirmation of the specific pathogen involved.

That response plan might be relatively effective, but it is not very efficient, if only because the implementation of mass prophylaxis procedures would be a costly and logistical nightmare. Which brings up an extremely difficult but absolutely unavoidable question: How does a community increase both the efficiency and the effectiveness of its bioterrorism-response capabilities (and/or resources)?

The science behind biological-agent identification systems has advanced considerably since those initially introduced in the aftermath of 9-11. The use of Polymerase Chain Reactions (PCRs) is a common and often indispensable technique followed in medical and biological laboratories world-wide. PCR tests are based on replication of the DNA that is unique to a specific threat agent. First introduced to the military in 2002, the newly modified RAZOR EX® (an instrument manufactured by Idaho Technology) became available for field use by first responders in 2007. A hand-portable, ruggedized biological-agent identification system designed to move pathogen detection closer to the scene of an actual crisis, RAZOR EX can run an unknown sample against any of the top ten bioterrorism agents in under 30 minutes, and is now used regularly by hazmat teams, police departments, border-protection agencies, and port authorities throughout the United States. During an emergency, the use of RAZOR EX has the potential not only to make decision-making processes considerably more reliable, but also to greatly increase a community’s overall biodefense capabilities.

Finding Support in Unlikely Places

Ongoing all-hazard preparedness and response exercises also help build the community support networks that are essential for effective emergency preparedness and response. Staffing support has been provided through volunteer organizations, such as the Medical Reserve Corps – a national organization founded after President Bush’s comments – in his 2002 State of the Union Address – dedicated to ensuring hometown security. Of equal importance is the fact that, since the 9/11 attacks, new funding sources have become available through local emergency management, state and local health departments, environmental services, numerous public and private-sector laboratories, various research organizations, private companies, and local businesses. Thanks in large part to the additional funding now available, preparedness efforts are consolidated, and promoted throughout entire jurisdictions. Thanks also to the increasingly supportive efforts of the many groups actively involved, there are new outlets for public outreach, and an overall increased awareness of bioterrorism and all-hazards preparedness.

Christina M. Flowers, MPH (Master of Public Health), is currently working with ITI, a supplier of solutions in the field of biodefense preparedness. She previously served as an emergency planner for the Virginia Department of Health, possesses a wealth of experience in grants management, and participated in a number of emergency preparedness and response efforts in Norfolk, Virginia. Certified both in tropical medicine for vector-borne emerging infectious diseases and as a Level 1 hazmat instructor, she also provided essential technical laboratory assistance during the anthrax attacks on Capitol Hill seven years ago and now manages the U.S. East Coast sales of real-time disease-identification equipment.