Download a Copy of this Document

HTML version ,Text Version

Saturday

The participants were divided into three groups to develop timelines and responses, using present technology, for the following scenario.  At Dartmouth College, students begin having flu-like symptoms and report both to the college infirmary and to local hospitals.  How would you decide if there was a terrorist attack, how would you handle forensics, and what would be your response timeline as students start dying from a confined space biological agent release?

Each group allowed its members to use their expertise to work out a plan and timeline.  Group 1 discussed the following response elements.  How to deal with the worried well and avoid panic?  How would the campus and the community function under such stress?  They postulated that the local medical response would be overwhelmed and that antibiotics would need to be imported.  They foresaw a need for good communications between different provider systems who may be operating on different forms of technology.  They predicted that many students would flee the outbreak while locals would hesitate to leave.  Group one felt there would be trouble making a timely diagnosis with present technology.  With local first responders becoming quickly overextended, they saw a need to identify and activate relevant state agencies.  They felt forensics would be difficult.  Eventually there would be a need to transport patients to other state hospitals and intensive care units.

Group Two agreed with Group One that it would be difficult to identify this initially as a terrorist act or to make a diagnosis early.  They expressed concern about a lack of local stockpiles for vaccines, antibiotics, and other protective items.  They felt that isolation measures should be instituted to prevent possible spread and discussed strategic concerns regarding this, with two interstate highways and Canada nearby.  They postulated that campus connections would allow cameras to transmit live from many locations over the Internet to news media.  These transmissions could hog bandwidth and force officials to ask that the media be blacked out.  Group Two felt a command and control operations center would need to be set up.  Most felt that local police and other officials would remain at their posts while others felt that they would probably flee, requiring military units to replace their functions.  They wondered about whether a terrorist would issue a statement and how that might impact a response plan.  They also wondered about copycat false claims and how the op center could evaluate other threats.

Group Three decided that early diagnosis was the most important means of intervention.  They charted a flow diagram with 20 or more boxes representing local, state, and federal resources which would need to be contacted and coordinated.  They postulated that sentinel cases (patients with concurrent serious medical conditions) would be more quickly and thoroughly investigated resulting in an infectious diagnosis of plague within 4 to 5 days.  Group 3 felt that education and awareness by medical personnel could make a real difference but didn¹t know if local physicians had taken any special training for biological attacks.  They felt that due to the seriousness of the illness and the small Dartmouth College community, physicians would realize within 24 hours of the first sick student that an epidemic of some sort was occurring.  Group 3 theorized that 5 to 10% of the population may be on antibiotics at any time and be protected from some infections.  They theorized that some patients with flu symptoms would receive antibiotics early in the disease while others would be treated with antivirals which would not be protective.  They identified 7 negative pressure rooms for protective isolation available locally.  While this initially would be overwhelmed, they felt that once prophylactic antibiotics were started, containment would be less of an issue.  They felt that hotels and dorms would be converted to patient wards. 

In the discussion which followed the small group presentations, a timeline was established for identification of the agent of 5 to ten days post attack.  Suspicion of terrorist attack would be then quickly aroused by the unique infection- plague.  Identifying the site of the attack would take some good epidemiology to show where the agent was released.  The terrorists could be difficult to identify and be attacking other sites while the investigation proceeded.  Another point made by some participants was how different biological incidents are from other disaster planning.  Some felt that many parts of response planning were similar while others sided with the unique needs for vaccines, medicines, and infection control measures.  There was a sense that local responders would have difficulty with coordinating the response.  Some worried that a significant number might flee or refuse to perform assigned roles, requiring military units to substitute, possibly exposing more people to deadly organisms.  It was noted that the community would experience chaos.

At noon, Tracey McNamara, DVM, recounted the West Nile Virus epidemic, which caused New York City to ask if it had been attacked in the summer of 1999.  Her very detailed presentation gave nearly a day-by-day, month-by-month account of the challenge she and her colleagues faced in NY.  When the zoo first noticed dying crows and other birds, it was a struggle to make the correct diagnosis.  No secure veterinary labs are available comparable to the Level 4 lab which the CDC maintains.  Necessary diagnostic tools such as electron microscopy had to be begged for and waited on.  Tremendous communication barriers required daily conference calls with many different speakers.  A misdiagnosis was made of another mosquito borne virus.  There just aren¹t enough resources devoted to veterinary pathology laboratories, in this country, which played a central role in detecting and diagnosing this virus, which had not previously been known to be on the east coast.

Saturday afternoon was the whole group¹s opportunity to respond to another scenario, in 2005, with several participants grouped together to act as the FBI, FDA, FEMA, and so forth.  They were instructed to think how advanced technology might be useful if employed.  The local response group reported on the scenario, as time passed from the moment that Hanover¹s Chief of Police learned that 4 similarly ill patients had been treated in the local ER, with the staff now believing that it was smallpox clinically.  The Chief immediately placed a call to the governor¹s office to request assistance.

The CDC (Center for Disease Control) was contacted in Atlanta.  The CDC directed samples to be secured and transported to Atlanta by a field representative trained to handle such dangerously infective materials.  The FBI was notified to become the lead agency for possible terrorist incident.  FEMA was notified; vaccine mobilization was done, and planning undertaken.  CDC epidemiologists started determining where the cases have been and whom they have been in contact with.

The decision was made to place the hospital under protective quarantine for public health reasons.  The White House issued a press statement that all necessary measures were being taken to both protect the public health and to determine if a terrorist incident had occurred.  In Hanover,  the Police Chief was now awaiting for National Guard to arrive.  The local radio and TV stations were providing education and reassurance.  Further consideration was being given to how to deploy police and fire department assets to contain the infection.  While there were only 4 suspected cases of smallpox, it was decided that this could be a national emergency requiring an interstate quarantine.  The Attorney Generals for both VT and NH cooperated to achieve this.

By 24 hours after the Police Chief had been notified, the worried well and the news media had completely overwhelmed the 911 and commercial communication systems.  There are concerns about distributing food and water.  The roads and airport have been closed by state police.  The CDC is coordinating additional medical supplies.  They are utilizing PCR (polymerize chain reaction) and EM (electron microscopy) to study their samples. The preliminary diagnosis is pox virus.  Their epidemiology officers have found that all victims ate at Thayer dining hall, 8 to 9 days earlier. 

The Department of Defense is mobilizing additional resources for command and control.  The FBI has started to investigate the backgrounds of the sick patients  and other suspicious visitors for leads.  They are also helping the CDC determine where the cases have been and who their contacts have been.  The vaccines arrive but there is confusion on how to organize vaccination efforts.  The CDC personnel begin training local persons on how they want the vaccine administered.  They have told the White House that they need to contain this now as it would take 6 months to make enough vaccine to protect the country.

The Attorney General has briefed the President on the range of emergency powers he may exercise, including restricting immigration and use of quarantine for public health protection.  As Hanover approaches 48 hours since the emergency started, interactive video links and telesupport from remote sites are set up and staffed.  Hanover hasn¹t gotten any more food and the National Guard needs more resources.  The CDC is working on genetically identifying the virus and containment strategies.  National healthcare providers are briefed and their assistance requested.  Experts at USAMRIID are requesting samples and data to assist the CDC.

As we enter the third 24-hour period of the crisis, the President is notified that more smallpox cases are being diagnosed and that there is a concern that this is a terrorist attack which may be complicated by other attacks.  No group has claimed responsibility.  In Baltimore, there are two possible additional cases, which the CDC is investigating.  The military and the Department of Defense (DOD) are further developing logistics coordination, deploying immunized medical staff, providing security, and assisting with civil affairs.

In Hanover, residents are quarantined at home, containment of individuals is enforced, and there is need for more protective suits.  The CDC is working on national guidelines should the epidemic spread outside of current areas.  The Maryland National Guard has been put on alert. Available communication bandwidth has suffered several blackouts due to heavy demand and suspicious denial of service episodes.  Communication companies are attempting to manage networks but appear somewhat hampered by young, inexperienced, engineers and directors.

New Hampshire has issued a call for assistance from other states.  Volunteers, led by the Maryland National Guard, are ready to operate telemedicine remote hospital wards.  They include 500 physicians and 1500 nurses with other support staff, using a staffing ration of one physician and three nurses per 10 critically ill patients.  Other patients can be telesupported in their homes via Internet 2 bandwidth.

At one week out, 30% of the Hanover population is deceased with the number of deaths increasing each day.  The population doesn¹t believe the immunizations to be protective.  The CDC and USARMIID now believe that this is a monkey pox, biologically altered with smallpox, a deliberate act of terrorism.  It does not seem to be as contagious as smallpox.  They are unsure how to make the natural smallpox vaccine more effective.  They estimate it could take 6 months to develop a new vaccine.  They are performing susceptibility testing for the limited antiviral compounds currently approved for other indications.

By day 9, the Hanover area is passing through a second cycle of disease.  The ranks of the caretakers and their medical supplies are depleted.  Some inhabitants, principally students, are feared to have left the area.  Only families fully quarantined from the community are untouched by illness, staying indoors in their homes.  The military has fully taken control of police and emergency services and is suffering some casualties, despite previous smallpox vaccination and investigational prophylaxis with anitiviral medicinals.

In Maryland, there are currently 17 infected patients.  The airports are closed, the national guard has been called out, the worried well are flooding hospital emergency rooms with flu symptoms and minor rashes.  While the CDC has confirmed the second epidemic center, two other suspected outbreaks have been ruled improbable while investigation continues.

The White House has been issuing frequent press briefings to calm people while urging citizens to be aware of any suspicious activities.  They have agreed with Canada to close their Northern Boarder as a precaution while Mexico continues to monitor the situation.  There is a sense of terrible national crisis.  The European union is expected to ban travel and commerce.  They are setting up 30 day quarantine procedures, though no one knows how long a quarantine is needed to prevent transmission.

The good news is that although there have been isolated confrontations between affected citizens demanding medicine or vaccination, the populace has remained calm.  The country has rallied around the executive branch¹s vow to find and prosecute the terrorists, promising retribution to any country caught aiding them.  Congress meets in special session, passing emergency legislation for the FDA and other agencies to meet the urgent demand to find new vaccines or medicine.  

go back to page 2 or continue