Lessons Are Learned From San Antonio's "Pale Horse" Bioterrorism Response Exercise

SAN ANTONIO, Texas - Newswise -- "A terrorist biological attack with a highly infectious agent against a susceptible population would present immense command and control challenges," says Col. David Jarrett, MD, FACEP, in the current issue of the journal Disaster Management & Response, published by the Emergency Nurses Association (ENA). Jarrett, the director of the Armed Forces Radiobiology Research Institute in Bethesda, Md., examined the shortfalls and solutions identified during Pale Horse, a bioterrorism exercise conducted by the city of San Antonio, Texas, in August 2002, in cooperation with Fort Sam Houston, which stands within the city limits.

One of the most ambitious, large-scale bioterrorism exercises held, the purpose of Pale Horse was to test the command infrastructure within a large tabletop exercise. The program was prefaced by a series of plenary session lectures on relevant topics. Participants then dispersed to "command cells," and the exercise proceeded. Participants included military medical command personnel, civilian medical officials, the city government, boards of health, state medical, National Guard, and regional officials from the Federal Emergency Management Agency (FEMA) and the Department of Defense (DOD). The primary scenario was a terrorist attack involving aerosolized smallpox virus sprayed over attendees at the city's Alamo Dome during a sports event. No announcement or threat was relayed, and all attendees dispersed to their regular routines. The initial victims of smallpox then began seeking medical attention after the normal incubation period for the virus.

Jarrett examined several important lessons learned during the exercise, including:

Use of investigational new drug (IND) vaccines. Use of investigational smallpox vaccines protocol will be unable to control an epidemic resulting from a large-scale bioterrorism attack. Sufficient time and personnel cannot be made available to stem the spread of this communicable disease.

Ability to provide ring vaccination. Ring vaccination cannot be accomplished when contact tracing is impossible due to the nature of the attack. Adequate personnel did not exist to rapidly perform contact tracing due to the sheer number of primary infections. In this venue, where infected individuals were externally unidentifiable and dispersed widely before the symptoms appeared, the only workable option was mass vaccination without regard to the probability of exposure.

Multidisciplinary communication. Communication among the multiple emergency operations centers, the public, and health care providers was totally inadequate. In an ideal situation, all operations centers would rapidly provide each other with pertinent information. Potential improvements identified during the exercise, such as acquiring the equipment needed for rapid data analysis with secure communications, would require direction from the Department of Homeland Security.

Knowledge and authority deficit. The lack of knowledge of how to handle the bodies of smallpox casualties became a significant issue. The city's Medical Operations Center was unsure of its authority over other public and private groups. The absence of a public health officer created information delays; more frequent information updates were needed.

Lack of civilian personnel. The availability of grief counselors and clinic personnel was markedly insufficient considering the large mortality rate and the significant number of vaccinations and documentation needed.

Small hospital concerns. The small private hospital system suffered from a disaster plan that kept it from being integrated into the larger community. Due to staffing constraints, its managers were drawn into direct patient management, and had limited hazardous-material training. Staff physicians had primary responsibilities outside the hospital. The hospital's supplies were rapidly consumed and could not be replenished within the scenario. The overriding drawback of the hospital's disaster plan was that it was not integrated into the larger community.

Legal issues. The inclusion of legal issues added a perspective to the exercise often missed by operational planners. Quarantine implementation has difficulties. Even where quarantine is technically enforceable, implementation procedures are not current with modern civil law. The balance between public health and individual rights could not be found. Many vaccines against bioweapons are classified as investigational, which requires informed consent, and while the president has the authority to remove informed consent requirements for the military, he has no such authority for the civilian population. Another problem exists in the lack of any law defining personal and professional liability when acting on behalf of the government.

As noted in an accompanying editorial on disaster-preparedness exercises, Col. T.J. Cieslak, MD, of Brooke Army Medical Center, Fort Sam Houston, contends that, "The field of disaster management and response is too important and is becoming too complex for each organization to waste time repeating the mistakes of others. Lessons learned by one organization are much more valuable if they are shared with other organizations that might face similar challenges. The Pale Horse exercise demonstrates that incident command systems must be rapidly adaptive and involve the entire panoply of health care organizations, as well as government, legal, social and communications services, to meet the challenges of biohazard attacks."

Source: ENA