Tabletop Exercises Predict Biologic Disaster

What we can learn from Dark Winter and Atlantic Storm

Everyone remembers Hurricane Katrina. Did you know that about a year before Katrina there was another devastating hurricane? Just about a year before Katrina hit the Gulf Coast, Hurricane Pam ripped through causing the levee system to fail, flooding New Orleans, and causing destruction on nearly a life for life, dollar for dollar par with Katrina. The storm was Hurricane Pam and you didn’t read about this storm in the paper or see it on television. Why doesn't anyone remember Hurricane Pam? You don’t remember Pam because it never actually happened...Hurricane Pam was a tabletop exercise (TTX) that predicted with eerie accuracy what would happen if a major hurricane scored a direct hit on the Gulf Coast. The point is that we can learn a lot from our own exercises if we listen. In this post I’m suggesting we learn the lessons from two biologic event tabletop exercises...

In the setting of a naturally occurring or intentional biologic attack how will countries manage shortages of medicine, vaccines, and medical supplies? What mechanisms will be used to control or halt the spread of disease? How will local and national leaders balance their responsibilities to their own citizens with their responsibilities to the international community?

These are the questions we should be asking ourselves and these are the issues addressed by two tabletop exercises Dark Winter and Atlantic Storm.

Click the player below for staged media footage used in Dark Winter.

Watch Dark Winter Pretext for TOPOFF/CCMRF/CBRNE Martial Law Drills in Educational & How-To | View More Free Videos Online at Veoh.com
In June of 2001, the Johns Hopkins Center for Civilian Biodefense Strategies along with the Center for Strategic and International Studies, the Analytic Services Institute for Homeland Defense held a senior-level tabletop exercise that simulated the effects of a covert biological attack on the United States. The dissemination of highly contagious smallpox as an act of terrorism became known as the “Dark Winter” scenario. This one-of-a-kind TTx examined the ability of senior-level policy makers to face the challenges of a bioterrorist attack with outbreaks of highly contagious diseases.



A few years later, in January, 2005, a similar exercise took place. This time among the international leadership community, known as Atlantic Storm, this TTx continued on a larger scale from the Dark Winter exercise. Atlantic Storm simulated the heads of state and senior international governmental leaders attempting to manage a simultaneous bioterror attack. The attack was centered on Istanbul, Frankfurt, Warsaw, Rotterdam, New York, and Los Angeles with Smallpox as the weapon.

Already know it all? Think again. Atlantic Storm verbalizes many of the issues discussed in recent studies as well as historic preparedness problems. An excellent real-life example, Atlantic Storm is also a high quality tabletop exercise, complete with PDF user guides and downloadable documents, Atlantic Storm provides an outstanding example of power a tabletop exercise (TTX) can bring to the planning and training process.

A review of Dark Winter and Atlantic Storm is a useful tool for traditional and non-traditional responders. Take an hour and view the presentation, review the documentation. To view Atlantic Storm; go to: http://www.atlantic-storm.org/flash/index-b.html and turn up you speakers!

What good plans have that bad ones don't

Six points that every plan must have.

1. Good plans are your plans. Taking the time to follow your own process and cover the basics of pre-incident planning pays huge benefits. Plans that are based on a template or borrowed from another agency are difficult to work with. Planning is not a one size fits all proposition.  The copy and paste template approach opens up gaps with little room for meeting the needs of your community and may be damaging to your credibility. Take the time to follow your planning process and do your own assessments and write your biologic event plan for the unique needs of you community. Do this and you'll be well on the way to preventing planning error and saving lives. Learn more about incident planning click here
2. Good plans follow the exercise design process. Mainstream thinking is to write a plan then test the plan with a series of drills and exercises, then reevaluate the plan and edit as needed. I suggest turning this procedure upside down...challenge your people with a scenario presented in a tabletop exercise (TTX) and let their actions be the foundation for writing your plan. A simple TTX that is well thought out will give your people the ability to express concerns and put forth ideas that should become part of your plan. Your response community will feel like a valued part of the planning process (because they are!) making buy-in easier. You'll still need to follow the proper steps in establishing the plan such as training and reevaluating. Click here for tips on exercise design and click here for even more on the use and design of exercises.
3. Good plans are written with your personnel in mind. Consider your personnel and their needs in any crisis event and the protection of personnel while drafting your biologic plan. Studies have indicated that large numbers of any workforce will be impacted by illness in a biologic event. Those that remain healthy may be indirectly impacted resulting from the need to care for family members or children who become ill. Some healthy persons may stay away from the workplace simply out of fear of the disease itself. Your plan should address the family care and education issues.
4. Good plans are ready to receive help. A biological plan must have provisions for requesting and receiving help. Help can be in the form of mutual aid from local jurisdictions, state or Federal agencies. We're not talking only about money. Receipt of large resources such as the National Pharmaceutical Stockpile will be impossible to manage without a per-arrival plan. 
5. Good plans distribute factual information. In the pre-incident environment information about the plan and areas of responsibility within the plan are crucial. Getting this information out to those who are responsible for actions within the plan will help ensure readiness. Plan for getting information out to the public. Public information planning should be in every emergency planners toolbox. Public Information Officers (PIO) and Joint Information Centers (JIC) are critical to a consistent and factual message. Social media, including text messaging and podcasting can also be used to your advantage. I recommend pre-event material be written/recorded and ready to be released much like press releases written ahead of time for any given event. 
6. Good plans are made to be shared. Notice I said shared...not copied. Sharing your plans with other organizations within your jurisdiction brings the response community together. This applies to healthcare planning as well. Hospitals and healthcare systems should share their plans and compare planning needs with other institutions.

MJ 222: Writing biologic event plans - what good plans have that bad ones don't

Click image for free audio download

Its been another busy month in the basement bunker of knowledge! We're wrapping up one of the most exciting months of blogging and podcasting I can remember with our Biologic Events theme. Reader response has been fantastic and the blog has drawn another record number of visits this month along with several comments, emails, and podcast downloads.We still have a few posts waiting to finish the biologic topic, so be sure to check Mitigation Journal next week...or, join our free newsletter mailing and get MJ posts directly on your email as they are published. Email subscription is free. Just enter your email in the subscription box in the top right side-bar. Mitigation Journal podcast is available as a free subscription in iTunes

This week on the podcast we're pushing out a brief how-to on writing your biologic plan. We also discuss a few important items that every good biologic event plan has...and  bad ones don't.

I'm also working on a few extra features on the blog page. You'll notice changes in the coming weeks.

Click the player below to listen to the latest podcast!

How to Write your Biologic Plan

The first step in creating a workable biologic plan is to realize that a biologic plan is not the same as a pandemic plan. Plans written for a specific disease rather than for a biologic situation will fail. Plans should be guidance documents for a spectrum of events addressing the commonalities among disease outbreaks and the reasonable steps needed to respond to the situation. Labeling your plan a Pandemic Plan or Avian Flu Plan implies that the plan will only be activated if the situation becomes a pandemic or a specific pathogen is discovered. This will delay plan activation resulting in further escalation of the situation. Planning for generalities allows for greater flexibility and integration of action into a variety of situations. Your plan should be established for seasonal events as well as an intentional acts of bio terrorism. Although the risk of a true biological terrorism event is small, the impact will be huge. One way to prepare for low-frequency, high impact events is to look for other similar events to hone our skills.

Seasonal influenza is an often overlooked opportunity to test our biologic planning. Expected seasonal outbreaks of various diseases provides us with the opportunities to review plans, test communications and public information, and even exercise “what if” scenarios with tabletop exercises. The added benefit of this real-world exercise is enhanced preparedness for large scale biological event as well as improved response to seasonal or expected biologic events.

Keys for workable Pandemic Biologic Plan

Follow a planning process. Every community and organization must follow a planning process. Establishing a consistent planning process helps reduce error in critical situations and supports positive outcomes.

• Planning in stages or granular planning allows for mistakes and ideas to be identified and explored.
• Identify a planning team and team leader. Written authority should be given.
• The planning team should conduct a threat assessment and hazard analysis identifying not only the probability of a biologic event, but the consequences as well.

Conduct a threat and hazard assessment. Every jurisdiction should have conducted a threat assessment in hazard vulnerability assessment as part of their general preparedness planning. Our vulnerability to that hazard requires a bit of detail:

• Loss of personnel - Personnel may not report to work due to direct or indirect impact of a biologic event. Personnel may become ill and not able to report (direct impact) or may remain away from the work environment resulting from indirect impact such as school or day care closure, ill family members, or fear. These losses apply to uniformed and civilian employees in public service organizations as well as clinical and non-clinical staff in health care.
• Loss of surge capacity - surge capacity is a function of physical space, resources and personnel. Loss of personnel will limit ability to manage surge even when plenty of bed space exists.
• Need for decontamination and personal protective equipment - if not properly decontaminated, the environment of care can act as a reservoir of disease and cause infection of otherwise healthy persons. Personal protective equipment (PPE) may be scarce and vendors may not be able to keep up with demand or deliver as needed. PPE should be appropriately stockpiled and not subject to just-in-time inventory.
• Impact of surrounding communities on your operation - Are neighboring jurisdictions and facilities as prepared as well as you are? If not, expect an influx of people into an area that is prepared and operating well. This influx from surrounding areas can collapse even the best prepared organizations.

Conduct a review of existing infrastructure and systems. A proactive and constructive review of existing infrastructure will provide the framework for good planning. Assuming your systems will be viable if they haven’t been assessed or tested invites disaster.

• Do you have robust planning, training and preparedness activities?
• What is your ability to manage surge capacity measured by physical space, numbers of victims, and ability to provide treatment?
• Have you established protocol for triage of limited critical services during a community-wide event? Are the triggers identified for making the change from standard response to sufficiency of response?
• Has the preparedness of partner agencies, suppliers and vendors been evaluated? Without your partner agencies or contractors you may not be able to continue to provide service or carry out your mission.

Summary - your biologic plan should be:

• a Pandemic Avian Flu Seasonal Flu generic plan written for a spectrum of events

• following your established planning process and design activities

• established for naturally occurring diseases and man-made intentional acts of bio-terrorism

• become an annex to your larger preparedness planning document

• be based on your threat and hazard vulnerability assessments

• account needs identified while reviewing existing resources and infrastructure

Pre-incident Planning: An Introduction

 Steps to better Pre-Incident Planning

Pre-incident planning is known by many terms: emergency, contingency, disaster, crisis management planning all say the same thing. Regardless of the type of term you apply to the situation Pre-incident planning is essential for successfully minimizing the effects of crisis and disaster situations in any community. We've all heard the old adage “failing to plan is, planning to fail” . But how many of us put enough time into our pre-incident planning to do all we can to prevent “failing”? Here are some simple steps… a few things to think about… when doing your pre-incident planning:

What are you planning for? 

Pre-incident plans are valuable for any crisis situation or emergency. That is, anything that happens suddenly–disrupts daily activities, jeopardizes citizens and the economy, and of course, demands your immediate attention. The pre-incident phase is exactly as it sounds; planning before the situation happens. In order to do this effectively you have to know or at least be able to predict the possibilities that your community may face. You make these predictions based on your hazard assessment and risk assessment. Your pre-incident plans also become an important tool for successful training activities later on.

Planning Overview

Pre incident planning has a single yet complicated goal; that is to minimize effects of any given situation. again, we have to assess the threat, the vulnerability, and the potential risk of emergency or crisis. Keep in mind that there is no one single plan or pre-incident plan for every community. Also, your pre-incident plan is only as good is the data you build the plant on that is, you only get out what you put in.
Remember, most pre-incident plans don't deal with normal or everyday situations… and routine policies, procedures, standard operating guidelines may not apply in certain crisis situations. Therefore it becomes important to develop policies procedures and standard operating guidelines for disaster situations that go along (hand-in-hand) with your pre-incident disaster plans.

Planning expected outcomes

Your pre-incident planning process will help you ensure that appropriate levels of personnel supplies and equipment are available at times of disaster or crisis. Your planning process will also add your organizational structure and make sure the structure is in place and updated. Another major benefit of the pre-incident planning process is the ability to make recommendations in through the audit process; ensure that these recommendations are implemented. Pre-incident plans can also validate your risk assessment and hazard analysis by bringing all the data into one place.

Pitfalls in planning

 Above all else you must avoid Optimism Bias in your planning process. As said earlier, your plans are only as good as the data you used to build them. Along with that you have to evaluate your ability to implement the plan. Again, you have to be realistic and don't assume you have all the capabilities or resources you'd like. Emergency and disaster case studies throughout history underscore the need for pre-incident planning that emphasizes delivery of a sufficient operation over a standard operation.

BioAgent Facts app lacks virulence

BioAgent Facts app image UPMC

Facts, yes...pizazz, no.

BioAgent Facts app from the University of Pittsburgh Medical Center (UPMC) provides facts about diseases that could be encountered as a result of a naturally occurring event or intentional release. UPMC hosts the Center for Biosecurity and publishes several on-line publications such as Biosecurity News Today and Clinicians' Biosecurity News. I'm a subscriber to the UPMC/Biosecurity newsletter and familiar with their content quality.

Below is the text description of the BioAgent Facts app as given in the iTunes Store:

BioAgent Facts gives you facts about pathogens that could cause serious disease resulting from a natural epidemic or use as a biological weapon. This new app is offered by the Center for Biosecurity of the University of Pittsburgh Medical Center (UPMC) for those interested in learning more about these important diseases and the threat of bioterrorism. iTunes description

Overview:

BioAgent Facts screenshot (UPMC/iTunes)

BioSecurity Facts are listed for each pathogen convered. The pathogens covered in this release are:

• Anthrax
• Botulism
• Flu
• Plague
• SARS
• Smallpox
• Tularemia
• Viral Hemorrhagic Fevers (VHF)
• and...Zombies? (Yes, Zombies)

Facts for each pathogen are categorized by tabs for:

1. Background
2. Illness
3. Treatment

Background information includes further details on transmission and potential for use as a bioweapon.

Background screen (iTunes/UPMC)

Under the illness tab the user will find general signs and symptoms for each pathogen and variations. As with Anthrax and Plague, for example, the various types have their own subcategories.

The treatment tab includes information on prophylaxis, vaccine, as well as decontamination and personal protection as appropriate for each pathogen. BioAgent Facts app users are reminded to contact local health departments for more information during a confirmed biological attack and encouraged to report to your local hospital if you think you've been exposed, or exhibit unusual signs or symptoms.

Generally speaking, information in this app is well defined and the content written for those of us without advanced microbiology degrees. The source (UPMC) is a trusted authority and the facts are consistant with other sources including the Centers for Disease Control and Preventions Bioterrorism Agents/Diseases page.

The graphics and color choices used in the BioAgent Facts app are appealing, albeit somewhat spooky. The app is rated 9+ by iTunes for Infrequent/Mild Horror/Fear Themes. (Click here learn more about iTunes ratings) While the graphics/color scheme are engaging, I found the white text on blue background difficult to read. Use of the app was complicated by the inability to re-size the screen with gestures and small text.

Although the pathogens included in this release are potential threats, Dengue Fever and West Nile Virus may be timely additions. The "special feature" on Zombies is a complete waste of valuable real estate in this app. With all respect to popular culture, including zombies in BioAgent Facts diminishes the value and credibility of the app. The section dedicated to Zombies would be better served by including details of personal protective equipment such as N95 masks, guidelines for hand hygiene, respiratory etiquette, and appropriate social distancing during a biologic event. A segment on the importance/risks/benefits of vaccines would be more appropriate use of space as well.

BioAgent Facts is compatable with iPhone, iPod touch, and iPad with iOS 4.2 or later. I'm running this app on an iPhone4 with iOS 4.2. Its stable and runs quickly. The link for BioAgent Facts Support on iTunes links back to the UPMC homepage where the BioAgent Facts app icon has you running in circles back to iTunes. There is no mention of versions, additional features or anticipated upgrades.

Final Score:
Content: 2.0 I'd like to see more detail and better use of information. Telling people to report to your local hospital may not be the ideal action to take in every biologic situation and contacting the local health department may be impossible. The inclusion of a Zombie category lowers credibility, too. Dumping the Zombies and adding personal protection information or vaccine facts, and provide links for information rather than reporting to hospital or contact health department makes this a 4.0 app! I would not recommend this version BioAgent Facts for anything more than casual use.

Aesthetics/graphics: 4.0 I liked the graphics and color combinations.

Ease of Use: 2.0 I found the tabs/buttons too small and kept hitting the info button when trying to tap the home tab. Text is too small and white text on blue background was hard to read. Although stable on an iPhone (iOS 4.2) there is no clear support/FAQ available.

YOU: the Biological Bomber

Suicide bomber attacks are a fact of life in other nations. Suicide bombers are notorious for strapping on an explosive-laden vest, walking into a soft target location, and...detonating. Corpses, walking wounded bloodied and maimed walk in the midst of collapsed buildings and broken glass. (more on soft targets: Mall shootings here, MD shot in hospital here, 2011 planning problems here

Envision the carnage and hysteria caused by a suicide bomber.

Now envision a bombing scenario that's exponentially more deadly. More lethal than conventional explosives with an impact far greater than a nuclear weapon. In this attack there will be no detonation, no big bang to call us to action. Chances are we wont even know this bombing has taken place until our hospitals are overflowing.

The biological bomber is one such scenario. A Typhoid Mary of our time, rather than strapping on explosives, the biological bomber infects themselves with a disease and goes into society with the intention of infecting as many people as possible.

Like their suicide bomber counterparts, the biological bomber may actually be bombers working in a coordinated simultaneous attacks on several locations. Unlike suicide bombers who can only blow themselves up once,  multiple biological bombers in a coordinated attack could infect hundreds in multiple locations. Would you be able to recognize a biological attack?

The biological bomber will want to spread a disease that is transmitted easily from person to person. A disease that has a lingering incubation period, a disease that will present with commons signs and symptoms of flu. Diseases of interest may come from the Centers for Disease Control and Preventions category A list. Something exotic like Smallpox, plague, or the Nipah virus may be the choice. Even seasonal flu would make an effective agent of attack. The strains of Type A influenza included in seasonal flu vaccine are know to anyone who can search the internet. A would-be biological bomber would only need to infect themselves with a flu strain not included in the vaccine or some novel stain of virus to bypass our first line of biological defense. Of course, our ability to obtain vaccine and other medications will be an issue.

Soft targets and locations of critical infrastructure would be prime locations for the biological bomber attack. Shopping malls, sporting events, and public gatherings make the list of potential targets. Of all the soft target/critical infrastructure locations, your local hospital takes the prime spot on the list. Hospitals hold special value for the biological bomber:

1. Many patients have compromised immune systems making them more susceptible to infection and a greater mortality.
2. Hospitals have a large transient visitor population in the form of visitors and suppliers. These people will move in and out the hospital and into the community and will help spread any disease. 
3. Medical providers in the hospital will also be at risk for infection...a biological attack on a hospital may cripple the ability to respond to the medical needs of a community. Forget about surge capacity...there will be no capacity when physicians, nurses, and non-clinical staff become too ill to work or refuse to report to work. (not to mention a lack of preparedness on the part of many health care systems)

YOU: The Biological Bomber. 
Much of what you've read about the biologic bomber is theory; apocalyptic, cataclysmic theory. But there is a biologic scenario that puts you in the staring role and can be every bit as dangerous as the terrorist biological bomber.

Failing to practice the personal responsibility of hand hygiene, respiratory etiquette, and appropriate social distancing when ill puts  you in a position to spread disease including seasonal flu or other diseases. These simple practices along with getting the appropriate vaccines can help prevent YOU from becoming an unwitting biological bomber.

Vaccine and non-pharmacological interventions (hand hygiene, respiratory etiquette, appropriate social distancing) are also effective methods used to prevent the spread of disease, naturally occurring or otherwise. Proper use of these interventions along with personal protective equipment will boost protection for health care and traditional responders adding to our resiliency.