Recommendations show promise for future biological event success
Terrorist
attacks using biological agents are potentially deadly beyond
imagination. In 2001, the dissemination of engineered Anthrax struck
panic with American civilians and emergency service responders resulting
in exaggerated responses and near-ridiculous actions. Inhalation
anthrax is fatal if not treated appropriately, but there is treatment.
How would be as population fair if the biological agent was something
more devastating than anthrax; an agent with no cure or treatment? Let’s
use smallpox as an example.
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 know 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 bio terrorist attack with outbreaks of highly contagious
diseases.
A similar event took place in January, 2005, this time
among the international leadership community. Known as Atlantic Storm,
this TTx continued on a larger scale from Dark Winter. Atlantic Storm
simulated the heads of state and senior international governmental
leaders attempting to manage a simultaneous smallpox bio terror attack on
Istanbul, Frankfurt, Warsaw, Rotterdam, New York, and Los Angeles.
Both
Dark Winter and Atlantic Storm focused on government leadership and
ability to manage issues in public health, medical services, diplomacy,
domestic response, and critical infrastructure. Both exercises were well
developed and planned...they did, however, reached differing results.
What follows is a comparison of the tabletop exercises Dark Winter
(2001) and Atlantic Storm (2005). Despite commonalities in scenario and
biological agent, glaring differences have emerged that leave those
studying such material wondering and concerned. The opinions and
concerns addressed herein are based upon study of documents, video where
available, objective analysis of the scenarios themselves, of course,
smallpox.
Comparison of Assumptions
Dark
Winter focused on the United States as the only target in a
“worst-case” scenario; Atlantic Storm targeted the international
community with “best-case” circumstances. This primary difference may
prove to be a single most perturbing factor when comparing the two
exercises.
Although both scenarios simulated the use of smallpox
as the agent with similar methods of dissemination, there were
concerning differences in the projected infection rates, death rates,
and person-to-person transmission potential. Dark Winter assumed a
thirty percent fatality rate while deaths from smallpox were projected
at twenty-five percent in Atlantic Storm. Atlantic Storm also assumed
that there was residual immunity among the affected population with 300
million doses of vaccine available. Dark Winter was somewhat less
optimistic; simulating a CDC stockpile of 15.4 million doses of vaccine
and allowing for up to twenty percent of stockpile loss due to
contamination or improper use.
Dark Winter hypothesized that 1g
of smallpox could generate 100 infections when aerosolized resulting in
3000 first generation cases from 30gms of virus. There is no mention of
virus quantity in Atlantic Storm; however, both scenarios disseminate
the virus via an aerosolizing device under similar conditions. Dark
Winter used 1:10 transmission rate (every one person with smallpox could
infect ten others) as compared to Atlantic Storms rate of 1:3. Atlantic
Storm also anticipated 1: 0.25 for second to third generation while no
mention was made in the Dark Winter scenario of second to third
generation transmission. Dark Winter planners integrated herd immunity
of twenty percent into the scenario which was not accounted for in
Atlantic Storm. I found the following excerpt from the Dark Winter
scenario an interesting commentary on person-to-person transmission
rate. A sidebar reads:
“…Given the low
level of herd immunity to smallpox and the high likelihood of delayed
diagnosis and public health intervention, the authors of this exercise
used a 1:10 transmission rate for Dark Winter and judged that an
exercise that used a lower rate of transmission would be unreasonably
optimistic, might result in false planning assumptions, and, therefore,
would be irresponsible. The authors of this exercise believe that a 1:10
transmission rate for a smallpox outbreak prior to public-health
intervention may, in fact, be a conservative estimate, given that
factors that continue to precipitate the emergence and reemergence of
naturally occurring infectious diseases (e.g., the globalization of
travel and trade, urban crowding, and deteriorating public health
infrastructure) [26, 27] can be expected to exacerbate the transmission
rate for smallpox in a bioterrorism event…”
In
contrast, the Atlantic Storm best-case scenario planned for adequate
disease control, compliance with public health “social distancing”
(a.k.a. quarantine), available vaccine, higher herd immunity, residual
protection granted by prior vaccination, and lower transmission rates.
The wide range of transmission rates between the two exercises may
account for the differences in total number of smallpox cases and
deaths. Dark Winters worst-case predicted 1,000,000 deaths with
3,000,000 infections while the Atlantic Storm exercise predicted 660,000
cases and approximately 495,000 deaths.
Summary: Lessons/RecommendationsDark
Winter summarized the exercise with a list of lessons and Atlantic
Storm used the term recommendations to summarize. Below is a list of
lessons from Dark Winter or recommendations from Atlantic Storm that
seem to be common to both events despite being conducted years apart.
Various excerpts from the text have been added to aid explanation.
- Leaders are unfamiliar with the character of bioterrorist attacks, available policy options, and their consequences.
- After a bioterrorist attack, leaders’ decisions would depend on data and expertise from the medical and public health sectors.
- …they
were given more information on locations and numbers of infected people
than would likely be available in reality.” Statement concerning the
amount of infromation given out in both TTx's.
- …lack of
information, critical for leaders’ situational awareness in Dark Winter,
reflects the fact that few systems exist that can provide a rapid flow
of the medical and public health information needed in a public health
emergency.”
- …it was difficult to quickly identify the locations of the original attacks…”
- The lack of sufficient vaccine or drugs to prevent the spread of disease severely limited management options.
- After a bioterrorist attack, leaders’ decisions would depend on data and expertise from the medical and public health sectors.
…
[This] reflects the fact that few systems exist that can provide a
rapid flow of the medical and public health information needed in a
public health emergency.”
“What’s the worst case? To make decisions
on how much risk to take…whether to use vaccines, whether to isolate
people, whether to quarantine people…I’ve got to know what the worst
case is” (Sam Nunn).
- The lack of sufficient vaccine or drugs to prevent the spread of disease severely limited management options.
- The US health care system lacks the surge capacity to deal with mass casualties.
- The
numbers of people flooding into hospitals across the country included
people with common illnesses who feared they had smallpox and people who
were well but worried.”
“…[the challenges]of
distinguishing the sick from the well and rationing scarce resources,
combined with shortages of health care staff, who were themselves
worried about becoming infected or bringing infection home to their
families, imposed a huge burden on the health care system.”
- To
end a disease outbreak after a bioterrorist attack, decision makers
will require ongoing expert advice from senior public health and medical
leaders.
“…the imposition of geographic
quarantines around affected areas, but the implications of these
measures (e.g., interruption of the normal flow of medicines, food and
energy supplies, and other critical needs) were not clearly understood
at first. In the end, it is not clear whether such draconian measures
would have led to a more effective interruption of disease spread.”
“A
complete quarantine would isolate people so that they would not be able
to be fed, and they would not have medical [care].…So we can’t have a
complete quarantine. We are, in effect, asking the governors to restrict
travel from their states that would be nonessential. We can’t slam down
the entire society” (Sam Nunn).
- Federal and state
priorities may be unclear, differ, or conflict; authorities may be
uncertain; and constitutional issues may arise.
“My
fellow governors are not going to permit you to make our states leper
colonies. We’ll determine the nature and extent of the isolation of our
citizens…You’re going to say that people can’t gather. That’s not your
[the federal government’s] function. (Frank Keating).
“…worried
that it would not be possible to forcibly impose vaccination or travel
restrictions on large groups of the population without their general
cooperation."
“The federal government has to have the cooperation
from the American people. There is no federal force out there that can
require 300,000,000 people to take steps they don’t want to take” (Sam
Nunn).
“…Atlantic Storm showed that even experienced politicians
have unrealistic notions of what WHO would be able to deliver in a
crisis, given its current budgetary, political, and organizational
limits.”
“In Atlantic Storm, leaders viewed
border closings and travel bans as an unattractive option for
controlling the spread of disease, but, given the lack of vaccine or any
other mechanism to control disease, they were forced to consider these
measures.
“…leaders were provided with far more
situational awareness than they would have had in a real crisis. They
were given the locations and numbers of reported smallpox cases in
almost real time, and they were constantly updated as information
changed. If this had been a real bioattack or epidemic affecting cities
in multiple countries, leaders would have had a great deal of trouble
getting even this level of basic information.”
Questions:In
the end it would appear that we are not much closer to answering (or
instituting) the questions posed by these two exercises. The results of
the two events, despite being years apart, have come to similar end
points…without resolution. Since Dark Winter, we have seen the 9-11
attacks, dealt with WNV, witnessed SARS, and begun preparing for H5N1.
Yet, these questions continue to be re-invented.
Given
the time frame of the two exercises, one being pre-9-11 and the other
post-9-11, is there any expectation change in the “post-9-11 mindset”?
Can
any correlation be drawn between the expectations of national leaders
towards international cooperation and state/local leaders towards
cooperation with the Federal government?
Will
the American public respond differently to a biological attack that
threatens only the United States in contrast to an attack threatening
the U.S. as well as other nations?
How
will we approach issues of evacuation, quarantine, mandatory
vaccination, and loss of freedoms? Will compliance be better or worse
based on the events of Katrina?
Can we compare the expectations of FEMA during Katrina to the expectations of the CDC during a biological terrorist attack?
Why
are we not closer to resolving the issues mentioned in these exercises?
So many of the Atlantic Storm recommendations are strikingly similar to
the lessons of Dark Winter that one has to ask if the organizers have
even read the Dark Winter scenario!
