Aerosolized Anthrax Concept of Operations
Organization: Background HHS Strategic Response Goals Response Trigger Points Credible Intelligence of a Plan to Conduct a Biological Attack Using Aerosolized Anthrax,
- Actions at the Region, Tribe, Territory, State and local levels
- Actions at the Federal level
Notification of a BioWatch Actionable Result (BAR)
- Actions at the Region, Tribe, Territory, State and local levels
- Actions at the Federal level
Confirmed Cases of Inhalation Anthrax Identified in a U.S. City
- Actions at the Region, Tribe, Territory, State and local levels
- Actions at the Federal level
Demobilization (Upon Release from Region, Tribe, Territory, State and local Authorities)
- Actions at the Region, Tribe, Territory, State and local levels
- Actions at the Federal level
Background
Of the many possible biological agents that could be used as weapons, Bacillus anthracis, the bacterium that causes anthrax, has been identified as one that could cause a significant amount of disease and mortality and have a grave impact on the economy of a particular city or region. The case fatality rate for cases of anthrax varies with the form of the disease, with up to 20% case fatality for untreated cutaneous cases and up to 85% case fatality for inhalation cases; even with aggressive therapy of inhalation cases in 2001, case fatality was 45%. The combination of a significant mortality rate coupled with the difficulty of making a correct diagnosis (without some type of previous indicator), makes anthrax one of the more serious bioterrorism threats.
HHS Strategic Response Goals
The goal of HHS in response to a bioterrorism attack using anthrax will be to rapidly assess the situation and to support Territory, Tribal, State and local public health officials in their response efforts. The types of support most likely to be needed by State and local public health officials will include subject matter expertise on Bacillus anthracis, epidemiological support, support of post-exposure prophylaxis efforts (personnel and material), management of large numbers of patients developing inhalation anthrax, and finally recovery efforts (occupational health, mental health, etc.).
Trigger Event 1 - Credible Intelligence of a Plan to Conduct a Biological Attack Using Aerosolized Anthrax
“Credible intelligence” is a term which referred to information which the intelligence community believes to be reliable. Nevertheless, credible intelligence is a very subjective term and the analysis of intelligence “is not a science; it’s an art.” Actions taken at the Federal, Region, Tribe, Territory, State and local levels will be highly dependent on the level of credibility of the intelligence and other factors, such as corroboration of the intelligence, the specificity of the intelligence, especially as it relates to information on specific targets and dates, and other factors.
The Homeland Security Advisory System, in use at the Federal, Region, Tribe, Territory, and State level, is designed to target our protective measures when specific information to a specific sector or geographic region is received. It combines threat information with vulnerability assessments and provides communications to public safety officials and the public.
- Homeland Security Threat Advisories contain actionable information about an incident involving, or a threat targeting, critical national networks or infrastructures or key assets. They could, for example, relay newly developed procedures that, when implemented, would significantly improve security or protection. They could also suggest a change in readiness posture, protective actions, or response. This category includes products formerly named alerts, advisories, and sector notifications. Advisories are targeted to Federal, state, and local governments, private sector organizations, and international partners.
- Homeland Security Information Bulletins communicate information of interest to the nation’s critical infrastructures that do not meet the timeliness, specificity, or significance thresholds of warning messages. Such information may include statistical reports, periodic summaries, incident response or reporting guidelines, common vulnerabilities and patches, and configuration standards or tools. It also may include preliminary requests for information. Bulletins are targeted to Federal, state, and local governments, private sector organizations, and international partners.
- Color-coded Threat Level System is used to communicate with public safety officials and the public at-large through a threat-based, color-coded system so that protective measures can be implemented to reduce the likelihood or impact of an attack. Raising the threat condition has economic, physical, and psychological effects on the nation; so, the Homeland Security Advisory System can place specific geographic regions or industry sectors on a higher alert status than other regions or industries, based on specific threat information.
Region, Tribe, Territory, State, and Local Response
Actions taken by Region, Tribe, Territory, State, and local officials will be highly dependent on the confidence in the intelligence they have received. Typically, when credible intelligence is received concerning a terrorist attack, the threat level is generally raised to a high or severe condition, depending again on the specificity of the intelligence. Regions, Tribes, Territories, States and local government have developed preparedness standards and response activities that will occur at the various threat levels. Typical actions include:
High Condition (Orange)
There is a high risk of terrorist attacks. Key Region, Tribe, Territory, State and local agencies are notified, and regulatory agencies issue appropriate alerts to critical infrastructure, including utilities and medical facilities. State emergency and response resources - such as specialized law enforcement agencies, Fire Response Teams and statewide bio-lab facilities - are placed on stand-by or recall status. In addition, the Governor's Office will work with Federal Homeland Security officials and coordinate the response of state law enforcement agencies and the National Guard.
Severe Condition (Red)
There is a severe risk of terrorist attacks. In addition to the actions taken under a high threat level, the State's Emergency Management Council and emergency response resources will be activated. Warnings and threats will be disseminated as appropriate to state agencies and entities controlling critical infrastructure. Large public events will be identified and security will be assessed. State personnel will be redirected as needed to address critical emergency needs.
Federal Response
Actions at the Federal level will also be highly dependent on the confidence in the intelligence they have received. Typically, when credible intelligence is received concerning a terrorist attack, the threat level is generally raised to a high or severe condition, depending again on the specificity of the intelligence. Typical actions at the Federal level include:
High Condition (Orange)
A High Condition is declared when there is a high risk of terrorist attacks. In addition to the Protective Measures taken in the previous Threat Conditions, Federal departments and agencies should consider the following general measures in addition to the agency-specific Protective Measures that they will develop and implement:
- Coordinating necessary security efforts with Federal, State, and local law enforcement agencies or any National Guard or other appropriate armed forces organizations;
- Taking additional precautions at public events and possibly considering alternative venues or even cancellation;
- Preparing to execute contingency procedures, such as moving to an alternate site or dispersing their workforce; and
- Restricting threatened facility access to essential personnel only.
Severe Condition (Red)
A Severe Condition reflects a severe risk of terrorist attacks. Under most circumstances, the Protective Measures for a Severe Condition are not intended to be sustained for substantial periods of time. In addition to the Protective Measures in the previous Threat Conditions, Federal departments and agencies also should consider the following general measures in addition to the agency-specific Protective Measures that they will develop and implement:
- Increasing or redirecting personnel to address critical emergency needs;
- Assigning emergency response personnel and pre-positioning and mobilizing specially trained teams or resources;
- Monitoring, redirecting, or constraining transportation systems; and
- Closing public and government facilities.
Triggering Event 2 - Notification of a BioWatch Actionable Result (BAR)
The BioWatch system works by continually sampling air on to filters in urban areas and subsequently testing the material collected on the filters for potential bioterror agents. As part of BioWatch, approximately 10 – 20 air samplers at air quality monitoring stations in the cities are equipped for 24 hours-per-day monitoring. The filters from these sampling stations are removed at least once each day and transported to the public health laboratory for analysis using highly sensitive and specific polymerase chain reaction (PCR) laboratory assay technology. (Note: The basic BioWatch timeline suggests that by the time a sample has passed confirmatory testing, anywhere from 5 to 40 hours may have passed since the threat agent was deposited on the BioWatch filter.)
On a daily basis BioWatch filters are removed from the environmental air sampling units and delivered to the local LRN laboratory. Upon receipt of filters, laboratory personnel divide the filter into quarters. One quarter of the filter is tested and the remaining portion is archived for future testing, if necessary. Laboratory tests for the BioWatch program consist of molecular assays developed by HHS/CDC and Lawrence Livermore National Laboratory (LLNL), which were distributed through the LRN. The LRN BioWatch Laboratory Director, after consulting with DHS and HHS/CDC experts, makes the final determination of a BioWatch Actionable Result and decides a bioterrorism event has occurred. The LRN Laboratory Director begins communicating the results to appropriate parties within the health department and outside according to the local notification plan.
Notification
Immediately following declaration of a BioWatch Actionable Result from the BioWatch system, the Bio Watch notification protocol is executed. The BioWatch Advisory Committee (BAC) is convened within two hours of the BioWatch Actionable Result and begins to collect and interpret data, and participate in bioterrorism threat and public health risk-assessments. The affected Region, Tribe, Territory, State will contact the CDC’s Director’s Emergency Operations Center (DEOC) and will contact individuals on the BAC of the pending conference call with time and phone number. Once the SOC is advised of the call by the DEOC, watch officers in turn will notify other Federal agencies via the NOC of the BioWatch Actionable Result, including DHS and the DOJ/FBI WMD Coordinator.
The BAC typically consists of individuals capable of directing activities to collect and interpret data and assess whether or not the BioWatch Actionable Result is an early indicator of a significant and immediate risk to public health. The BAC is chaired by the local public health officer in the affected community. Members of the BAC may include the LRN laboratory director, epidemiological investigations team leader, modeling and data visualization team leader, the local FBI WMD coordinator, regional Environmental Protection Agency (EPA) representative, state epidemiologist, or emergency response coordinator, in addition to other experts as necessary. Representatives from Federal partnering agencies including HHS, EPA, and DHS participate in BAC meetings.
Region, Tribe, Territory, State, Local Response
After quickly completing a rapid technical consultation during a conference call with HHS/CDC and LLNL, the local Public Health Officer and/or other members of the BAC immediately begin notifying appropriate local, regional, and state agencies. Other members of the local and Region, Tribe, Territory, State Public Health Offices begin rapidly collecting and interpreting information from various data sources to appropriately determine if there is significant and immediate bioterrorism threat and/or a risk to public health. With the assistance of Region, Tribe, Territory, State officials, the elements of the LRN activates their surge staffing plan, and Region, Tribe, Territory, State officials alert several other labs within the Region, Tribe, Territory ,State to be prepared to assist with environmental sample testing. HHS/CDC begins to surge appropriate reagents to local and Region, Tribe, Territory, State laboratories to prepare them for the large numbers of tests that will need to be conducted. Additional environmental sampling teams as well as public health surveillance and epidemiological investigations teams are activated. These teams begin collection of environmental samples near positive sampling units to try and determine the extent of the attack. Teams also initiate reviews of syndromic surveillance data and reportable disease data. Medical treatment facilities in the vicinity of samplers which tested positive are visited and veterinary surveillance is initiated. At the same time, a Modeling and Data Visualization Team is formed, coordinating with Interagency Modeling and Atmospheric Assessment Center (IMAAC) and National Atmospheric Release Advisory Center (NARAC) to begin meteorological data analysis and plume modeling. Modeling results are forwarded to the BAC and sampling teams to refine sampling plans. Local officials in the BAC will also implement a media relations strategy to notify citizens that a biological agent may have been detected in the city and what risk, if any, exists to public health in the area. This may also include establishment of a single point of contact for the media, activating a local incident help hotline, and making case identification and treatment information available.
As results from investigative teams (environmental, epidemiological, public health, law enforcement, data visualization, etc) become available, the BAC determines the level of federal support that may be needed and communicates the request, through Region, Tribe, Territory, State offices, to the Department of Homeland Security.
Depending on the results of initial environmental and epidemiological testing, the Local Public Health officer and Emergency Management Coordinator may activate the local EOC and recommend activation of the Region, Tribe, Territory, and State EOCs. Continued environmental sampling and computer modeling will begin to determine the estimated boundaries of release. Local Public Health officials will distribute warnings and clear case definitions to local clinicians and hospitals and may recommend that a public health alert or declaration of local state of emergency be declared. The BAC may deployment of appropriate medical supplies and materials from the SNS. If the SNS is released, a distribution warehouse will be selected and local point of dispensing (POD) setup operations will begin at sites predesignated in the cities emergency response plan.
Federal Response
Once the HHS Secretary, ASPR and relevant Federal agencies are notified, the SOC begins their internal notification procedures, alerting the HHS Emergency Management Group (EMG) points of contact of the BioWatch Actionable Result from a BioWatch collector. In consultation with the Secretary and after an update from the SOC, the ASPR directs HHS to transition from normal operations to coordinated Departmental emergency response operations, with each HHS OPDIV activating its Emergency Operations Center. The SOC begins the process of identifying liaison officers needed at other Federal Agencies as well as establishing a HHS EMG. With guidance from the ASPR, the SOC alerts a Incident Response Coordination Team (IRCT), augmenting the team with subject matter expertise on epidemiological investigations and POD operations. The SOC alerts ESF #8 partners and makes contact with Region, Tribe, Territory, State and local public health officials managing the response, closely monitoring activities such as epidemiological investigations, environmental sampling results, and data visualization and computer modeling efforts. The SOC establishes communications with the CDC DEOC. The CDC DEOC will bring together subject matter experts for analysis and planning for the event. This alert notification will include the SNS. In coordination with the ASPR, Region, Tribe, Territory, State and local officials, and other Federal agencies, the SOC will publish a schedule listing key daily events during the management of the response, including conference calls and video teleconferences, update briefings, press conferences, etc.
HHS will coordinate with state and local officials to review emergency management plans as well as procedures for making assistance requests to the Federal government. In close coordination with Region, Tribe, Territory, State and local public health officials, HHS will begin exploring methods of increasing the effectiveness of Region, Tribe, Territory, State and local healthcare and emergency response operations. These efforts may include deployment of Federal assets such as the PHS CC for epidemiological and laboratory support (for expected surge of LRN requirements), the National Disaster Medical System (NDMS) teams for critical care capability and Points of Dispensing (PODs) capabilities. HHS will also begin coordinating with Federal agencies, including DOD and VA, for potential support in the event of large numbers of patients developing inhalation anthrax. The ASPR directs CDC to begin preparation to deploy the appropriate countermeasures and supplies from the SNS and consults with the Office of Force Readiness and Deployment to prepare the PHS CC for deployment in support of the Region, Tribe, Territory, State and local response.
HHS begins consultations with HHS/FDA, HHS/CDC, Region, Tribe, Territory, State and local officials, and manufacturers as to the availability of, safety of, and rapid manufacturing capabilities of inhalation anthrax-related countermeasures such as vaccines and antibiotics. HHS also begins the implementation of communications and media campaigns designed specifically to for responding to an anthrax attack.
Triggering Event 3 - Confirmed, Cases of Inhalation Anthrax
Patients will begin presenting at local hospitals 1-2 days after the release and/or very soon after any type of public health warning. Initial patients will most likely present exhibiting the prodromal symptoms of inhalation anthrax, such as:
- Sore Throat
- Mild Fever
- Muscle Aches
- Shortness of Breath
- Tiredness
- Other Cold or Flu-like symptoms
Proper diagnosis of inhalation anthrax, without some type of initial indicator or warning, will be very difficult. In this case, previous warnings from Region, Tribe, Territory, State and local officials ensure a proper diagnosis. If appropriate, based upon patient symptoms and other factors (patient interview, epidemiological investigations, etc), the patient may be started immediately on antibiotic treatment.
Region, Tribe, Territory, State and Local Response
At a point following the initial diagnosis of cases of inhalational anthrax within a city, Region, Tribe, Territory, State and local officials are continuing all of the investigations regarding the release. Environmental sampling teams are continuing to collect samples and refining the limits of release. In collaboration with the environmental sampling teams and plume modeling/data visualization teams, the epidemiological investigation teams are beginning to identify additional at-risk areas and buildings/gathering points which were exposed. The data visualization team will continue working with plume models by analyzing wind patterns from the expected date/time of the release. Syndromic surveillance and veterinary surveillance also continue. Region, Tribe, Territory, State and local public health officials participate in regular coordination conference calls with Federal officials, and participate in regular media briefings and updates. Based on information gathered by the modeling, data visualization, epidemiological, syndromic surveillance, and veterinary surveillance teams, Region, Tribe, Territory, State and local officials have initiated a post-exposure prophylaxis campaign. Region, Tribe, Territory, State and local officials receive and accept the initial supplies from the SNS and process the delivery into the distribution warehouse. Secured shipments begin to move from the distribution warehouse to local hospitals and POD locations. PODs are soon fully operational, and media begins to disseminate information about actions required by the public.
PODs are generally set up in schools, churches, community centers, and sport/entertainment venues. Local officials will determine POD schedules to accommodate the expected numbers of people to be treated. The American Red Cross helps to provide information about resources available at each of these locations, and facilitates opening and providing support staff for PODs. Each POD has an expected throughput, typically determined by the size, design, and staffing of the POD. The typical processing of people through a POD includes greeting patients, removing and transporting patients with an immediate medical need, completing paperwork required for receiving PEP, receiving a briefing on the purpose of prophylaxis, disease process, and medications, a physician or other clinical professionals reviewing the paperwork, and finally the actual dispensing of medication.
Federal Response
Given the rarity of inhalation anthrax infection, the initial confirmed cases of IA should trigger a substantial response from HHS and other Federal agencies. In all likelihood, the Secretary of HHS will declare a Public Health Emergency and the Secretary of the DHS will declare and Incident of National Significance to initiate the NRP and raise the Terror Threat Advisory Level. As the NRP is activated, the HHS EMG will take immediate action by establishing the ESF #8 command structure in coordination with supporting agencies. The SOC will maintain contact with Region, Tribe, Territory, State and local public health officials managing the response, closely monitoring activities such as epidemiological investigations, environmental sampling results, and data visualization and computer modeling efforts as well as communications with the CDC DEOC.
The IRCT rapidly deploys to the area to begin immediate assessments on Region, Tribe, Territory, State and local POD operations in collaboration with the CDC Senior Management Official and the team lead of the Technical Advisory Response Unit (TARU) from the SNS, and epidemiology investigations. The IRCT also begins coordination with HHS regional personnel and other Federal assets such as the PFO and/or FCO. Lastly, it begins providing field/on-site management for all deployed HHS assets as well as ESF #8 support agencies.
HHS will monitor the Region, Tribe, Territory, State’s distribution and administration of vaccines as well as allocate vaccination resources to state and local PODs, if appropriate. HHS will also monitor vaccine usage, initiate rapid clinical safety studies on vaccine, and implement existing vaccine-monitoring systems to respond to adverse effects. In cases in which vaccines are being administered in an EUA or IND status, HHS closely monitors established record-keeping mechanisms. With respect to antibiotics, HHS will monitor antibiotic use and distribution as well as acquire additional antibiotic resources if necessary. HHS will also monitor the occurrence of adverse events following administration of antibiotics, the effectiveness of treatment and prophylaxis, and drug resistance.
HHS will provide ESF #8 LNOs to appropriate agencies and organizations while completing the ESF #8 Mission Assignment Subtasking Requests. HHS will monitor and implement surge capacity requirements by gathering data on bed usage around the region focusing on locations with capabilities to support high acuity inhalation anthrax cases. HHS will continue to alert, roster, and deploy Federal medical and public health personnel at the request of Region, Tribe, Territory, State and local governments and or recommendations from the IRCT. HHS will also begin coordinating with DOD and VA to initiate patient transport to other facilities.
Lastly, HHS will continue the execution of their Communications Plan by providing regular updates to public and local officials and disseminating additional guidance on the medical response to include information releases on PODs, PEP, and CRI. HHS will remain in contact with media outlets in order to instruct the public on preventative and response measures. Other portions of outreach include regularly updating the HHS website, providing staff support for informational/hotline telephone lines, and provide healthcare providers clinical management guidelines.
Widespread Cases of Inhalation Anthrax Diagnosed Within a U.S. City
The effectiveness of the Region, Tribe, Territory, State and local post-exposure prophylaxis program will have a significant impact on the number of inhalation anthrax cases that are diagnosed and treated. Even with an efficient post-exposure prophylaxis program rapidly established, there is still likely to be a significant number of inhalation anthrax cases due to the size of the population exposed, the dose those closest to the source received, and other factors. Inhalation anthrax cases require aggressive and intensive critical care support and an attack of this size will quickly overwhelm intensive care and critical care units in the local area.
Region, Tribe, Territory, State and Local Response
By this time, a significant portion of the population would have received post-exposure prophylaxis at a POD in the area, but a significant number of cases of inhalation anthrax will have developed. POD operations, epidemiological investigations, and communications efforts will all continue. In all likelihood, diagnosed cases of inhalation anthrax will overwhelm local critical care capabilities despite Emergency Management Assistance Contracts and agreements with other nearby communities. Local and Region, Tribe, Territory, State public health officials continue to request assistance from the Federal government to assist in the transportation of these patients to other healthcare facilities and for other types of support.
Federal Response
EMG and IRCT support continues as well as Federal ESF #8 support to the Region, Tribe, Territory, State, and local PODs (antibiotics, medical supplies, personnel) from PHS Commissioned Corps assets as well as ESF #8 assets. HHS, VA and DOD become heavily involved in the regulation of patients from local hospitals to other facilities throughout the country. HHS will be heavily involved in coordinating the movement of these patients as well as reception at accepting facilities.
Triggering Event 4 – Decision to Demobilize
Redeployment and demobilization activities for Federal teams and assets will occur upon release by Territory, Tribal, State or local authority(ies) have determined that the situation has been deemed manageable if not over, prompting the release of Federal assets from the response engagement. Consideration must be given to:
- Fulfillment of statutory requirements under the provisions of PHS Section 319 declaration
- Protecting the response force in their redeployment activities under ESF #13 and Health surveillance upon return to home station
- Accountability of all deployed equipment
- Collection of After Action Reports
- Coordination of transportation assets for redeployment to include SNS material
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