Operation Topoff--Lessons on Responding to Bioterrorism.

Suppose you read the following lead sentence of a story in your local newspaper: "On May 17, 2000, a release of pneumonic plague virus occurred at a local theater hosting a sold-out performance of a popular play." What would you do? Suppose, too, that over the next several weeks, the scenario included thousands of citizens becoming ill and more than a thousand dying.

That scenario represented the beginning of a recent national operation testing the readiness of federal, state, and local agencies to respond to a bioterrorist attack. An increasing rate of simulated hospital admissions was reported, all of them manifesting similar signs and symptoms of a plaguelike illness three days after exposure. The report was sufficient to activate federal, state, and local health and medical, disaster management, and law enforcement agencies. For several days those agencies exercised their authority and used their expertise in response to the medical and criminal aspects of the event with the goal of controlling the outbreak and protecting the unaffected population.

The exercise contained numerous "injects" of challenging events to test the capacity of participants. It was also designed to tax the local health, medical care and law enforcement systems beyond their normal capacities and to observe when those systems broke down under the stress. Operation Topoff (exercise for top officials) was successful in generating community awareness and informing government agencies and the medical and emergency response systems about deficiencies in their responses to a simulated bioterrorist incident.

Each agency learned several lessons. Many of those lessons are particularly relevant to public health professionals, whom the community expects to be prepared for a significant public health emergency whether intentional or not.

The sheer magnitude of the Topoff scenario helped identify what factors might most quickly lead to system failure. A large public health emergency of the type modeled in this exercise is probably not very likely It is not, however, beyond the realm of possibility Furthermore, while Topoff addressed bioterrorism, virtually all the principles relevant to the response are also applicable to other natural disasters, chemical incidents, and unintentional disease outbreaks.

Planning for a public health emergency requires the development of a basic response system that can then be scaled to address a specific incident, ranging from minor to substantial and measured by the number of people affected, the geographic area affected, property damage, and so forth. That planning should be initiated long before an incident occurs.

The concept of incident planning is certainly not foreign to environmental health professionals. Responses to major floods, hurricanes, tornadoes, and forest fires are planned in this way There are also response plans for man-made disasters such as chemical releases via spills or fires in virtually every community.

So, what lessons did Operation Topoff reinforce? To many participants, the need for effective communication and sound response management were most visible. Effective communication and working relationships among the responding agencies are pivotal. Topoff combined several key elements that strained relationships. Those were high stress, the magnitude of the event, the feeling of being overwhelmed, and the consequent difficulty in establishing and maintaining effective communication among the key agencies and individuals involved.

When multiple agencies are involved, resources are overtaxed and stress is high. There is usually not a single, most effective method of responding. That is where the value of prior planning can be realized. Strong, trusting, pre-existing relationships will reduce confusion, misinterpretation, misunderstanding, and miscommunication. In short, know your counterparts in other response agencies and practice working together, whether in a training exercise or in real situations. Those relationships are the first step to effective communication, especially when routine communication devices are not available.

What if communication systems fail? For example, if a large outbreak that affects the entire community occurs, it is very likely that the traditional communications systems, including telephone, cell phone, pager, and others, would be quickly overwhelmed. Something as simple as calling all staff to work might be impossible. Do you have a plan to contact staff in the absence of telephones? Have you worked with your counterparts in other agencies enough to know what their backup plans for communication consist of? Did you have a plan for Y2K communication that might work?

Stress and emotion can undermine the best plan. What happens if staff refuse to show up for work because they are concerned about becoming ill, because they are ill, or because they have fears for the safety of their families? After all, the Topoff scenario suggested thousands ill and many deaths. Have you got a backup plan that will allow you to activate other resources? Are those relationships established now and ready to be called upon?

Although it was difficult to simulate the emotional component of an outbreak, Topoff provided a reminder that the psychological impact cannot be ignored. Factors such as the number of illnesses, the high mortality rate of a disease such as plague, community outrage about a widely destructive terrorist event, and the emotions of staff and relatives of victims are substantial sources of psychological distress. Other, practical considerations include managing the proper disposition of large numbers of deceased victims. Participation in policy decisions that may deny prophylaxis to unexposed individuals will result in additional emotional issues.

What is your agency's capacity for disease surveillance and epidemiology? In the case of an outbreak associated with an infectious agent, state and local health agencies will likely be the primary resource for disease investigation. That step may be the critical element of a response that will dictate how far the outbreak spreads in the community. Effective and timely follow-up to the initial reports of disease are critical in determining if the cases are related and represent the beginning of an outbreak or are just a coincidence. Have you talked about how you will implement your existing day-to-day investigation-and-response capacity at a scale involving more cases than normal by several orders of magnitude?

The circumstances of Topoff suggested that mass prophylaxis to protect the unexposed population might be indicated. Numerous logistical issues are raised in many agencies by the need to manage triage of large numbers of people, as well as to address the worried well and those who probably have not been exposed but want additional protection. These tasks may constitute the ultimate communication and coordination challenge. For example, how does law enforcement provide security while enabling health professionals to dispense medication in an orderly manner? How, at the point of distribution, do you triage and separate those exposed, those unexposed, and those with unknown exposure--and keep order?

This discussion has provided only a snapshot of the issues that are critical to a controlled and effective response to a bioterrorist attack or other major public health disaster. After the local health department review of Topoff was completed, however, there was one recurring theme, providing some hope that an orderly response to such an incident is possible: Each time we were challenged with a new wrinkle that further complicated the incident, we found ourselves not looking for an instruction manual but calling on our training and experience. We were then able to act within the general parameters of a response plan to manage the issues for which we had responsibility. Our response involved gathering staff who had a wide range of skills and responsibilities, holding a thorough discussion of the issue, and weighing the pros and cons of response alternatives. We then made reasoned decisions. Under the circumstances, it was not a question of the right or wrong answer but of making the best decision we could. We were more comfortable calling on those in other agencies with whom we had worked previously and we learned the most from those situations we had not encountered before.

As a result, we have identified weaknesses in our general plan. We have committed to engaging in dialogue, planning, and communication with other community agencies--and to thinking more clearly through the factors that must be considered in the face of the unthinkable, a major bioterrorist attack. Through training, skill building, and dialogue with others, agencies can increase the likelihood of calling on people with the appropriate expertise, convening a productive dialogue, and responding effectively.

Ultimately, our ability to minimize tragedy depends on whether we are able to contemplate the unthinkable, plan for what is possible, and hope for the best. We increase our chances of success if we rely on the motto made famous by Lord Baden Powell: "Be prepared."