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Medical Preparedness for a Terrorist Incident Involving Chemical and Biological Agents During the 1996 Atlanta Olympic Games

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Medical Preparedness for a Terrorist Incident Involving Chemical and Biological Agents During the 1996 Atlanta Olympic Games

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During the 1996 Centennial Olympic Games in Atlanta, Georgia, unprecedented preparations were undertaken to cope with the health consequences of a terrorist incident involving chemical or biological agents. Local, state, federal, and military resources joined to establish a specialized incident assessment team and science and technology center. Critical antimicrobials and antidotes were strategically stockpiled. First-responders received specialized training, and local acute care capabilities were supplemented. Surveillance systems were augmented and strengthened. However, this extensive undertaking revealed a number of critical issues that must be resolved if our nation is to successfully cope with an attack of this nature. Emergency preparedness in this complex arena must be based on carefully conceived priorities. Improved capabilities must be developed to rapidly recognize an incident and characterize the agents involved, as well as to provide emergency decontamination and medical care. Finally, capabilities must be developed to rapidly implement emergency public health interventions and adequately protect emergency responders.
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EMS/CONCEPTS
214 ANNALS OF EMERGENCY MEDICINE 32:2 AUGUST 1998
Trueman W Sharp, MD, MPH
*
Richard J Brennan, MBBS, MPH
Mark Keim, MD
II
R Joel Williams, DVM, MS
§
Edward Eitzen, MD MPH
Scott Lillibridge, MD
From the Headquarters, United States
Marine Corps, Washington DC
*
; the
National Center for Environmental
Health
and Center for Infectious
Diseases,
§
Centers for Disease Control
and Prevention, and the Division of
Emergency Medicine, Emory Univer-
sity,
II
Atlanta, GA; and the United
States Army Medical Research Institute
of Infectious Diseases, Fort Detrick,
MD.
Received for publication July 11, 1997.
Revisions received October 2, and
October 17, 1997. Accepted for
publication January 1, 1998.
Copyright © 1998 by the American
College of Emergency Physicians.
Medical Preparedness for a Terrorist Incident
Involving Chemical or Biological Agents During
the 1996 Atlanta Olympic Games
During the 1996 Centennial Olympic Games in Atlanta, Georgia,
unprecedented preparations were undertaken to cope with the
health consequences of a terrorist incident involving chemical or
biological agents. Local, state, federal, and military resources
joined to establish a specialized incident assessment team and
science and technology center. Critical antimicrobials and anti-
dotes were strategically stockpiled. First-responders received
specialized training, and local acute care capabilities were sup-
plemented. Surveillance systems were augmented and strength-
ened. However, this extensive undertaking revealed a number of
critical issues that must be resolved if our nation is to success-
fully cope with an attack of this nature. Emergency preparedness
in this complex arena must be based on carefully conceived prior-
ities. Improved capabilities must be developed to rapidly recog-
nize an incident and characterize the agents involved, as well as
to provide emergency decontamination and medical care. Finally,
capabilities must be developed to rapidly implement emergency
public health interventions and adequately protect emergency
responders.
[Sharp TW, Brennan RJ, Keim M, Williams RJ, Eitzen E, Lillibridge
S: Medical preparedness for a terrorist incident involving chemical
or biological agents during the 1996 Atlanta Olympic Games.
Ann Emerg Med
August 1998;32:214-223.]
INTRODUCTION
The 1996 Centennial Olympic Games in Atlanta, Georgia,
focused national attention on the need for an effective medi-
cal response to a terrorist attack involving chemical or bio-
logical agents. The country had just experienced a series
of highly visible and destructive terrorist attacks with con-
ventional weapons, including the bombing of the Federal
Building in Oklahoma City. The chemical attack with the
nerve agent sarin in the Tokyo subway system in March
1995 had demonstrated both the extensive social disruption
that can ensue from a terrorist attack involving chemical
weapons and the complexities involved in mounting an effec-
MEDICAL PREPAREDNESS FOR A TERRORIST ATTACK
Sharp et al
AUGUST 1998 32:2 ANNALS OF EMERGENCY MEDICINE 215
helicopter to conduct a rapid assessment of an incident
site, collect critical evidence, and assume command and
control of the scene from local first-responders. The FBI
team included military ordnance disposal experts and per-
sonnel from the US Army Technical Escort Unit. This unit,
which was formed during World War II to transport the
first atomic bomb, specializes in identification and safe
transport of weapons of mass destruction. Their role was
to make a preliminary identification of any chemical or
biological agents (Table 1) and to transport samples out of
the area for definitive analysis.
The FBI assessment team also included military physi-
cians with extensive training in the identification and man-
agement of patients exposed to chemical or biological agents.
These physicians were available to evaluate the presenta-
tion of any affected persons and correlate clinical findings
with any other available information, such as readings from
rapid chemical agent detector devices.
Science and technology center
A Center was created at the Centers for Disease Control
and Prevention (CDC), which was conveniently located in
Atlanta, to provide emergency public health, medical, tox-
icologic, forensic, and scientific consultation after a sus-
pected terrorist event involving chemical or biological
agents.
22
The Center was closely linked with the FBI assess-
ment team and included representatives from a number of
the environmental and infectious disease laboratories at
CDC, the Agency for Toxic Substances and Disease Registry,
and the military. The Center also had representatives from
the local public health and emergency medicine commu-
tive medical response.
1-4
The use of biological agents as
weapons of terrorism was regarded as having the potential
to cause tens of thousands of casualties and to cost billions
of dollars to the US economy.
5-9
With more than 10,000
athletes, 2.2 million visitors, and 35 heads of state expected
in Atlanta for the Olympic Games, and approximately 2
billion persons expected to watch on television, the possible
implications of a terrorist incident, particularly one involv-
ing chemical or biological agents, were profound.
10-14
An addition to the Federal Response Plan that described
the national response to a chemical or biological incident
was developed before the Olympic Games by the Office of
Emergency Preparedness of the Department of Health and
Human Services.
15
This plan defined roles and responsi-
bilities for the health response on the federal level. Before
the Atlanta Olympic Games, however, only certain special-
ized units within the military and the law enforcement
communities were prepared to cope with chemical or bio-
logical agents. The literature that dealt with protecting the
public health at large events did not address terrorism or
these agents in any detail.
16,17
There was no single plan
or organization to guide response preparations. The city
of Atlanta had little indigenous capability to recognize or
deal with terrorism involving chemical or biological agents.
Efforts undertaken to cope with chemical or biological ter-
rorism for the Olympic Games were therefore the result of
the federal plan plus the diverse initiatives of many organiza-
tions and agencies from both within and outside of the city.
Extensive preparations were undertaken in Atlanta to
meet the expected demand for health services in the hot
summer conditions of the Games. These included establish-
ment of a system of medical clinics for athletes and visitors;
enhancement of public health support, particularly regard-
ing food safety and prevention of heat illness; augmenta-
tion of EMS systems; and disaster response planning.
18-20
In addition, extensive and unprecedented efforts were under-
taken involving local, state, federal, and military resources
to prepare Atlanta for the medical consequences of chemi-
cal or biological terrorism. In this article, we highlight some
of the many complex issues with which the nation is faced
in trying to develop an effective medical response to this
threat.
PREPARATIONS IN ATLANTA
Specialized assessment team
An assessment team for chemical and biological terror-
ism was established by Federal Bureau of Investigation (FBI)
scientists and placed on 24-hour call at the start of the
Olympic Games.
21
This team’s mission was to proceed by
Table 1.
Examples of chemical and biological agents that could be used
in a terrorist attack.
Category Examples
Military chemical agents
Nerve agents Sarin, soman, tabun
Blister agents Mustard compounds, lewisite
Choking agents Phosgene, chlorine
Incapacitating agents Phenothiazines, BZ
Blood agents Hydrogen cyanide
Industrial chemicals
Organic compounds Dioxin, organic acids
Pesticides Methyl isocyanate
Toxic gases Ammonia, chlorine
Biological agents
Bacteria Anthrax, tularemia, plague
Viruses Viral hemorrhagic fevers, smallpox
Toxins Botulinum, ricin
Veterans Administration at Dobbins Air Reserve Base, just
north of Atlanta. The quantities assembled were based on
an arbitrary estimate for planning purposes of 10,000 casu-
alties with 10% to 15% of these casualties requiring tertiary
care. (Military estimates assume that 6% to 10% of similar
casualties on the battlefield will require tertiary medical
care.) Stockpiled drugs included antimicrobials for the
treatment of biological agents and antidotes for chemical
agents (Tables 2 and 3). In the event of a suspected attack,
supplies of the appropriate medications would have been
transported rapidly by road or helicopter to health facilities
throughout Atlanta.
Because treatment must be given very soon after chem-
ical agent exposure, additional supplies of chemical agent
antidotes were distributed to local hospitals. Nerve agent
antidotes and cyanide kits were included in chemical agent
treatment packs that were provided to selected emergency
responders. Antimicrobials were not provided to hospitals
before the Games because the incubation period of infec-
tious agents and the slower onset of clinical symptoms
would have allowed time for distribution of needed drugs
to appropriate locations. Similarly, emergency responders
were not provided with antimicrobials in their emergency
treatment packs.
Specialized training for first-responders
Before and during the Games, approximately 1,700 fire
department, police, hazardous material response team,
emergency department staff, and other prehospital response
personnel in Atlanta, as well as other host cities (Miami,
Athens, Birmingham, Orlando), attended a variety of semi-
nars and courses on chemical and biological agents. Course
curricula were either modified from existing US Army
courses
23,24
or were developed for the Olympic Games by
local physicians. The courses typically involved an overview
MEDICAL PREPAREDNESS FOR A TERRORIST ATTACK
Sharp et al
216 ANNALS OF EMERGENCY MEDICINE 32:2 AUGUST 1998
nities to provide additional expertise and to help ensure an
integrated emergency response.
A US Army laboratory team that monitors international
chemical weapons treaties established a mobile laboratory
at the Center that was equipped with gas chromatography,
mass spectrometry, and other advanced technologies to
definitively identify chemical agents, particularly military
chemical agents such as the nerve, blister, incapacitating,
and blood agents. A unit from the Naval Medical Research
Institute in Bethesda, Maryland, which had a number of
technologies for the rapid identification and confirmation
of biological agents, established operations in the Center.
This unit had recently developed handheld assays, confir-
matory polymerase chain-reaction assays, confirmatory
immunoassays, and culture techniques to rapidly identify
Bacillus anthracis, botulinum toxin, Francisella tularensis,
Brucella melitensis, and other biological warfare agents. The
US Army Research Institute for Infectious Diseases stood by
to provide additional specialized laboratory support if
necessary.
The Defense Special Weapons Agency provided a team
with the capability of preparing a computer simulation to
predict the dispersion plume of any released chemical or
biological agents. The Food and Drug Administration sent
a liaison team to help identify and deal with foodborne and
waterborne agents or product adulterations. An Environ-
mental Protection Agency Emergency Response Team was
assigned to the Center to provide a capability to enter a
site where there is a known or unknown industrial chemical
agent, identify the compound, delineate the hazard area,
and begin mitigation of the environmental contamination.
A US Coast Guard National Strike Force, a unit with similar
capabilities, was also present.
Stockpiling and distribution of antimicrobials and antidotes
Drugs appropriate for the treatment of patients exposed
to chemical and biological agents were stockpiled by the
Table 2.
Antimicrobials stockpiled in Atlanta during the 1996 Olympic
Games, and the diseases against which they are effective.
Antimicrobials Diseases
Ceftriaxone injection Salmonella, typhoid
Ciprofloxacin injection Anthrax
Ciprofloxacin tablets Anthrax, salmonella, shigella, plague
Doxycycline capsules Brucellosis, cholera, plague (prophylaxis),
Q fever, tularemia
Penicillin G injection Anthrax
Streptomycin sulfate injection Brucellosis, plague, tularemia
Table 3.
Chemical agent antidotes and treatments stockpiled in Atlanta
during the 1996 Centennial Olympic Games, and the chemical
agents against which they are effective.
Antidote Chemical Agent
Atropine sulfate injection Chemical nerve agents
Diazepam injection Chemical nerve agents
Pralidoxime injection Chemical nerve agents
Diazepam autoinjector Chemical nerve agents
(provided to emergency responders)
Atropine-pralidoxime autoinjector Chemical nerve agents
(provided to emergency responders)
Cyanide antidote kit Cyanide
MEDICAL PREPAREDNESS FOR A TERRORIST ATTACK
Sharp et al
AUGUST 1998 32:2 ANNALS OF EMERGENCY MEDICINE 217
equipped with personal protective gear into a contaminated
area to provide emergency triage, stabilization, decontami-
nation, and evacuation of exposed persons. No other orga-
nization in Atlanta had this capability.
Thirty Public Health Service Disaster Medical Assistance
Teams (DMATs)
27
from throughout the United States were
rotated through Atlanta over the course of the Games. For
this occasion, basic DMATs were modified to consist of a
physician, a physician’s assistant, a nurse, and two EMTs.
The teams developed portable treatment packs with essen-
tial medications and supplies. Most DMATs were on call at
Dobbins Air Reserve Base and stood by ready to deploy to
a disaster site by helicopter. Some were stationed in major
hospitals around Atlanta. DMAT personnel received spe-
cial training in the management of casualties of a chemical
or biological attack, principally from physicians from the
US Army Medical Research Institutes for Infectious Diseases
and Chemical Defense. In the event of a chemical or bio-
logical incident, DMAT personnel were to augment local
care providers and provide a link between the Marine Corps
unit and local fixed medical facilities.
Members from one of a group of federal response teams
currently under development, the Metropolitan Medical
Strike Teams, which are intended to be rapidly available
medical units stationed around the country to deal with
chemical and biological agents,
15
were also present. A num-
ber of other military units were standing by in the south-
eastern United States to augment local response efforts if
necessary.
DISCUSSION
Almost all of the major federal and military organizations
in the United States that would have had a role in respond-
ing to a chemical or biological terrorist incident were
deployed to Atlanta during the Olympic Games. Before
this time, few of these organizations had ever collaborated
to respond to a terrorist action, nor had many worked with
local emergency response personnel. The Games served as
an unprecedented opportunity to develop and refine inte-
grated response plans through daily interactions, formal
planning sessions, tabletop exercises, conferences, and field
exercises.
In addition, on the 10th day of the Games a terrorist
bomb was detonated in Centennial Park. This bomb was
judged by first-responders not to involve chemical or bio-
logical agents. Members of the FBI specialized assessment
team evaluated the situation as a precautionary measure,
and samples from the scene were transported to the Science
and Technology Center for analysis. Testing of bomb frag-
ments confirmed within a few hours that no chemical or
of the major potential chemical and biological agents and
associated clinical syndromes and instruction in the use of
personal protective equipment, decontamination proce-
dures, and therapeutic strategies, including use of antidotes
and antimicrobials. Many first-responders procured com-
mercially available chemical agent detection equipment,
additional treatment modalities, personal protective gear,
and decontamination equipment. The Atlanta Poison Control
Center developed and disseminated special information on
treatment of persons exposed to military chemical agents.
Many emergency response organizations, such as hospital
EDs and hazardous materials response teams, conducted
exercises and drills that involved simulated casualties from
a chemical or biological attack.
Enhanced surveillance
Two complementary public health surveillance systems
were established specifically for the Olympic Games by
local and state health authorities in conjunction with CDC
to detect outbreaks requiring a public health response. These
systems built on the preexisting passive surveillance system
for notification of infectious diseases and other significant
conditions in Georgia.
18
The first system focused on ath-
letes and spectators in the Olympic Village and the 25
Olympic venues, and the second focused on local hospitals.
Standardized data from patient encounters were trans-
mitted on a daily basis to a surveillance coordination center,
where they were compiled, summarized, and reported
promptly to state and federal officials. Reports from the
state public health laboratory and the state’s major private
medical diagnostic laboratory were also transmitted on a
daily basis to the surveillance center. Additionally, local
physicians were encouraged through various announcements
and newsletters to promptly report any unusual clinical
presentations to the Georgia Division of Public Health.
Identification of a terrorist incident involving chemical or
biological agents was not the goal of these systems; they were
primarily designed to detect heat illness, foodborne outbreaks,
and other more routine public health problems. However,
they provided a critical means of detecting an insidious attack
with a chemical or biological agent. If an outbreak of any type
had been detected, the investigation and response could have
been augmented rapidly by Epidemic Intelligence Service
officers from CDC or the Science and Technology Center.
Augmented clinical capabilities
A US Marine Corps unit that was created just before the
Olympic Games, the Chemical Biological Incident Response
Force, was stationed and on alert in downtown Atlanta
near the major competition venues.
25,26
This unit had the
capability to rapidly send Marines and medical personnel
military chemical agents, particularly nerve agents (Table 4).
This approach probably was influenced by the recent sarin
attack in Tokyo. Also, most of the detection equipment,
training, and procedures that were available had been devel-
oped by the military to deal with military chemical agents
on the battlefield.
23,24
However, Atlanta has many major manufacturing indus-
tries that receive by rail and truck approximately 100,000
shipments per year consisting of 30,000-gallon tank cars
containing hazardous materials. Many of the major trans-
portation routes pass through downtown Atlanta, with many
routes near the Olympic venues. Relatively little effort was
made to identify and prepare for incidents involving these
industrial chemicals, such as ammonia or chlorine gas.
32
Also, possible biological scenarios were not well devel-
oped,
33,34
and a response plan to a biological attack was
not well delineated. Of note, although the sarin attack re-
ceived much publicity, the Aum Shinrikyo group had also
previously attempted to disseminate anthrax spores and
had attempted to obtain Ebola virus.
35
Data on the total cost of the response effort that dealt
with chemical and biological terrorism are not available.
The units enumerated here, not including Atlanta-based
personnel, involved the deployment of approximately 1,000
people. Deployment of the Marine Corps unit alone cost
approximately $7 million. In few other situations will poten-
tial responders have access to the extensive resources that
were available for the Olympic Games.
Members of the Science and Technology Center, together
with additional consultants from the fields of toxicology,
infectious diseases, and nuclear physics, met during the
Games to develop a prioritized list of the most likely terror-
ist scenarios. According to these deliberations, terrorists
may have been more likely to take advantage of accessible
industrial chemicals rather than the technologically more
MEDICAL PREPAREDNESS FOR A TERRORIST ATTACK
Sharp et al
218 ANNALS OF EMERGENCY MEDICINE 32:2 AUGUST 1998
biological agents were involved. Although most of the orga-
nizations described here did not become involved in the
response to the bombing, this incident served in some re-
spects to test the preparations that had been made to rec-
ognize and cope with chemical or biological agents.
The preparations for the Games, and the actual detona-
tion of a bomb, demonstrated that although there are many
sophisticated capabilities available in the United States,
there are still many difficult problems to be solved if we are
to have an effective capability to manage the health conse-
quences of a chemical or biological incident at the local
level. Some of the most significant issues that emerged are
described in the following sections.
Establishing priorities for medical preparedness
Although predicting the location and nature of a terror-
ist attack is difficult and perhaps impossible,
28-31
rational
articulation and prioritization of potential threats is essen-
tial for effective planning. Critical aspects of preparedness
that rely on a medical threat assessment include the place-
ment of necessary treatment drugs in medical facilities and
the provision of appropriate training to prehospital respon-
ders and other medical personnel. Also, the cost of prepa-
rations is a critical factor. With limited resources to deal
with the various chemical and biological threats, assets in-
vested in this area should be appropriate to the magnitude
of the various threats and must be balanced against com-
peting health priorities.
In Atlanta, there was considerable discussion of poten-
tial threats, and law enforcement and intelligence agencies
identified and tracked potential terrorists. However, a well-
conceived and prioritized medical threat list was not readily
available for emergency health responders. Consequently,
as preparations evolved, most organizations focused on the
management of a single discrete terrorist event involving
Table 4.
Time-line of the planned response to a terrorist incident involving chemical agents during the Atlanta Olympic Games, 1996.
Response Time 0–20 min 20–40 min >40 min 2–6 hr
Emergency responders Police, fire department, FBI assessment team, DMATs, EPA ERT, USCG ST Army teams, EPA, ATDSR, FDA
EMS, HAZMAT units CBIRF, local hospitals
Command and control Local authorities FBI FBI/FEMA FEMA/FBI
Agent identification Observational reports Field assays Samples sent to labs Definitive identification
Public health actions Situation assessment Public warnings, Antidote stockpiles distributed, Long-term strategy developed
decontamination, evacuation technical consultations initiated
HAZMAT, local hazardous materials response teams; CBIRF, US Marine Corps Chemical Biological Incident Response Force; DMAT, US Public Health Service Disaster Medical Assistance Teams;
EPA ERT, Environmental Protection Agency Emergency Response Team; USCG ST, US Coast Guard Strike Team; EPA, Environmental Protection Agency response elements; ATDSR, Agency for Toxic
Diseases and Substances Registry response elements; FDA, Food and Drug Administration emergency response team; FEMA, Federal Emergency Management Agency.
MEDICAL PREPAREDNESS FOR A TERRORIST ATTACK
Sharp et al
AUGUST 1998 32:2 ANNALS OF EMERGENCY MEDICINE 219
used would almost certainly have occurred in time. The
Science and Technology Center had extensive state-of-the-
art capabilities to identify virtually any biological agent or
chemical compound. Furthermore, arrangements were in
place to send samples to cooperating laboratories with expe-
rience in these areas, such as the US Army Medical Research
Institute for Infectious Diseases in Fort Detrick, Maryland.
However, given the time needed for the collection and safe
transport of samples, and then to perform necessary con-
firmatory tests, definitive identification would have taken
at least several hours, or possibly even several days in the
case of a biological agent.
8,33
Rapid on-site identification of an agent, on which many
early interventions would have depended, may have been
problematic. Many responders relied on military equipment
such as the handheld Chemical Agent Monitoring System,
which is a device designed to identify known military chem-
ical agents.
23,24
If one of the standard military agents had
been used in an attack, it most likely would have been de-
tected on-site by these devices. However, currently available
information suggests that military rapid detection equip-
ment has high sensitivity but low specificity and is there-
fore prone to false-positive readings.
24
(Exact performance
characteristics of this equipment are classified.) In addition,
it is not clear how well current military rapid detection
technologies would have performed in identifying variants
of the currently known military agents or new chemical
agents. Recent reports suggest that the Russian government
may have developed new types of nerve agents that are not
readily detectable with current technologies.
41
Rapid identification of an unknown industrial chemical
can be a complicated process.
42
A wide variety of technolo-
gies are under development to rapidly identify biological
agents in clinical and environmental settings. However, bio-
logical detection technologies, most of which are in research
and development, still have limitations. These systems have
complex military chemical or biological agents (Figure).
Although such a priority list does not predict what a par-
ticular terrorist organization will do, it might have been use-
ful earlier in the planning processes to provide guidance
for those trying to plan for the most likely threats and appro-
priately allocate limited medical resources.
36
Recognizing an incident and rapidly characterizing the agent
A fundamental assumption of local response plans was
that first-responders would recognize that a chemical or
biological agent had been used. However, the use of such
agents might not have been readily apparent, particularly
if the attack involved a biological agent.
6,8,13,33
Because anthrax spores are invisible and can be dissem-
inated by means of inexpensive, commercially available
spray devices, the first indication of an anthrax attack would
probably have been when exposed persons began to develop
characteristic clinical symptoms. Anthrax initially causes a
nondescript, influenza-like illness 2 to 3 days after exposure,
with clinical deterioration and characteristic symptoms
occurring a few days later.
6
Patients would have presented
in diverse locations throughout Atlanta, and probably re-
motely from Atlanta as well. In time, diagnoses of anthrax
would have been made and an outbreak identified, but
probably not until well after the attack.
Attempts to verify allegations of the use of chemical or bio-
logical agents, such as the alleged “yellow rain” in southeast
Asia and the use of anthrax as a weapon in Zimbabwe, have
revealed many of the potential difficulties that can be encoun-
tered in a retrospective investigation.
33,37-40
Although the
investigation of anthrax cases in Atlanta would have been
straightforward once the agent was identified, other infec-
tious agents occur naturally in Atlanta, and differentiating
a “natural” from an “unnatural” outbreak and conclusively
identifying modes of spread could have been very difficult.
The Centennial Olympic Park bombing showed that
even in an overt incident, emergency response units did
not have standard observational criteria or screening pro-
cedures to help determine whether the attack involved
chemical or biological agents. This determination relied
solely on the suspicion of first-responders. Although the
appearance of a cloud of gas is obvious, biological or radi-
ologic contamination may not be evident. In the Centennial
Park incident, bomb fragments ultimately were collected
on an ad hoc basis and shown by the Science and Tech-
nology Center not to contain any chemical or biological
agents. However, criteria for recognizing an attack and a
standard approach to sampling would have been useful.
If the use of a chemical or biological agent had been
suspected, definitive identification of the agent or agents
Figure.
Most likely methods of terrorist attack in order of the
threat, as determined by the Science and Technology Center
at the Centers for Disease Control and Prevention during
the Centennial Olympic Games, Atlanta, Georgia, 1996.
1. Use of a conventional explosive
2. Release of an industrial chemical agent
3. Release of a military chemical agent
4. Use of a conventional bomb laced with chemical, biological, or radiologic
agents
5. Release of a biological agent
6. Detonation of a nuclear device
vide more than emergency interventions in the field with-
out risking contamination of hospital facilities.
The provision of medical care within a site contami-
nated by a chemical or biological agent also raises many
difficult questions.
48
Current military doctrine is to main-
tain almost all medical care capability in an uncontaminated
area where clinicians are safe from exposure and do not
have to work in cumbersome personal protective gear.
23,24
This may be appropriate for battlefield conditions; however,
decontamination of exposed persons and their evacuation
to uncontaminated areas can be a prolonged process, espe-
cially for exposures to chemical agents, and some may re-
quire antidotes or other interventions urgently (eg, airway
management).
The Chemical Biological Incident Response Force worked
to develop and refine procedures to send skilled health care
professionals and enhanced treatment capabilities (eg, port-
able respirators) into a contaminated area.
25,26
They also
acquired telemedicine technologies, such as a small helmet-
mounted microphone and camera which would have allowed
real-time visual and audio communications with health care
providers in the contaminated area. However, procedures
for providing care in a contaminated zone and algorithms
for providing care to contaminated patients were not yet
developed by the time of the Games. In addition, triage cri-
teria for patients exposed to a chemical or biological attack
were not defined. Difficult ethical and legal questions, such
as whether emergency responders not licensed to adminis-
ter medications should be permitted to provide emergency
treatment to persons in a contaminated area, were also
unresolved.
Developing and implementing emergency public health
interventions
In addition to the problems of providing acute care to
the exposed, a number of public health issues would almost
certainly have arisen after any agent release.
47-51
The pros-
pect of coping with mass exposure to anthrax spores, for
example, is daunting. The appropriate use of prophylactic
antibiotics, immunizations, quarantine, isolation, and other
measures to minimize or prevent further exposures and
illness would have been complex and critical concerns.
6
After the sarin release in Tokyo, the majority of those
seeking medical care did not exhibit any clinical signs or
symptoms.
1-4
Therefore, had there been a chemical or bio-
logical emergency in Atlanta, protocols for screening those
who appeared well but might have been exposed would
have been necessary. If a cloud of gas had been released
and immediately detected, urgent decisions on whether to
attempt evacuation or to rely on sheltering in place also
MEDICAL PREPAREDNESS FOR A TERRORIST ATTACK
Sharp et al
220 ANNALS OF EMERGENCY MEDICINE 32:2 AUGUST 1998
been difficult to develop, and capabilities exist at present
to identify only certain biological agents, primarily those
deemed to be of military importance, such as anthrax and
botulinum toxin. The performance characteristics of these
technologies are not yet well established.
43
In addition, no
matter what detectors are available, rapidity in identifying
an agent may depend on clinical evaluation and on corre-
lation of observed signs and symptoms with other informa-
tion, such as findings from rapid detectors. Only the FBI
specialized assessment team had clinicians who were expe-
rienced in identifying signs and symptoms of exposure to
chemical and biological agents.
Providing appropriate decontamination and medical care
to exposed persons
Assessments of the ability of military and civilian
medical personnel to recognize and manage cases of
exposure to chemical or biological agents invariably empha-
size that appropriate training and practice exercises are
required.
8,13,42-45
Although some medical training was
undertaken in Atlanta, most health care professionals had
only a brief introduction to chemical and biological wea-
pons, or no training at all.
A fundamental concern was the medical management
of contaminated patients,
46,47
particularly those exposed
to chemical agents. Persons exposed to biological agents
generally require little decontamination. For an incident
occurring in downtown Atlanta and involving a relatively
small and contained number of casualties, the Chemical
Biological Incident Response Force was well placed and
prepared to decontaminate and stabilize approximately
100 exposed persons. However, had there been a larger
number of chemical casualties, or casualties in more remote
and dispersed locations, most emergency response person-
nel, DMATs, and health facilities had very limited means
to decontaminate exposed persons. Most local hospitals,
for example, had the capability to decontaminate only one
or two patients at a time. In the event of deaths, mortuary
facilities had little or no means to handle contaminated
bodies.
Even after a small, discrete event, some people would
almost certainly have sought care directly at local health
care facilities. After the sarin release in the Tokyo subway,
the majority of those exposed who were ambulatory by-
passed the local EMS and sought care directly in a multi-
tude of medical facilities.
1-4
As a result, some health care
workers in Tokyo were symptomatic after being exposed
secondarily to sarin vapor. If patients had had traumatic
wounds with deep contamination, which are very difficult
to decontaminate, there would have been no means to pro-
MEDICAL PREPAREDNESS FOR A TERRORIST ATTACK
Sharp et al
AUGUST 1998 32:2 ANNALS OF EMERGENCY MEDICINE 221
were implemented by responders in Atlanta. Whether such
programs were needed, and if so how they should have
been used, were unresolved issues. Of note, pyridostigmine
and most relevant immunizations, with the exception of
anthrax vaccine, remain in investigational new drug status
for these indications.
In Atlanta, emergency health responders were not sup-
posed to enter an incident site until the crisis was resolved
and the scene was considered safe. However, after an inci-
dent, particularly one involving chemical agents, there
probably would have been substantial pressure to provide
immediate emergency care to victims, which could have
placed responders at risk.
57
Emergency response operations and coordination
The sequence of events that would have ensued after a
discrete incident was well planned out by the conclusion
of the Games. In sum, the first-responders to an incident,
local fire department personnel and police, would promptly
have notified their superiors through the appropriate chains
of command if they suspected a terrorist incident involving
chemical or biological agents. Emergency support opera-
tions on the local, state, and federal levels would, in turn,
have been activated, and the organizations enumerated here
would have been mobilized. However, the presence of many
organizations from different jurisdictions created confusing
and sometimes conflicting chains of command. In addi-
tion, had there been an occult attack involving biological
agents, or attacks in multiple locations, it is not clear how
the response would have evolved. Some response units had
different, and incompatible, communications gear. Local
telephone services, which were taxed by the large number
of visitors and media personnel, would have been over-
whelmed. Dedicated communications networks were
unavailable for some of the local hospitals that might have
received the majority of the patients.
RECOMMENDATIONS
Our experience in Atlanta showed that an effective response
to terrorism involving chemical or biological agents is com-
plex and multifaceted. In the event of a terrorist incident
involving such agents, effective management of the conse-
quences would have to involve a rapid and coordinated
response from local, state, federal, and military agencies.
Based on the Atlanta experience, we present the following
general recommendations and observations to guide future
preparedness and response activities. Although the Atlanta
experience was unique in many respects, we believe that
these principles have broad application.
would have been needed. Complex and sensitive issues re-
garding containment and cleanup of an agent also would
have been critical concerns; many questions would probably
have arisen regarding air quality, food safety, animal expo-
sures, and residual soil or water contamination.
A rapid epidemiologic investigation documenting expo-
sures and health outcomes would have been important
during the immediate response period to facilitate identifi-
cation of the agent or agents used, to identify exposed per-
sons, and to develop appropriate curative and public health
interventions.
49
Long-term epidemiologic surveillance, in-
cluding the establishment of disease and injury registries,
would have been necessary to guide appropriate follow-up
of exposed persons, to develop long-term control measures,
and to analyze the response effort.
52
Protecting emergency responders
Providing emergency medical response safely in an
environment where chemical or biological agents have been
used mandates careful attention to safety procedures. Even
then the response may involve substantial risks.
53,54
In
responses to hazardous materials incidents, there must be
an overall site safety manager with ultimate authority to en-
sure safety. For the Olympic Games, although safety was
certainly a major concern for responders, it was uncertain
who, if anyone, would have assumed this critical over-
sight role at an incident site. Military units in Atlanta were
equipped primarily with battlefield self-protective gear
(Saratoga suits and M-40 masks), which are designed to
protect troops against military chemical agents and biologi-
cal agents on the battlefield, rather than more fully protec-
tive suits.
23,24
This gear would not have provided protection
against exposure to some industrial chemicals, particularly
gases. Whatever the protective suit used, the ambient tem-
perature and humidity in Atlanta typically were greater
than 90° F and 90%, respectively. Working in protective
gear for more than about 30 minutes risked serious injury
from heat illness. Recently developed cooling vests were
found to be practical and to prolong safe work times some-
what,
54
but during exercises and drills responders had to
work slowly, consume large quantities of fluids, rotate out
often, and be monitored closely for signs of heat stress.
Chemoprophylaxis and immunoprophylaxis measures
did exist for responders who conceivably could have been
exposed to chemical or biological agents during a response.
Survival after exposure to certain nerve agents is improved
substantially by the prophylactic use of pyridostigmine.
55,56
Safe and effective immunizations exist for some potential
biological agents, such as anthrax and botulinum toxin.
However, no immunization or chemoprophylaxis programs
development of appropriate policies on immunization and
chemoprophylaxis.
• Finally, an effective response must be multidisciplinary,
involving clinicians, EMS personnel, laboratory workers,
toxicologists, public health personnel, and others. Those
providing a health response must work closely with law
enforcement agencies, not only for reasons of safety but
also to ensure a coordinated response.
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... 34 Few published studies we reviewed were focused on how to respond at the scene of a CBRNE incident with subsequent scene management and specialist support. 13,20,30 The majority of articles emphasized mitigation and preparedness for CBRNE threats aligning with some practices suggested in NATO and World Health Organization (WHO) reports, but there are still differing approaches and applications. 2,3,34 While the NATO and WHO reports provide overarching general advice, the body of literature we examined gave specific cases and examples based on real world experience as seen in Table 3. ...
... There were five articles that mentioned chemical threats but only two gave prescriptive advice that specifically applies for chemical attacks. 9,13,20,26,30 This can be attributed to the fact that these chemical threats were typically included with the broader CBRNE measures, and many of the chemical and biological preventative measures tend to overlap. For example, in the XIV Pan-American Games, live animals were used in the detection of chemical and biological threats. ...
... 9,27 In terms of treatment of both chemical agents and biological threats, they require initiation immediately after exposure, so hospitals need to be stockpiled with adequate PPE and proper antidotes. 30 Plans against chemical attacks should be prepared for military grade chemicals, eg, sarin and other nerve agents, as well as readily available harmful industrial chemicals such as ammonia or chlorine gas. 30 There must be standard observational criteria or screening procedures in place to recognize a sudden chemical attack or a biological incident, which may not be immediately obvious by observation. ...
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... In any case, sufficient amounts of antidotes should be immediately available in mass-casualties situations [56]. Thus, radiological preparedness of a hospital requires stockpiling of adequate quantities and types of such medications; several consensus guidelines for radiological antidotes stockpiling have been proposed [57]. These should be added in the preparedness list for hospital medications against radiological accidents ( Table 2). ...
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... According to the WHO, the number of persons may be as few as 1,000, although much of the available literature refers to gatherings exceeding 25,000 persons [5]. MGs are highly visible events with the potential for serious health and political consequences if not managed carefully and effectively [6][7][8][9][10]. MGs of any nature present specific challenges for authorities in terms of maintaining public health. ...
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