Lessons Learned

Lessons Learned: The “Pale Horse” BioterrorismResponse Exercise

Col. David Jarrett, MD, FACEP

The city of San Antonio, Texas, and the Fort Sam Houston Army Post conducted abioterrorism response exercise to test the command infrastructure in a large tabletopexercise. A number of local, state, and federal agencies participated in the exercise. Thescenario, program format, and multiple lessons learned from this experience are described.Needs for additional services, planning, and legal issues are identified. (Disaster ManageResponse 2003;1:114-8.)

For related Guest Editorial, see p. 98

And I looked, and behold, a pale horse: and his name thatsat on him was Death, and Hell followed with him.

Book of Revelation 6:8

I n August 2002, the city of San Antonio, Texas, and theFort Sam Houston Army Post (located within the city)conducted “Pale Horse,” one of the most ambitious,

city-based, large-scale, tabletop bioterrorism response ex-ercises to date. The exercise used significant executive-level resources from the Department of Defense (DOD),city, state, and region.

The purpose of the bioterrorism response exercise wasto test the command infrastructure in a large tabletopexercise. The exercise included command-level playersfrom military medical (major Army and Air Force medicalfacilities located in San Antonio), civilian medical, citygovernment, boards of health, state medical, NationalGuard, regional Federal Emergency Management Agency(FEMA), and Department of Defense (DOD) communities.The initial goals of the exercise were to foster criticalthinking, identify roles and responsibilities, and exercise

and validate existing plans. The programmed corollary tothe exercise was to develop solutions for the inevitableshortfalls and controversial issues that would arise duringplay. Primary participants of the exercise are listed in Table1. This article will discuss the experience with attention tothe shortfalls and controversial issues identified during theexercise.

The purpose of the bioterrorismresponse exercise was to test thecommand infrastructure in a largetabletop exercise.

MULTIGROUP TABLETOP EXERCISE

ScenarioTo develop realistic play, the city of San Antonio began

with its normal level of preparedness. No artificial readi-ness was contrived to “look better.” The primary scenariowas an unannounced terrorist attack wherein aerosolizedand appropriately stabilized smallpox virus was sprayedover the attendees at the Alamo Dome during a footballgame. No announcement or threat was relayed (covertattack), and all attendees dispersed to their normal routine.Initial victims of smallpox then began to present to medicalproviders with the onset of fever in congruence with thenormal incubation period. Several assumptions were madeon the basis of demographics of the San Antonio population.Because many residents have prior military service, the exer-cise planners assumed that approximately 20% of the popu-lation would have remote vaccination and could be consid-ered relatively herd-immune. (The U.S. military ceased

Col David Jarrett, MD, FACEP, is the director of the Armed ForcesRadiobiology Research Institute, Bethesda, MD

Reprint requests: Col David Jarrett, MD, FACEP, 8901 Wisconsin Ave,Bethesda, MD 20889-5603. (E-mail david.jarrett@us.army.mil)

Copyright � 2003 by the Emergency Nurses Association.

1540-2487/2003/$30.00 � 0

doi:10.1016/j.dmr.2003.08.001

114 Disaster Management & Response/Jarrett Volume 1, Number 4

performing routine vaccinations in 1990.1) The remainder ofthe population was assumed to be immunologically naı̈ve.The transmission ratio for smallpox in this scenario was pos-tulated to be 3 to 5 secondary cases per primary case. Thistransmission rate was considered appropriately conservative;the 1972 Yugoslavia outbreak resulted in 11 to 13 secondarycases per primary case and is consistent with the recentassessment by Gani and Leach.2

Program FormatThe program prefaced play with a series of plenary

session lectures by various subject-matter experts in war-gaming; medical capabilities; local first-responder capabil-ities; and smallpox, bioterrorism, and disaster responseagencies. After the lecture series, all participants dispersedto either preassigned or self-assigned groups, referred to as“command cells” specific to their base organizations. Indi-vidual hospital organizations, the city government, publichealth authorities, Fort Sam Houston officials, and otherseach had their own preplanned emergency operation con-figuration or operational center serving as their commandcells. As play proceeded, individual cells responded totheir own internal problems and to both external requestsfrom other cells and to new situational information fromthe planners (program injects). Overall control was to bemaintained by a “White Cell” who simulated requirementsfrom state and federal agencies, and placed new programinjects where and when required.

After the game play, each group presented its prelimi-nary “lessons learned” to the plenary session. The follow-ing discussion is an overview of the lessons learned fromthis exercise.

Primary Lessons LearnedUse of investigational new drug vaccines. Use of an

investigational new drug (IND) smallpox vaccine protocolwill be untenable to control an epidemic resulting from alarge bioterrorism attack. Sufficient time and personnelcannot be made available to stem the spread of the com-municable disease.

Use of an investigational new drug(IND) smallpox vaccine protocolwill be untenable to control anepidemic resulting from a largebioterrorism attack.

Ability to provide ring vaccination. “Ring vaccina-tion” cannot be accomplished when contact tracing is un-tenable, as would be in a situation in which thousands ofprimary cases are due to exposure to an aerosolized virus.Adequate personnel did not exist to rapidly perform con-

tact tracing due to the mass number of primary infections.In this venue, in which the infected individuals were ex-ternally unidentifiable and dispersed widely before thedevelopment of symptoms, mass vaccination without re-gard to exposure probability was the method of resort.

Multidisciplinary communication. Communicationamong the multiple emergency operations centers, thepublic, and health care providers was totally inadequate.In an ideal situation, all operations centers would rap-idly provide each other pertinent information. Computernetworks that have incorporated “instant messaging”have accommodated this function in other operationalmilieus. Rapid establishment of data collection and anal-ysis points with secure-trunk communication will benecessary. This would be an item of great expense andwould require direction from the new Department ofHomeland Security.

Rapid Vaccination Secondary Lessons LearnedKnowledge deficit. There is a dearth of knowledge

about the disposition of smallpox remains (eg, how longthe body is infectious and whether special embalmingprocedures are indicated). The health care providers’ cell(the largest single cell) was concerned about the potentialcommunicability of smallpox in a modern population thatincludes a substantial number of immunocompromisedindividuals. Recent chemotherapy, radiotherapy, or corti-costeroid therapy treatment and infection with HIV, AIDS,or other immunocompromising conditions substantially al-ter an individual’s susceptibility to infectious disease. Thishigh-risk group was significantly smaller when routinesmallpox vaccination was halted in the mid-1970s. Thelack of familiarity with normal smallpox vaccine reactionsand complications made the decision to use available vari-cella immune globulin very difficult. Appropriate usewould have resulted in consumption of the vaccine beforethe midpoint of the crisis.

Who has authority? The public health Medical Oper-ations Center which had been designed to coordinate com-munity medical response required a much more rigid char-ter in order for members to fully discern their mission. Thegroup was unsure of its authority over private and publicinstitutions and its relationship to both. While the initialvaccination program centered on health-care workers inthe receiving facilities, no consideration was made forvaccinating the support personnel necessary for continuedfacilities operation.

Immunization manpower requirements. Opera-tional plans required the use of diluted smallpox vaccine.Under the auspices and resultant informed consent anddocumentation required of an IND protocol for one to fivediluted vaccinia, per-patient vaccination time was in-creased to between 10 and 20 minutes. This 4-per-hourrate is in stark contrast to the 500 vaccinations per day pervaccinator that was routine in the vaccination centers dur-ing the smallpox-eradication program.3

October-December 2003 Disaster Management & Response/Jarrett 115

NEED FOR ADDITIONAL SERVICES ANDPLANNING

The city of San Antonio had configured a Medical Op-erations Center that worked well as a clearance house.However, many of the members had difficulty with scien-tific questions due to the absence of a public health rep-resentative. Information flow was often delayed with otherindividual agency emergency operations centers until thedaily conference calls. More frequent information updateswould have been beneficial.

Military medical centers were active in the program andthe Brooke Army Medical Center had excellent successwith the Hospital Emergency Incident Command System(HEICS). This system was particularly amenable to inte-grating personnel as they entered game play from outside.For example, a field hospital was deployed into the matrixon its own initiative. The HEICS was able to accommodatethis additional resource as a fait accompli without externaldirection. An additional innovation was the deployment ofexternal triage teams that could evaluate patients whoremained in both personal and rescue vehicles, and thendispatch them to the appropriate care area via their originaltransport. This significantly diminished traffic infiltration ofthe hospital complex proper.

As a counterpoint, the Wilford Hall Air Force MedicalCenter (AFMC), which is located across town, elected tomaintain its status as a Level 1 trauma center to supportthe Air Force’s worldwide mission. The personnel atAFMC assumed that an attack on San Antonio also wasan attack on the United States as a whole. Therefore, themedical center was locked down and no nonessentialpersonnel were allowed in or out. All potential smallpoxpatients were transferred to the Brooke Army MedicalCenter.

The difficulties that AFMC encountered included a lackof knowledge of local homeland defense plans that incor-porated the use of Wilford Hall in the city plan. AFMC hada heavy dependence on civilian contract supplies andequipment that suddenly became unavailable and causedsignificant disruption in internal plan implementation.Both internal and external communications became diffi-cult because no prior coordination had occurred betweenthe medical operations group at AFMC and key medicalpersonnel (eg, public health, infectious disease, city Med-ical Operations Center, and Joint Task Force cell represen-tatives).

Fort Sam Houston was represented by an emergencyoperations center cell. This group was able to determinethat sufficient manpower for crisis action team and garri-son facilities was available. Crisis communications difficul-ties hampered interplay and cooperation among militaryand civilian key emergency medical services. While on-post communication via local-access television was avail-able, post officials could not communicate with off-postworkers and family members, who essentially were cut offfrom information regarding the post. They were thus un-

able to receive information on where and how to accessmilitary facilities.

Crisis communications difficultieshampered interplay andcooperation among military andcivilian key emergency medicalservices.

The Army’s Joint Task Force-Civil Support (JTF-CS) hadminimal input into the exercise because it was only pro-grammed for a few hours of the exercise and was notadequately integrated into the response. The JTF-CS wasnot familiar with available DOD assets, which limited itsusefulness, and civilian agencies were essentially unawareof the JTF-CS’ presence. The only requests the JTF-CSreceived came from other military organizations, a totalreversal of its intended role as an advocate and liaison fromthe civil authorities to the military.

Civilian facilities and disaster response groups wereorganized as subordinate to overall control by the cityMedical Operations Center. The largest group was primar-ily composed of direct patient-care providers. Thesegroups were lacking in the following areas:

1. Grief counselors and clinic personnel. The lack ofgrief-counseling expertise was identified as the mor-tality figures grew. Grief counselors usually are notconsidered to be first responders, but because of themagnitude of the crisis, their services were neededvery early.

2. Sufficient manpower. The manpower for vaccinationclinics was markedly insufficient due to the largenumber of patients and documentation required.

3. Ability to vaccinate health care workers. Postexpo-sure prophylaxis of health care workers was rapidlydefeated by the epidemic kinetics. Pre-event vacci-nation of first responders might have obviated thisproblem.

4. Proximity of hospitals. San Antonio’s major hospitalsare primarily located in a few multihospital areaswith nearby contiguous campuses. The UniversityHealth Systems utilizing the HEICS was designatedthe primary smallpox facility. Unfortunately, the uni-versity system did not have as part of its plan asustainment package for this designation. The result-ant situation potentially would have resulted in aquarantine of the entire multihospital area. The Uni-versity Hospital also is a primary Level 1 traumacenter. The self-imposed isolation of Wilford HallAFMC and the designation of the university system asa smallpox center essentially left the city without aprimary trauma-receiving point.

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5. Small hospital concerns. The smaller private systemwas represented in the program by Nix Hospital. Dueto size and staffing constraints, upper middle man-agement personnel were drawn into direct patientmanagement, as no other expansion capability waspresent. Management employees had very limitedhazardous material training.. Medical staff was notavailable because all physicians had primary respon-sibilities to other facilities. Since the hospital’s supplysystem was based on demand and limited stocks, allmedical material was rapidly consumed and couldnot be replenished. The basic error in their disasterplan was that it was limited to problems occurringwithin their hospital only and was not integrated intothe plan of the larger community.

LEGAL ISSUESLegal experts were included as participants in medical

and governmental affairs within the game play. This al-lowed valuable insights into valid technical problems oftenmissed by operational personnel.

QuarantineQuarantine is a legal rather than medical action, and its

implementation appears fraught with difficulties. Eventhough many quarantine laws still are technically in effectin various jurisdictions, some have lapsed. Even wherequarantine technically is still enforceable, the proceduresfor implementing it have not kept pace with modern civillaw.

Planners found there were numerous questions regard-ing the use of quarantine. For example, what “due process”is appropriate? When quarantine was commonplace, theprocess was simple and seldom contested. That is unlikelyto be the case now. Who will determine ingress and egressprocedures into a quarantine area? What will be the en-forcement against those persons demanding to leave aquarantine area? What level of force is justifiable? What isthe balance between public health and individual familyrights? This debate can easily be carried further to includedisposition of human remains.

Even where quarantine technicallyis still enforceable, the proceduresfor implementing it have not keptpace with modern civil law.

LiabilityNo body of law exists to define what the professional

and personal liability of private health care providers is for

Table 1. Participants in Pale Horse Tabletop PlanningExercise, San Antonio, Texas

Local ParticipantsSan Antonio City and Bexar County Agencies

Office of the MayorOffice of Emergency ManagementMetropolitan Health DistrictMedical Examiner’s OfficeEmergency Operations Center representativesDistrict Attomey’s OfficeInformation Technology Services DepartmentFire/Emergency medical servicesPolice

San Antonio Water SystemBexar County Medical SocietyGreater San Antonio Hospital CouncilLocal media outletsLocal Red Cross representativesUniversity Health System/University of Texas Health

Science CenterBexar County Emergency Management OfficeState ParticipantsTexas Department of Emergency ManagementTexas Department of HealthTexas National Guard Bureau, 6th Civil Support TeamFederal ParticipantsDepartment of Health and Human Services

Centers for Disease Control and PreventionOffice of Emergency PreparednessNational Disaster Medical SystemFood and Drug Administration

Federal Emergency Management AgencyFederal Bureau of InvestigationVeteran’s AdministrationDepartment of Defense ParticipantsUnited States Army Medical Command

Army Medical Department Center and SchoolUnited States Army Medical Research & MaterielCommand

United States Army Medical Research Institute ofInfectious Diseases

United States Army Medical Materiel AgencyUnited States Army Center for Health Promotion andPreventive MedicineGreat Plains Regional Medical Command

Brooke Army Medical CenterJoint Forces Command, Joint Task Force-Civil SupportUnited States 5th Army, Joint Task Force-Consequence

ManagementJoint Medical Planners OfficeUnited States Army Chemical SchoolTRICARE Regional OfficeBrooks Air Force BaseRandolph Air Force BaseLaokland Air Force Base, Wilford Hall Air Force Medical

CenterFort Sam HoustonNavy Bureau of MedicineUnited States Air Force Applied Solutions for Operational

Medicine

October-December 2003 Disaster Management & Response/Jarrett 117

emergency actions when acting on behalf of the govern-ment. Does malpractice insurance afford financial protec-tion in this instance?

Many vaccines used against potential bioweapons aretechnically classified as IND, and as such, their usagerequires informed consent. The President of the UnitedStates has the authority to remove informed consent re-quirements for military personnel under exceptional cir-cumstances. No such authority is granted to the presidentregarding nonmilitary civilians. Food and Drug Adminis-tration procedures can be expedited but not circumvented.Currently, the only flexibility allowed the Food and DrugAdministration is the decision to eliminate violation pen-alties under special circumstances.

Social StructurePlanners in this free-play simulation were allowed to

consider such decrements in the community services aswould result from personnel losses and inability to replen-ish supplies. They could consider potentially rate-limitingsteps such as loss of normal utilities, unavailability of repairpersonnel, loss of food-service workers. No provision hadbeen made to preferentially vaccinate utility workers inservice or retail industries who deal with large numbers ofpeople daily. Would they show up for work? How long cancritical industries work on minimal essential staffing? Evenfatality management requires protected workers. In thisinstance, the medical examiner’s office lost 50% of its staffbefore the disease was identified. Human remains disposalbecame an overwhelming problem, and the power to dis-pose of remains varied considerably among various juris-dictions.

Control and dissemination of information. Infor-mation management, risk communication, and psycho-logical impact are dramatically intertwined. When peo-ple are urged to stay in their homes, they are subjectedto a continual barrage of news with repetition of thelimited data available. Public health officers must bemade available on a regular basis to provide accuratenew information or to deal with the lack of data. Thedefault of mass media communication is to repetitivelyreport the most dramatic instances when no new an-nouncements are forthcoming—a form of “no news isbad news.”

When people are urged to stay intheir homes, they are subjected toa continual barrage of news withrepetition of the limited dataavailable.

Accurate news transmission is not solely a function of themainstream media. Health-care providers also need theability to locally transmit clinical data. There is a lack ofexperience in treating acute smallpox or other diseasescaused by agents of bioterrorism, and rapid peer-to-peercommunication of “what works” and “what doesn’t work”must occur. During a time when personal, cellular, andland-line communications become untenable, this maypresent a formidable challenge. Practitioners frequentlyfound themselves without direct information about vacci-nation plans, which hospitals had been designated for“dirty” versus “clean” casualty care, and the provision ofalternative treatment sites.

CONCLUSIONA terrorist biological attack with a highly infectious

agent against a susceptible population would present im-mense command and control challenges. Contingencypreparations must involve not only direct health care or-ganizations but the entire panoply of governmental, legal,communication, and social services. The preconfiguredincident command system structure must be rapidly adap-tive because it will encounter challenges for which noprogrammed response is available. Substantive groups willboth initiate and deny assistance outside the command andcontrol networks. These circumstances must be rapidlyaccommodated and incorporated into the command re-sponse.

REFERENCES1. Grabenstein J. Deputy director, Military Vaccine Agency.

Personal communication, 2003.2. Gani R, Leach S. Transmission potential of smallpox in con-

temporary populations. Nature 2001;414:748–51.3. Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Small-

pox and its eradication. Geneva, Switzerland: World HealthOrganization; 1988.

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