BW-ch19.pdf

Consequence Management: The National and Local Response

Chapter 19

ConsequenCe ManageMent: the

national and loCal Response

Kermit D. Huebner, mD, FACeP * ; and JAmes W. mArtin, mD, FACP †

intRoduCtion

the national Response

legislation

the national Response plan

defense support to Civilian authorities

the Biological index annex

defense department Bioterrorism Response assets

the loCal Response

initial Response to a Biological incident

Mass patient Care

Mass logistics

Mass prophylaxis

Mass Fatalities

legal issues

suMMaRy

* Major, Medical Corps, US Army; Chief, Education and Training, Operational Medicine �epartment, US Army Medical Research �nstitute of �nfectious

�epartment, US Army Medical Research �nstitute of �nfectious

, US Army Medical Research �nstitute of �nfectious

�iseases, 1425 Porter Street, Fort �etrick, Maryland 21702

† Colonel, Medical Corps, US Army; Chief, Operational Medicine �epartment, US Army Medical Research �nstitute of �nfectious �iseases, 1425 Porter

�epartment, US Army Medical Research �nstitute of �nfectious �iseases, 1425 Porter

Street, Fort �etrick, Maryland 21702

415

, US Army Medical Research �nstitute of �nfectious �iseases, 1425 Porter

Medical Aspects of Biological Warfare

intRoduCtion

response to an intentional biological attack is likely

to overwhelm local and regional healthcare facilities

and resources, requiring the use of national assets to

treat the infected and contain the disease. As stated in

the biological incident annex of the national response

Plan (nrP), “no single entity possesses the author-

ity, expertise, and resources to act unilaterally on the

many complex issues that may arise in response to a

disease outbreak and loss of containment affecting a

multi-jurisdictional area.” 1 there must be coordination

among healthcare facilities, local authorities, public

health officials, state agencies, and federal agencies

for an effective and efficient response to terrorism

events. biological response plans must be integrated

at all levels, and cooperative efforts to leverage assets

from nonaffected areas must be planned and exercised

before the event. Critical tasks for healthcare facilities

responding to an outbreak include treating the ill and

preventing nosocomial spread of disease; however, fa-

cilities must also be prepared to expand surge capacity

and personnel, deal with large numbers of infectious

remains, and provide risk communication to the pub-

lic and the media. Additionally, healthcare facilities

and personnel may be involved in epidemiological

investigations, contact tracing, and distribution of

mass antibiotic prophylaxis and vaccinations to the

community. this chapter reviews some of the legisla-

tion and authorizing acts relevant to the response to a

biological event, the nrP, the role of the Department

of Defense (DoD) in support of civil authorities, and

key features of the local response, including disease

containment, mass patient care, mass prophylaxis, and

mass fatality management.

DoD healthcare providers and planners must be

familiar with these concepts because they may be

required to provide the medical response on military

reservations or in the deployed setting, or they may

need to augment the medical response in civilian com-

munities after a natural or artificial biological incident.

For example, the military may be called on to “effect

a quarantine,” possibly using national Guard troops

under federal control in response to an avian influenza

outbreak. 2

military medical treatment facilities should main-

tain an emergency management plan outlining their

response to disasters and mass-casualty incidents

using an all-hazards approach. these plans should

include specific annexes that detail the response to an

intentional release of a biological agent and outbreaks

of emerging or reemerging infectious diseases.

the national Response

legislation

quest disaster assistance from the federal government.

under this act, a state governor may request that the

president declare a major disaster or emergency and

direct federal assistance to the state, as long as the di-

saster is of such severity and magnitude that effective

response is beyond the capability of the state.

national policy and legislation concerning biologi-

cal warfare and terrorism provide the foundation for

key aspects of the federal response to a biological

event. An overview of the pertinent legislation is

provided below.

Defense Against Weapons of Mass Destruction Act

The Stafford Act

the robert t stafford Disaster relief and emer-

gency Assistance Act 3 is the cornerstone legislation for

providing federal assistance to states and territories

during disasters and emergencies. this act outlines the

federal programs available and procedures for disaster

preparedness, including mitigation assistance, major

disaster and emergency assistance administration, ma-

jor disaster assistance programs, emergency assistance

programs, and emergency preparedness. the stafford

Act provides an orderly and continuing means of as-

sistance by the federal government to state and local

governments in carrying out their responsibilities to

“alleviate the suffering and damage resulting from

disasters” and establishes procedures for states to re-

in 1997 Congress enacted the Defense Against

Weapons of mass Destruction Act, 4 referred to as the

nunn-Lugar-Domenici Act. this act contains initia-

tives to improve the overall national preparedness for

large-scale terrorist attacks of a chemical, biological,

radiological, nuclear, or high-yield explosive (Cbrne)

nature. Among its provisions is the Domestic Prepared-

ness Program, which provides training, expertise, and

equipment grants to the 120 largest us cities. Originally

assigned to the DoD and administered by the soldier’s

biological and Chemical Command (now the research,

Development, and engineering Command), the Do-

mestic Preparedness Program has provided data on

modeling of biological incidents as well as templates

and guidelines to assist communities in improving

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Consequence Management: The National and Local Response

preparedness for such events (some of these products

will be discussed in more detail in the section on local

response). the Domestic Preparedness Program was

transferred to the Department of Justice, under the Of-

fice of Domestic Preparedness, in 2002, 5 and later to the

Department of Homeland security (DHs).

• an event overwhelms the resources of state

and local authorities, and those authorities

request federal assistance;

• more than one federal department or agency

is substantially involved in responding to an

incident; or

• the president has directed the secretary of

Homeland security to assume responsibility

for managing a domestic incident. 8

Emergencies Involving Chemical or Biological

Weapons Act

this act allows the attorney general to request DoD

assistance directly in response to an emergency involv-

ing biological or chemical weapons of mass destruction

that exceeds the capability of civilian authorities. this

DoD assistance may consist of identifying, monitoring,

containing, disabling, or disposing of the weapon, but

not direct law enforcement actions. 6

the nrP integrated previously existing plans,

including the initial nrP, the Federal response Plan,

the us Government interagency Domestic terrorism

Concept of Operations Plan, and the Federal radiologi-

cal emergency response Plan, to establish a compre-

hensive, national, all-hazards approach to domestic

incident management across a spectrum of activities,

including prevention, preparedness, response, and

recovery.

the nrP established the national incident manage-

ment system (nims) as a standardized approach for

managing all major incidents, regardless of etiology,

that unifies federal, state, and local lines of government

for incident response using the incident Command

system. the incident Command system standardizes

the organization of incident management response by

creating five sections: (1) command, (2) operations, (3)

planning, (4) logistics, and (5) finance/administration. 9

nims incorporates a unified command structure to

ensure coordination and joint decisions on objectives,

strategies, plans, priorities, and public communica-

tions among different jurisdictions and multiple

agencies. A key component of the nrP, nims allows

several different agencies and organizations to work

together with similar command, control, and coordi-

nation elements.

The Homeland Security Act of 2002

this act established the DHs to prevent terrorist

attacks within the united states, reduce the country’s

vulnerability to terrorism, minimize the damage of

and assist in the recovery from terrorist attacks, and

act as the focal point for natural and manmade crisis

and emergency planning . 7 the DHs is charged with

the following:

• coordinating federal-level preparedness and

working with state, local, tribal, parish, and

private-sector emergency response providers

to combat terrorism;

• consolidating previously existing federal

emergency response plans into a single, co-

ordinated nrP;

• ensuring adequate planning, training, and

exercise activities;

• conducting risk and vulnerability assessments

of critical infrastructure;

• identifying priorities for protection; and

• securing the borders, territorial waters, ports,

terminals, waterways, and air, land, and sea

transportation systems of the united states.

The National Response Plan Base Plan and Emergency

Support Functions

the nrP is designed to handle incidents at the

lowest jurisdictional level possible. the secretary of

Homeland security executes the overall coordination

of federal incident management activities, and other

federal departments and agencies carry out their inci-

dent management and emergency response responsi-

bilities within the nrP’s overarching framework.

there are 15 separate emergency support functions

(esFs) that make up the response components of the

nrP (listed in table 19-1). each esF has a primary

lead agency responsible for implementation and

oversight for that aspect of the response, and addi-

tional federal agencies provide support to the primary

agency. For example, in esF #10 (Oil and Hazardous

the national Response plan

released in December 2004, the nrP provides a

framework for the response to incidents of national

significance when the following situations occur (see

chapter 20):

• a federal department or agency acting under

its own authority requests the assistance of

the secretary of Homeland security;

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Medical Aspects of Biological Warfare

taBle 19-1

eMeRgenCy suppoRt FunCtions oF the national Response plan

esF # esF title

esF Coordinator

transportation Annex

Department of transportation

Communications Annex

Department of Homeland security/information Analysis and

infrastructure Protection/national Communications system

Public Works and engineering Annex

Department of Defense/us Army Corps of engineers

Firefighting Annex

Department of Agriculture/Forest service

emergency management Annex

Department of Homeland security/emergency Preparedness

and response/Federal emergency management Agency

mass Care, Housing, and Human services Annex Department of Homeland security/emergency Preparedness

and response/Federal emergency management Agency

resource support Annex

General services Administration

Public Health and medical services Annex

Department of Health and Human services

urban search and rescue Annex

Department of Homeland security/emergency Preparedness

and response/Federal emergency management Agency

Oil and Hazardous response Annex

environmental Protection Agency

Agriculture and natural resources Annex

Department of Agriculture

energy Annex

Department of energy

Public safety and security Annex

Department of Homeland security/ Department of Justice

Long-term Community recovery and

Department of Homeland security/emergency Preparedness

mitigation Annex

and response/Federal emergency management Agency

external Affairs Annex

Department of Homeland security

esF: emergency support function

material response Annex), the esF lead agency and

coordinator is the environmental Protection Agency

(ePA), and the us Coast Guard (part of DHs) is a

supporting agency. Agencies that provide support

for this esF include the Department of Agriculture,

Department of Commerce, DoD, Department of

energy, Department of Health and Human services

(DHHs), DHs, Department of the interior, Depart-

ment of Justice, Department of Labor, Department of

state, Department of transportation, General services

Administration, and the nuclear regulatory Commis-

sion. 1 the esF modular structure allows mobilization

of the precise components that can best address the

requirements of the incident. Localized events may

be resolved with the activation of a select number of

esFs, whereas some large-scale disasters may require

activation of all esFs.

the federal-level medical response begins with

the activation of esF #8 (Public Health and medical

services Annex). esF #8 is coordinated by the secre-

tary of the DHHs principally through the assistant

secretary for public health emergency preparedness.

Activation of esF #8 includes the following core func-

tional areas: ( a ) assessment of public health/medical

needs (including behavioral health), ( b ) public health

surveillance, ( c ) provision of medical care personnel,

and ( d ) provision of medical equipment and sup-

plies. 1 As lead agency, DHHs coordinates all esF

#8 response actions with its internal departmental

policies and procedures. 10 each support agency is

responsible for managing its respective response

assets after receiving coordinating instructions from

DHHs. esF #8 response is coordinated through the

DHHs secretary’s operations center, which maintains

frequent communications with the Homeland secu-

rity Operations Center.

The National Response Plan Concept of Operations

the secretary of Homeland security utilizes mul-

tiagency structures at the headquarters, regional, and

field levels to coordinate efforts and provide appropri-

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Consequence Management: The National and Local Response

ate support to the incident command structure. At the

federal headquarters level, incident information shar-

ing, operational planning, and deployment of federal

resources are coordinated by the Homeland security

Operations Center, and its component element, the

national response Coordination Center.

Joint Field office . the multiagency joint field office

(JFO), established locally during incidents of national

significance, provides a central location for coordination

of federal, state, local, tribal, nongovernmental, and

private-sector organizations. the JFO’s scalable organi-

zational structure (Figure 19-1) uses the nims incident

Command system for managing both preincident and

postincident activities. the JFO does not manage on-

scene operations; rather, it provides support to on-scene

efforts while also conducting broader support opera-

tions that may extend beyond the incident site.

the JFO’s coordinating officials include the princi-

pal federal official, the federal coordinating officer, the

state coordinating officer (appointed by the governor),

and other senior federal officials. the federal coordi-

nating officer, who works in partnership with the state

coordinating officer and the governor’s authorized

representative, conducts an initial appraisal of the

assistance most urgently needed and coordinates the

timely delivery of federal assistance to affected state,

local, and tribal governments and disaster victims. the

JFO coordination staff includes the chief of staff, exter-

nal affairs personnel, Office of the inspector General

personnel, the defense coordinating officer (DCO), the

safety coordinator, and liaison officers.

the defense Coordinating officer . As the DoD’s

single point of contact at the JFO, the DCO coordinates

and processes requests for defense support for civil

JFO Coordination

Group

Principal Federal Official

The SCO represents

the state, and in some

instances, the JFO

Coordination Group may

include local and/or tribal

representatives as well

as NGO and private-

sector representatives,

as appropriate.

FBI Special

Agent-in-Charge

State Coordinating

Officer

Federal Coordinating

Officer

Senior Federal

Officials

JFO Coordination

Staff

Chief of Staff

External Affairs

Safety Coordinator

Liaison Officer(s)

Infrastructure Liaison

Others as needed

Office of

Inspector General

JFO Sections

Defense Coordinating

Officer

Operations Section

Planning Section

Logistics Section

Finance/Admin Section

(Comptroller)

Law Enforcement

Investigative Operations

Branch

Response and

Recovery Operations

Branch

Domestic Emergency

Support Team

(Branches and sub-units established as needed)

Fig. 19-1. Organizational structure of the Joint Field Office

Fbi: Federal bureau of investigation

JFO: Joint Field Office

nGO: nongovernmental organization

sCO: state coordinating officer

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