ISSUE: Responding to a bioterrorism incident requires effective coordination among state, local, and hospital emergency management systems. This 500-bed academic health center (AHC) in a rural state participated in a 3-day, statewide drill testing the integration of response of participating agencies to a simulated biological event.

PROJECT: Dubbed “Red Clover” after the Vermont state flower, the drill was a simulation of release of 5 kilograms of Yersinia pestis into the air-handling system of a building, exposing 500 people attending a summer theatrical festival. The resulting outbreak of severe pneumonia and febrile illness inundated two local hospitals and our AHC, the only tertiary-care center in the state, and triggered the governor to declare a statewide emergency.

RESULTS: The first day of the drill tested the efficiency of the emergency departments (EDs) of the three participating hospitals to recognize an unusual cluster of illness and notify the Vermont Department of Health (VDH). Active surveillance was initiated in all 13 hospitals in the state. AHC activated its emergency operations center in response to the suspected bioterrorist event; this included deployment of a portable bio-isolation tent used for triage of patients outside the ED. VDH simultaneously activated its emergency operations center. The VDH laboratory “identified” the causative agent the first day, and the governor activated the state emergency operations center. By the second day, local ambulances were overwhelmed with transfers to AHC and requested assistance from other state ambulance services. A total of 80 patients were evaluated or admitted to AHC at the main campus and several primary care/family practice satellite locations. AHC cancelled elective surgeries and began discharging patients; within 6 hours an additional 200 patients could have been admitted, including 100 who required ventilators. Activating the strategic national stockpile was simulated to provide prophylactic antibiotics. On the third day of the drill, the VDH held two clinics to distribute prophylactic antibiotics.

LESSONS LEARNED: Statewide exercises simulating mass casualty events are necessary to ensure coordination among involved agencies. A biological event presents unique challenges, including recognizing the event, instituting appropriate isolation prior to identification of the agent, administering post-exposure prophylaxis, and communicating with the public.